Using An Interpretive Method To Understand Nurses Practice When Dealing Childrens Pain.

Using an Interpretive method to understand nurses practice when dealing children’s pain

By Henny Suzana Mediani, SKp, MNg *

Background

In Indonesia inquiry about pain management in children is limited and there have been no studies conducted in Indonesia about nurses’ practice regarding pain management in children using a qualitative study. Therefore this research provides new information which will be useful to Indonesian nursing practice. During my experience as a nurse, I observed that many nurses had very little to do with pediatric pain assessment. They rarely used assessment tools for measuring pain in pediatric patients. I have seen when nurses assessed pediatric patients in pain, they mainly considered children’s behavioral responses such as crying and facial expression. Moreover, I observed that many Indonesian nurses managed children’s pain with mainly pharmacological approaches and seldom used non-pharmacological methods. Therefore, it is possible that Indonesian children in hospital may receive inadequate pain relief from health care professionals and that pain management in Indonesian hospitals may be ineffective. Hence my interest in researching the topic. My observations were consistent with international literature that indicates children experiencing of pain are not always given adequate pain relief (Kotzer 2000; Clark et al 1996; Gadish, Gonzales & Hayes 1988) and that health care professionals often underestimate and under medicate children’s pain (Nash et al 1999).

Meanwhile nurses as child advocates have a pivotal role in dealing with children’s pain. As nurses have more frequent contact with pediatric patients than any

other health professionals, nurses have a responsibility to provide adequate care for pediatric patients in pain (Brunier, Carson & Harrison 1995). However, I noticed that many Indonesian nurses seemed to lack attention in caring for children experiencing pain. They tended to be more focused on routine activities such as wound care and giving injections than assessing children’s pain.

Aims of this study

This study aimed to explore some of the issues discussed above. The aims of the study were to answer the following research questions:

1. What are nurses’ beliefs regarding assessment and management of pain in children?

2. How do nurses intervene to support children experiencing pain?

Literature review Definition of pain

Pain is a common human experience. However, pain is a concept that is difficult to understand. It may be that because pain is not a simple stimulus and is a subjective experience. Among the most popular definitions of pain are those of the International Association for the Study of Pain (1979) and McCaffery & Beebe (1994). The International Association for the Study of Pain subcommittee on taxonomy (1979 cited in McGrath & Unruh 1987, p. 45), asserted that ‘pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage’. McCaffery & Beebe (1994, p. 15) offered a more personal explanation of pain, which states that 'pain is whatever the experiencing person says it is and exists whenever he says it does’. Basic to this definition is the

The role of nurses in dealing with children’s pain

Most literature asserts that nurses have an important role in dealing with children’s pain (McCaffery & Beebe 1989; Price 1992: Hunt 1995; Jacob & Puntillo 1999; Salantera et al 1999; Carlson, Broome & Vessey 2000). Nurses are central to pain management because they provide twenty-four hour care to pediatric patients in acute and chronic pain care, and have more frequent contact with patients than any other health professionals. According to Price (1992) nurses have a professional responsibility to the community to provide the highest standard of nursing care. This means that nurses have a professional responsibility to provide adequate assessment and appropriate nursing interventions for pediatric patients experiencing pain. Nurses also are ethically responsible to manage pain and relieve suffering (Potter & Perry 1995).

Assessment of pain in children

Assessment is a fundamental part of taking care of children in pain. However, many researchers have investigated the difficulty of pain assessment in children (Salantera et al 1999; Jacob & Puntillo 1999; Allcock 1996; Brunier et al 1995). The main problem faced in assessment of children’s pain is because children have limited ability to express their pain to those who take care of them such as health professionals and parents, especially in neonates and young children (Salantera et al 1999; Soetenga, Frank & Pellino 1999; The Royal College of Nursing Institute 1999; Twycross 2001). The problem may relate to inability to understand the instruction of pain measurement (McGrath & Unruh 1987; Bradshaw & Zeanah 1986). Thus the assessment of children’s pain continues to be an important challenge for health care providers in clinical practice (McCaffery & Pasero 1999; LaFleur & Raway 1999; Stone et al 1998).

A number of studies have identified that nurses do not always assess pain effectively (Caty et al 1995; Zalon 1995; Vessey & Carlson 1996; Woodgate & Kristjanson 1996; Carr 1997; Jacob & Puntillo 1999). A possible reason is that the subjective and multidimensional nature of pain experience and lack of knowledge about pain may influence accurate assessment of pain in children (LaFleur & Raway 1999; Thomas 1997; McCaffery & Beebe 1999; Caty et al 1995).

Reviews of pain assessment in children (McGrath & Unruh 1987; Atkinson 1996) have argued that because pain assessment in children is a complex procedure, it should be based on a variety of approaches, as no single approach provides all the required information. Multi dimensional pain assessment typically includes indicators such as verbal complaints of pain, behaviors such as facial expression and body movement and physiological arousal such as vital signs (Bradshaw & Zeanah 1986; Caty et al 1995; Rheiner et al 1999; Salantera et al 1999).

The tools for measuring pain in children

There is a wide range of qualitative and quantitative instruments for measuring the sensory and emotional aspects of children’s pain (Finley & McGrath 1998; Thomas, 1997; McGrath & Unruh 1987). These include projective methods, in which children’s attitudes or perceptions of pain are inferred from a selection of colors, their drawing, or their interpretation of cartoons and stories, and self-report measures, which directly describe their pain and rate pain intensity.

Thomas (1997) and Champion et al (1998) suggested that there are number of rating scales generally used to measure pain in clinical practice. Self-report scales which are published and commonly used for measuring pain in children include:

Faces Pain Scales (Bieri et al 1990); Visual Analog Scale (VAS), Visual Numeric Scale (Champion et al 1998). Visual Analog Scales (VAS) are reliable and valid measures of pain (McGrath & Unruh.1994).

Pain management

With regard to pain management approaches, there are two common strategies used to manage pain in children and these can be divided into non-pharmacological and pharmacological interventions (Atkinson 1995; Llwellyn 1997).

Pharmacological interventions

The commonly used analgesia for treating pain in children includes opioids (narcotics) and non-steroidal anti-inflammatory drugs (NSAIDs). Narcotics such as morphine, codeine, meperidine can be administered by intravenous, intramuscular, subcutaneous and oral route (Ball & Bindler 1999). Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and acetaminophen are effective for the treatment of mild to moderate pain and chronic pain, and they are primarily given orally 10-5 mg/kg q 4h (Ball & Bindler 1999).

The literature suggests that nurses often undermedicate children’s pain. For example, Jacob & Puntillo (1999) ; Gadish et al (1988); Schecter et al (1986); Asprey (1994) found that nurses administered prescribed morphine to children less frequently than prescribed acetaminophen and that both were administered only once or twice in a 24 hour period. Some prescribed medications were not administered in the 24 hours. The study showed that nurses administered analgesics to pediatric patients infrequently.

Some researchers have indicated there are two major factors that may contribute to under medicating children for pain including lack knowledge about analgesia and attitudes to pharmacological pain management policies (Twycross 2001; Hamers et al 1994; Gadish et al; Clarke et al 1996; Abu-Saad & Hamers 1997; Salantera 1999; Caty et al 1995).

Non-pharmacological interventions

Non-pharmacological interventions are nursing authority in taking care of children’s pain. Non-pharmacological intervention is a broad construct encompassing a variety of approaches designed to relieve pain which do not involve medications (Vessey & Carlson 1996).

Number of studies suggested evidence for effectiveness of non-pharmacological interventions in managing acute pain (Good et al 2001; Mediani et al 1997; Vessey & Carlson 1996; Vessey et al 1994). Good et al (2001) conducted a randomised controlled trial to investigate the effects of relaxation, music and the combination of relaxation and music on postoperative pain, across and between two days and two activities (rest and ambulation) and showed that music, relaxation and their combination reduced pain on day one and two and during ambulation and rest. Furthermore, longitudinal effects were found over two days and across both activities on each day. These treatments were clearly effective and patients can ambulate with greater relief without increasing opioid intake and possible side effects. However, non-pharmacological interventions are not always used by nurses when dealing with children’s pain in clinical practice.

used in clinical practice. Coffman et al (1997) found that non-pharmacological interventions were used less as pain relief modalities by nurses than pharmacological methods because nurses believed that critically ill children’s pain cannot be managed by non-pharmacological methods. Interestingly, nurses tended to perform in intuitive ways and they rarely documented what they did. Furthermore, nurses also assumed that these interventions were not a specific nursing intervention for pain relief.

Research design and method

An interpretive qualitative approach was chosen to explore and gain an understanding how nurses dealing with children’s pain. Through qualitative research, the nurse researcher comes to know the perceptions of nurses and the people for whom they care (Munhall & Boyd 1993; Streubert & Carpenter 1995).

Minichiello et al (1995) stated that the interpretive approach seeks to understand direct lived experience rather than make an abstract generalisation. Similarly, Taylor (1994) suggested that through the accounts of their lived experiences, people are able to reflect the meaning they find within themselves and things around them. For instance, in this research, nurses’ practices in dealing children’s pain are explored through nurses’ personal accounts.

The general perspective of the interpretive approach suggests that reality is subjective and what an individual believes it to be (Taylor 1994). Reality is built on social and historical contexts (Neuman 2000). This means that reality may change based on features of times, place, and circumstance (Neuman 2000). Understanding meaning and interpretation are crucial elements of knowledge.

With an interpretive approach, the perspectives of the participants are taken into account. Neuman (2000) points out that in the interpretive approach the researcher

shares the feelings and interpretations of the people being studied through their eyes. Thus, both participants and interviewer may share their knowledge and experience. In this study nurses were asked to discuss their perceptions about pain assessment and management of pain in children and how they cared for children experiencing pain. According to Taylor (1994) the interpretive approach is based on the assumption that people are the interpreter of their own experience and that elements of context and inter-subjectivity are important components of how they can make sense of their experiences. Thus, in this study I wished to learn what is meaningful to the nurses being studied with regard to their experiences in dealing with children’s pain. It was my purpose to listen, record, understand and interpret nurses’ beliefs and perceptions regarding pain in children and its assessment and management.

Methods of data collection Setting

I chose pediatric surgical ward in a general government teaching hospital in Bandung as the setting for this research. It is also a referral hospital for other hospitals. The total number of nurses in the Pediatric surgical ward was 17. Most had a qualification from vocational school (70 %). Meanwhile, 30 % had a qualification at a diploma level. None of nurses had a university degree.

Selection and recruitment of participants

To recruit participants I sent a letter of introduction to nurses on the Pediatric surgical ward at the hospital. Nurses were chosen and approached on an individual

on the Pediatric surgical ward. The final number of participants was five (all female). This number allowed for adequate exploration of the question and related issues, and data saturation to be reached. For the purpose of this study, a convenience sampling method was considered to be the most appropriate, as the population to be researched was small and based on information needs (Polit & Hungler 1999). I selected nurses who had shown interest in the issue under investigation and had agreed to participate in the study.

Inclusion criteria

In this study I chose nurses with different education backgrounds, years of nursing experience and ethnicities. Inclusion criteria for this study were that nurses should be currently working on the Pediatric surgical ward, and that they should have more than one year’s working experience on this ward. Additional selection criteria included having a minimum nursing qualification from vocational nursing school. Therefore, these nurses all had direct experience caring for children experiencing pain. Another selection criterion was informed consent to be interviewed and recorded and to verify the transcript.

Data collection

The interview method was chosen to explore how Indonesian nurses’ practice in dealing children’s pain. Furthermore, the use of the interview in this study provided me with an opportunity to understand the significant issues concerning nurses’ perceptions, knowledge and practices regarding pain in children, and to describe their practices from their perspective, and to interpret their words (Koch 1998).

A semi-structured interview method, using open-ended questions was used to facilitate in depth exploration of nurses’ practice regarding children’s pain. The use of

a semi-structured guide kept the phenomenon of interest in focus (Wimpenny & Gass 2000) and facilitated in-depth exploration of nurses’ perceptions of children’s pain and their practice in dealing with children’s pain. Moreover, the interviews allowed participants freedom in answering the questions, and allowed me to adjust the interviews and explore emergent issues as they arose.

In-depth interviews encourage participants to ‘recall, reveal and construct aspects of subjective experiences and interpretations and to make discussion coherent and meaningful’ (Minichiello et al 1999, p.397). Meanwhile, the use of open-ended questions means that the questions are not structured or rigid, question order may be changed and extra questions may be added if necessary. By using open-ended questions participants are encouraged to expand on their own experiences (Appleton 1995), and consider their responses (Cormack 1996).

Interview process

In this study each participant was interviewed separately. Letters of introduction were provided and consent forms were signed prior to the interview. The interviews were conducted in a quiet, private room provided by the head nurse to avoid distraction, to enhance concentration and to maintain confidentiality. The duration of each interview was approximately 30 to 60 minutes. A mutually convenient time, date and place of interviews was organized between my self and each participant. Although participants were given the opportunity to select a place for the interview, all participants preferred to be interviewed in the Pediatric surgical ward at the hospital.

Interviews were conducted and guided by a list of 8 questions. These questions provided a focus and guidance for the participants, as well as allowing me to collect

All interviews started with the same question about demographic information, then a personal view: “I believe that as a nurse you have had experience in caring for children in pain, can you please describe to me what is pain?” This question allowed the nurses to feel comfortable and to freely express their opinions. During the interview further questions were asked to elaborate on responses to earlier questions. If participants had difficulties in answering the questions, I provided them with examples that might give them some ideas. I also took written notes. Note taking helped me to emphasize issues of key significance in the interview and to summarize the content of the interview.

The interviews were audio taped, and then transcribed and summarised by me. A copy of transcripts was returned to each participant with a covering letter. The covering letter instructed participants to make sure of the accuracy of the transcript and to add or change the content of the interview if necessary. I asked the participants if the transcripts were correct. These processes aimed to make sure I captured accurate information as told by the participants. All participants agreed that the transcripts were accurate.

Data analysis and presentation of findings

Data were analysed by organizing the data into two columns. One column listed key topics from the interview questions. The second column listed nurses’ responses to these topics. The interview data were transcribed in order to preserve the participants’ meaning. Participants who gave the same answer to the questions were put together under the same question. In order to become familiar with the data, I listened again and again to the interview tapes, and read and reread the transcripts to gain an overall picture of participants’ stories (Browne & Sullivan 1999). The data were analysed and refined until themes could be formulated. In this process, each

topic was analysed separately. To support my interpretation, direct quotations with false names of participants were used in the results (Mariano 1993).

Establishing rigour

The general term of rigour is more specifically known as validity and reliability (Roberts & Taylor 1998). Some authors (Guba & Lincoln 1985; Sandelowsi 1986; Koch & Harrington 1998) have suggested that it is inappropriate to apply quantitative rigour (validity and realibility) to judge qualitative products because of the difference in ontological and epistemological assumptions. Burns & Grove (1993, p. 64) indicated that rigour in qualitative research is ‘associated with openness, scrupulous adherence to a philosophical perspective, thoroughness in collecting data, and consideration of all the data in the subjective theory development phase’.

The criteria for rigour in this study were based on Sandelowski (1986), Guba & Lincoln (1981) and Beck (1993) which involved credibility, fittingness, auditability.

 Credibility

A research design is valid when the outcomes can be accepted as ‘true’. Guba & Lincoln (1981) mentioned that the ‘truth value’ of a qualitative study should be evaluated by its credibility rather than internal validity as in quantitative research methods. Research is credible when ‘participants and readers of the research recognize the lived experiences described in the research as being similar to their own’ (Robert & Taylor 1998, p.399).

Credibility in this study was achieved by sending and showing the transcript to the participants to confirm the truth and accuracy of content and the transcript. Also

frequent consultations with my research supervisors to ask question made sure that data analysis and discussion met adequate standards of research.

 Fittingness

Fittingness refers to ‘the extent to which a project’s findings fit into other contexts outside the study setting’ (Roberts & Taylor 1998, p.400). For instance, this study’s finding about nurses’ perceptions about pain relief on the Pediatric surgical ward would be expected to be similar to experiences of nurses from other wards or countries. Furthermore, fittingness of a study is shown when the findings are grounded in the life experiences studied and reflect the typical elements of data (Sandelowski 1986). By using interviews to collect data, I ensured that interpretations of the nurses’ perceptions regarding pain assessment and management of pain in children were grounded in the words of the nurses themselves and were not derived solely from my own point of view.

 Auditability

Sandelowski (1986, p. 33) pointed out that ‘a study and its findings are auditable when another researcher can clearly follow the ‘decision trail’ used by the investigator in the study’. In order to attain auditability in this study, I recorded decision making at every stage of the research process and consulted with my supervisors to examine whether the study was relevant, comprehensive and well developed (Koch & Harrington 1998). In addition, to achieve auditability in this study I kept a journal to record the research process. Thus, I wrote activities and experiences that occurred during the research.

Ethical considerations

Participants were provided with plain language information sheets and gave informed consent. I provided each participant with an undertaking that all data relating to them would remain confidential. The participants were assured that their names would not appear anywhere in the transcribed material. Pseudonyms were used. Furthermore, the name of the hospital in which the study was set is not disclosed in this thesis.

I informed the nurses of their right to withdraw or refuse involvement in the research project without prejudice. In the event of any distress or other problems arising from this research counseling would be offered by me or by the Head Nurse at the hospital.

Result of study

The participants’ demographic data are described first as these began the interview process. The interview results are presented using examples the participants’ own words in the following sections: the meaning of pain; nurses’ views on assessment of pain in children; nurses’ views on pain management in children and nurses’ role in dealing with children experiencing pain.

Participants’ demographic data

Five nurses participated in the study. All were female. The range of years of working experience was from 2 to 22 years. The average length of experience was 17.4 years. Most of the nurse participants were up to 40 years of age or between 40 and 55 years

of age. Most nurses had a qualification at diploma level. None of nurses had a university degree.

 Assessing pain in children

The nurse participants were asked to describe whether they found assessing pain in children difficult. The opinion among participants was that assessing pain in children is difficult especially in younger children, because crying is a common response to many unpleasant sensations such as hunger or being wet.

Bunga described her opinion by expressing: Children’s response to painful procedures usually is only crying. So that sometimes it is difficult to distinguish crying caused by pain from crying caused by other feelings such as hunger especially for young children such as infants, so that we have to investigate further the crying response. Similarly, Anyelir, Asri, Mayang and Tiara gave their view by saying that ‘infants cry if they are in pain or hungry, thus infants’ pain is difficult to define’

 The tools for measuring pain

The nurse participants were asked whether they were familiar with pain scales and if so, if they used them or not. All of the nurses knew about pain scales such as the Facial Analog Scale and Numeric Scale. Most of the participants had used the Facial Analog Scale when involved in previous research in the hospital, but they did not use it anymore. Reasons included that it was too time consuming to use and the tools were not available on the ward.

Bunga knew about the tools for measuring children’s pain. But she seldom applied them when she assessed patients’ pain due to them being too time consuming.

Interestingly, she gave the explanation: sometimes I used the facial analog scale for assessing children’s pain when I was teaching nursing students.

But, she revealed further that: I never use other pain scales such as numeric scales because I do not have much time. Moreover as far as I am aware nurses in this ward never use the tools in assessing children’s pain. I suppose they may have used them when they were involved in a study of pain a few years ago, but after the study had finished, they did not apply them anymore.

In the same way, Anyelir explained that: I have used pain scales (the facial analog scale) when I was involved in a study of pain few years ago. After the study had finished I never used it again because its taking time

Anyelir assumed that pain scales are never used on the ward because many nurses believed that a child’s facial expression is an important indicator of pain. She revealed: Honestly it happened due to nurses’ habit, commonly nurses in this ward never use pain measurement in assessing children’s pain, they just observe children’s facial expressions. So we do not know exactly how much pain children are feeling. Mayang gave an explanation why she did not use an assessment tool anymore by saying ‘because the tools are not available on the ward and I do not how to use them exactly.

Only one participant had never used pain scales to determine children’s pain. Tiara stated: ‘I never use the pain scales, I just ask the patient’. Further she described her reasoning by expressing: It is because the tool for measuring pain is not available in this ward. So I just assess pain based on my point of view. I observe the patient’s activities, if I see that the patient really needs our assistance, it means that the

patient’s pain is severe. If the pain does not disturb the patient’s activity it indicates that pain is mild.

How to assess pain

Nurse participants were then asked to describe how they went about assessing pain. In assessing children’s pain, all nurses considered children’s behavioral and psychological responses to pain. Interestingly, most participants also asked parents or families about their child’s response to pain.

Bunga and Anyelir used facial expressions or behavioral reactions to assess pain in children. As Bunga asserted: Firstly, I observe the location of the pain, facial expression, and how children express their pain, and how long the experience has lasted.

Meanwhile, Mayang mentioned: I observe facial expression, movement, and ask children whether they feel pain or not. Sometimes they told me that they were pain, but actually they were not in pain.

Tiara stated that children in pain should be monitored because their coping ability was not good. She asserted: First, I observe the patient’s condition and if they are able to communicate, I ask whether they feel pain or not, where the location of pain is and for how long; or we can observe their coping mechanism, because children’s coping skill is not good so we can ask their parent as well.

Meanwhile, Asri told that she usually observed the patient’s condition and asked how the experience felt. Whereas, Anyelir explained that in order to know information about children’s pain besides asking patients or parents, she looked at the child’s facial expression.

Nurses’ views on pain management in children How to relieve pain

The nurse participants were asked to explain how they managed children in pain. All participants believed that analgesic treatment (pharmacological approach) and distraction techniques such as reading books, conversation, and sponging patients’ bodies were effective ways to reduce pain in children, particularly for acute pain. However, activities such as music intervention were never used because of lack of facilities.

Bunga told how she used pharmacological pain relief after first trying a non-pharmacological approach. She stated: I usually use distraction techniques, such as conversation with patients, if it does not work I use pharmacology intervention using analgesic treatment such as profenid.

Anyelir used both pharmacological and non-pharmacological approaches when dealing with children’s pain. She stated: Beside medication I usually ask patient to do deep breathing or I sponge the patient’s body; keep talking with the patient or encourage the patient to read a book. I give analgesic treatment especially for post operative patients.

Interestingly, Tiara used another kind of distraction technique to minimize children’ pain. She commented: I usually use distraction and relaxation techniques. For example, I ask patients to read a storybook, or play with children using their toys. Meanwhile, for a little kid I encourage his mother to sponge her child; and give analgesic treatment.

In the same way, Asri and Mayang usually used pharmacological pain relief and non-pharmacological methods in alleviating children’s pain. Mayang revealed:

by holding the patient, making conversation and sponging his body in order for children to be able to forget their pain experience’.

Asri asserted: I usually gave analgesic and tried to change the patients’ attention of their pain by communication in order for children to be able to forget their pain experience.

 Non-pharmacological intervention approaches

The nurse participants were asked a question specifically about their views on non-pharmacological intervention approaches as a way of minimising children’s pain. As mentioned above most participants knew some types of non-pharmacological intervention. Indeed, all participants had applied distraction and relaxation techniques for decreasing patients’ pain, but other methods such as music intervention and play therapy were rarely used because they were not provided on the ward. Interestingly, even though participants agreed that non-pharmacological approaches can minimise children’s pain, these methods were not always used by nurses on the ward because they thought they were time consuming. Moreover, there is a belief that analgesic treatment (pharmacological approach) is a simple, effective and quick approach to managing pain.

Bunga argued: I know some of non-pharmacological approaches such as distraction and music intervention. I usually use distraction technique. I have used music intervention when I was involved in a study of pain. However, I never use it anymore due to unavailable facilities.

Anyelir explained that she knew distraction, deep breathing technique and music techniques as non-pharmacological pain relief methods. Moreover, she thought that these techniques were suitable for relieving children’s pain. Asri agreed that

non-pharmacological intervention is a fitting approach in decreasing pain. But, she stated she never uses music intervention. I never use other methods such as music intervention due to this facility in this hospital not being available and nursing’s workload is too heavy.

Similarly, Mayang agreed that non-pharmacological approaches were appropriate ways for reducing pain in children. However, she told that she often forgot to use the relaxation technique. She asserted: I often forget to apply the relaxation technique. I never use other methods such as guided imagery because I do not know about them. Music intervention is never used because it is not available on this ward. But, I did use it when I was involved in a study of pain a few years ago Tiara said that she did not recognise the term ‘distraction technique’ even though in caring for children experiencing pain she used distraction methods such as communication, and sponging. She knew about other non-pharmacological approaches such as music intervention. Also, she thought that hypothetically this method helps children to forget about their pain. She stated: I suppose communication with the patient and sponging the patient’s body will decrease children’s pain and children might forget their experience. I did not know exactly the term distraction techniques and also other methods, but I know music intervention.

 Pharmacological intervention approaches

The participants were asked to describe their views about pharmacological pain approaches to relief of pain in children. Moreover, they were asked how doctors offered pain relief to patients. According to some participants analgesic treatments are generally offered by the doctor post operatively, but others said that sometimes it is

instructions for giving the analgesic treatment. Interestingly, there were different beliefs regarding pain treatment among participants. Some participants assumed that analgesic treatment would be administered if patients were really in pain, and they believed that pain medication might cause children to become addicted to analgesic treatment. For instance, as Bunga and Anyelir stated, they did not always administer pain relief to children although doctors had ordered it. They administered pain medication in accordance with their judgment of the child’s pain.

Bunga revealed: Generally children are always offered analgesic treatment post-operatively. But, after they come to the ward, it is not always administered as ordered by nurses. I usually observe the patient’s condition first and if I judge that they are not in pain, I do not administer pain relief. Thus, pain relief is only given if really necessary, even if the medication is not used at all.

Anyelir’s reason for not administering pain relief was that for a minor operation such as a herniotomy or a hydrocelectomy, pain relief is not needed because the anesthesia is still working. Interestingly, she described her belief by stating: if children are given analgesic treatment continuously, children will bear greater risk for addiction to analgesic treatment, so that they need higher doses. Moreover, I assume that children tolerate pain better than adults. Thus analgesic treatment is administered only if children are really in pain.

Similarly Asri and Mayang described that she administers medication if she thinks that the patient really needs it and if the patient feels very painful. However, if the patient’s pain can be tolerated by using other techniques such as by touching, holding, the pain relief is not given. Thus, the medication is administered if really necessary.

However, Mayang argued that some doctors sometimes do not offer analgesic treatment to the patients post minor operation, they only gave antibiotics. She asserted: As far as I am concerned for minor operations some doctors seldom offered pain relief but they only gave an antibiotic. However, if I know that the patient was in pain, I always report and ask the doctors whether the patient should take analgesic or not. Meanwhile, Tiara argued that she always administer analgesic treatment as written up by doctors in the patients’ notes.

 Barriers to managing pain effectively

All participants noticed that pain management in children on the ward was not yet optimal due to some restrictions such as limited knowledge, in particular the theories of pain, pain assessment, and non-pharmacological approaches. Nurses assumed that their knowledge about theories of pain, pain assessment, pain management and non-pharmacological approaches was lacking. They revealed that although they have learnt about pain theory, it was very little, not in detail and it was never applied to the patients directly. Therefore, they realised that they still needed to learn more about pain and non-pharmacological intervention.

knowledge is a pivotal aspect for nurses in caring for paediatric patients effectively. Further, Dahlia argued that: Nurses on this ward have limited knowledge about theory of pain, pain assessment and management. We have not known yet how to do assessment and pain management using a non-pharmacological approach to the patients correctly.

Similarly, Mayang agreed that generally nurses on the ward have a lack of knowledge about pain assessment and management, especially non-pharmacological interventions.

Other barriers to giving pain relief were lack of resources and facilities. All participants agreed that facilities such as pain scales, toys and music intervention were not available on the ward. Moreover, all nurses assumed that ineffective pain management happened because they have heavy workloads on the ward. For instance, Bunga explained that: Nurses face some restrictions in dealing with children’s pain such as nurses’ workload being too high; nurses must do other activities besides nursing activities, for instance, consult with laboratories, do administration tasks etc, so we do not have enough time to assess children’s pain effectively.

Interestingly, Asri thought that ineffective pain management was influenced by nurses’ views about pain medication, nurses’ attitudes, besides limited knowledge, resources and also limited time for assessing children because nurses must do other activities beside caring for patients. Asri asserted that:

Another factor is that some nurses believe that pain relief is a quick and simple method for managing children’s pain and some nurses just know that medication is a tool for treating pain, also the total number of nurses is insufficient for the number of patients.

Mayang assumed that nurses’ attitude to children’s pain influences ineffective pain management on this ward. She explained that:

…Some nurses are too lazy to do assessment of children experiencing pain because they think that it was time consuming and some nurses on this ward do not know exactly the meaning of pain, they assume that pain occurred due to any hurt

Meanwhile, Tiara argued that nurses have tried to do pain management in children as best as they can. However, Tiara believed that: ‘caring for children in pain needs a special approach’. Further, she revealed: The main problem is that nurses’ workload is too heavy compared to the total number of patients. Another factor is that some nurses assume that they cannot care for the patients properly because they have to do routine activities such as giving injections, bed making and wound care. They thought that they have to do tasks routinely

Nurses’ role in dealing with children experiencing pain

All participants agreed that because nurses are primary care givers and are in close and frequent contact with patients, they have a good understanding of the patient’s condition as well. Thus, nurses have primary responsibility to assess and manage children’s pain. For instance, Mayang explained her opinion by stating that: It is exactly true that a nurse is a person who is really in close and more frequent contact with the patients, and nurses know the patients’ condition well.

Meanwhile, Asri revealed her opinion by asserting that: A nurse is a person who is really close to the patients, and I believe that pain is a patient’s problem, it should be resolved so that it does not interfere with children’s activities.

Results of this study provided a comprehensive picture of nurses’ attitudes, beliefs and perceptions regarding certain aspects of children’s pain and revealed complex factors that influenced nurses’ practices around children’s pain in a general teaching hospital in Bandung. In results of study found some themes related to the following headings: nurses’ views on assessment of pain in children; nurses’ views on pain management in children and nurses’ role in dealing with children experiencing pain.

Nurses’ views on assessment of pain in children

1. Assessing pain in children is difficult because infant and younger children usually crying

An important theme that emerged from this study was the view that assessing pain in children is difficult. Some of the nurse participants explained that pain assessment in younger children and infants was quite difficult because they usually respond to painful procedures only by crying. The results indicated that the nurses could not distinguish between a cry expressing pain and a cry expressing a response to another sensation in infants such as hunger or being wet. These findings are consistent with previous studies (Salantera et al 1999; Jacob & Puntillo 1999; Allcock 1996; Brunier et al 1995) which showed the difficulty of assessing pain in children.

Another reason for the difficulty of assessing pain is because pain perception is complex and pain is highly subjective therefore objective assessment of pain may be difficult. The language and behavioral responses used by pediatric patients to describe their experience may bring a different message from that which is proposed because patients and nurses use language in different ways owing to their experience and perspective (Thomas 1997). Problems with assessment of pain were evident from this study, but this is not be too surprising because other researchers have also highlighted

the difficulty of objectively assessing pain (Zacharias & Watts 1998; Thomas 1997; Carr 1997). Therefore, in order for nurses to be able to assess pain in children, it is important they are more aware of signs and symptoms of pain in infants and young children.

2. The assessment tools for pain in children are too times consuming to use

Another important theme that arose from this study was regarding the assessment tools for pain assessment in children. The results of this study indicated that although the participants knew about several pain scales such as the Facial Analog Scale, Visual Analog Scale and Numeric Scale, these tools were not applied in their clinical practice. These findings also are consistent with earlier studies (Wallace et al 1995; Margolius et al 1995; Clarke et al 1996; Jacob & Puntillo 1999; Salantera et al 1999). Participants in this study said they did not use the assessment tools because they were too times consuming to use, not available on the ward and some nurses did not know how to use them. Another reason was that the nurses believed the child’s facial expression and behaviour response are important and sufficient signals of pain. Findings of this study indicated that some of the nurses had limited knowledge about several valid and reliable tools for measuring children’s pain, such as behavioral scales and the Facial Analog Scale.

3. Children’s facial expressions and behavior responses as indicators of pain

Regarding how nurses went about assessing pain, the findings of this study indicated that children’s behavioral responses, verbal reports, facial expressions and psychological responses were the major criteria frequently used by the nurse

expressions and asked children how the experience felt. An important result of this study is that the nurses rarely considered physiological signs of pain when assessing their patients.

The results of this study are consistent with a previous study (Jones 1989) which found that behavioral signs such as crying, grimacing, and facial expression were commonly noticed as indicators of pain in children. Ideally, the nurses must consider not only children’s behavior but also physiologic signs for example, change in vital signs especially in infants, small children and preverbal children to determine the presence and quantity of children’s pain.

I agree with the view of Atkinson (1996); Stevens (1998); McGrath & Unruh (1987) that because pain is a subjective phenomenon it is difficult to quantify and qualify, and should be assessed by a variety of subjective and objective measurement approaches including self-report, behavioral and physiological indicators. Physiological measurements have been proved useful in acute pain (Soetenga et al 1999). However, the findings of this study indicated that some of the participants seemed to be less concerned about physiological indicators. This might be because they were not familiar with the physiological indicators of pain.

Another important finding of this study was that some of the nurses also asked parents about their children’s pain to obtain information. This is a good approach because involvement of the parents is essential in caring for children with pain; parents may be an important source of information in the assessment of children’s pain, as indicated by McCaffery & Beebe (1994). However, Hamers et al (1994) indicated that parent information about their children’s pain is not always to be trusted and that nurses should check and verify parents’ statements.

Although the nurses in this study tried to assess children’s pain by using behavioral signs, the findings indicated that the nurses had limited knowledge about pain assessment, especially about pain scales and physiological measurements. A lack of knowledge may contribute to an inability to assess patients systematically and may impact negatively on management and treatment of pain. Indeed, accurate assessment of pain is vital if effective pain management is to be achieved. Formal pain assessment tools help in providing effective communication and assessment by avoiding the chance of error or bias (Carr & Mann 2000).

Nurses’ views on pain management in children

3. Pharmacological approaches are usually used first for dealing children’s pain because more effective than non pharmacological approaches

In response to the questions about pain management in children, all the nurse participants asserted that both pharmacological agents and non-pharmacological intervention such as distraction or comfort techniques could reduce pain in children, particularly acute pain, and that these approaches were used to relieve pain in children. However, most of the nurses tended to use pharmacological pain relief first before trying a non-pharmacological approach.

Results of this study indicated that most participants knew about some non-pharmacological interventions. The majority of the nurses had applied non-pharmacological approaches for reducing children’s pain, for example, distraction techniques such as reading books, conversation, comfort measures and relaxation techniques, such as deep breathing exercise. Most of the participants believed that these strategies reduce pain by helping children to forget about their pain.

enhancing adaptive coping behavior (McGrath 1990). The effectiveness of these strategies in reducing pain and distress in children has been investigated and confirmed by several studies (Good et al 2001; Mediani et al 1997; Vessey & Carlson 1996). However, strategies such as music intervention, play therapy, hypnosis and acupuncture were not used in this study due to lack of facilities on the ward. According to some participants, they had tried to use music intervention with postoperative patients when they were involved in a previous study (Mediani et al 1997), which suggests that it effectively reduced intensity of postoperative pain in children. But music therapy was not applied anymore on the ward because facilities were unavailable. The nurses only used other non-pharmacological techniques such as distraction, relaxation and comfort measures to reduce pain.

4. Non-pharmacological interventions were used less often as a nursing intervention because nurses felt more comfortable with using analgesia

Interestingly, this study indicated that some of the nurse participants believed that non-pharmacological actions were not always used on the ward because they were considered time consuming to use, and some nurses believed that pharmacological agents provided simpler and quicker pain relief. The participants stated that some nurses on the ward may feel more confidence when using analgesic medication. These nurses may also have considered that pain in children would not be manageable with non-pharmacological strategies. Similarly, an earlier study (Coffman et al 1997) found that non-pharmacological interventions were used less often as a nursing intervention because nurses felt more comfortable with intravenous analgesics and administered them more frequently. They also indicated that nurses considered that critically ill children would not tolerate non-pharmacological methods.

Although the nurse participants in this study seemed to know a little about non-pharmacological methods and had applied some of these interventions, it was apparent that nurses on the ward might not realise that non-pharmacological modalities are useful for minimising children’s pain. It may be because the nurses on the ward possessed limited knowledge and lacked of interest in non-pharmacological approaches.

Because pain is a multidimensional experience, nursing interventions to deal with children’s pain should include non-pharmacological approaches, because the pharmacological approaches fail to recognise the impact of an individual’s thoughts and feelings about their pain perception (Llewellyn 1997). Therefore, the nurses need to apply non-pharmacological pain management strategies consistently to achieve adequate pain management for pediatric patients.

5. Giving analgesic to children were in pain and stopped when the pain had gone because it might be addictive for the children

Regarding pharmacological approaches, most nurses in this study suggested that they always administered pain relief medication to pediatric patients as written up by the doctors in patient notes, but some of the nurses evaluated the patients’ experience first before giving analgesia. They administered analgesic medication to the patients if they thought they were in pain and really needed it, and stopped administering it when they though the pain had gone. Interestingly, one nurse did not always administer prescribed analgesic treatment to postoperative patients because she believed that it might be addictive for children and that the anesthesia was still working. Thus the findings of this study indicated that there was discrepancy between the pain

Further, this study found that some nurses administered pain medication in accordance with their perceptions of patients’ pain and also that some nurses have misconceptions about analgesic treatment. Therefore, this study revealed a tendency for some nurses in an Indonesian hospital to administer insufficient doses of prescribed medication to children as well as underestimating children’s pain. Further, this study also indicated that inappropriate beliefs about analgesia may influence nurses’ decisions in administering pain relief to paediatric patients. These findings are supported by previous studies (Eland & Anderson 1977; Gadish et al 1988; Ross, Bush & Crummette 1991; Hamilton & Edgar 1992; Clarke et al 1996; Abu-Saad & Hamers 1997; Hamers et al 1998; Jacob & Puntillo 1999; Twycross 2000)

This study suggests that a significant reason for the inconsistent administering of prescribed medications to pediatric patients may be due to the nurses’ lack of understanding and education regarding therapeutic analgesia and causes of addiction and also inappropriate beliefs concerning pain management. Because nurses administer analgesic treatment to the patients, factors such as nurses’ knowledge, beliefs and attitudes may influence their decisions in managing children’s pain and play an important role in the effectiveness of pain relief.

Barriers to managing pain effectively

6. There were no available standardised methods for assessing pain in children and pain protocol on the ward

The participants also reported that some doctors did not always offer pharmacological agents to pediatric patients post operatively. In addition some doctors also have a tendency to undermedicate children’s pain. This may have

happened because there are no available pain protocols in the hospital. This study revealed that it is important to have a pain protocol to assist in decision-making by health care team members on the Pediatric surgical unit. When pain medications are prescribed on a standard basis and are based on pain protocols, nurses would not be hesitant about administering analgesia treatment to patients (Abu-Saad & Hamers 1997). Doctors are responsible for prescribing appropriate analgesic medication (Llewellyn 1997) because offering pharmacological approaches is their authority. Findings of this study indicated that some of the nurses said they often consulted with doctors in order to ensure adequate analgesia. As the child’s advocate nurses should consult with physicians prior to painful procedures in order to ensure adequate analgesia or/and sedation (Jacob & Puntillo 1999; Llewellyn 1997). Nurses’ ability to give appropriate medication will depend on the appropriate prescription of drugs by physicians (Allcock 1996). Nurses have responsibility for evaluating whether or not relief of pain in children is achieved.

7. Nurses have limited knowledge about pain assessment and management

Interestingly, all the nurses stated that pain management on the ward was not optimal yet because there were some restrictions that affected pain management for the pediatric patients on the ward. The main barrier was limited knowledge about the pain mechanisms, assessment and pain management approaches in particular non-pharmacological approaches. Findings of this study found that all the participants recognised their knowledge deficits and lacked confidence about pain assessment and management. It was apparent that the participants had learned very little about pain theories, and they had never been specifically educated about pain management.

1996; Salantera 1999; Twycross 2000) which found that nurses felt that a knowledge deficit was a barrier to providing adequate pain management. This lack of adequate knowledge about pain management is also confirmed by international literature which discusses how this knowledge deficit contributes to inadequate assessment and management of patients’ pain (Bradshaw & Zeanah 1986; Ferrel et al 1993; Zalon 1995; Brunier et al 1995; Field 1996; Mackintosh & Bowles 2000; Twycross 2001).

8. Lack of tools for measuring pain

Another barrier for effective pain management identified in this study was a lack of tools for measuring pain. There were no available standardised methods for assessing pain in children on the ward. Even though many pain assessment tools have been developed for children, none were applied in this clinical setting. This might influence effectiveness of pain relief in children.

Similarly, facilities for music intervention and play therapy were not applied by nurses in this study because they were not available on the ward.

9. There were heavy workloads on the ward

The findings of this study also indicated that nurses’ heavy workload on the ward impacted on pain management. All the nurses felt that they had insufficient time to deal with children’s pain effectively because they had many other pressing tasks such as administration and consultation with laboratories. Interestingly, results of this study indicated that nurses’ attitude to pain relief was another factor that influenced pain management on the Pediatric surgical. There are some nurses on the ward who believed that routine activities such as giving injections and wound care were their main task. It seemed that they were more task oriented than patient oriented. Results

of this study are consistent with a previous study (Woodgate & Kristjanson 1996) which showed that paediatric nurses tended to focus on technical aspects of care rather than assessing paediatric patients. If their work became more patient oriented rather than task oriented, nurses would spent more time with the patient and therefore would be able to assess and manage pain more systematically and adequately (Abu-Saad & Hamers 1997). Thus, the way a ward is organised may affect nurses’ decisions in caring for paediatric patients.

Nurses’ role in dealing with children experiencing pain

10. Nurses have responsibility in dealing with children pain but it seemed to give low priority to administering pain relief to children

The nurses participating in this study can be considered to be quite experienced with an average of 17 years of working experience in health care and 12 years of working experience in paediatric nursing. All participants agreed that as nurses they have a responsibility and an important role in dealing with children’s pain. In addition, nurses are the caregivers who have the most frequent contact with the patients and know the patients’ condition well. However, the findings of this study indicated that the nurses seemed to give low priority to administering pain relief to paediatric patients. There was evidence that some of the Indonesian nurses undermedicated and underestimated paediatric patients’ pain.

This study revealed that a significant reason for the low priority given to analgesia by nurses appears to be their limited knowledge and education about pain mechanism, pain assessment and management and this may influence the nurses’ role in dealing with paediatric patients’ pain. Ideally, nurses as a patient’s advocate, should

management. However, this study revealed that some of the nurses tended to have been insufficiently prepared to take on increased responsibility for dealing with paediatric patients’ pain. Therefore, this study suggests that it would be beneficial to increase nurses’ knowledge and provide higher quality pain education for nurses.

Conclusion

The following ten themes were found by exploring analysis of the data collected in the study:

1. Assessing pain in children is difficult because infant and younger children are usually crying

2. The assessment tools for pain in children are too times consuming to use 3. Pharmacological approaches are usually used first for dealing children’s pain because more effective than non pharmacological approaches

4. Non-pharmacological interventions were used less often as a nursing intervention because nurses felt more comfortable with using analgesia

5. Giving analgesic to children were in pain and stopped when the pain had gone because it might be addictive for the children

6. There were no available standardised methods for assessing pain in children and pain protocol on the ward

7. Nurses have limited knowledge about pain assessment and management 8. Lack of tools for measuring pain

9. There were heavy workloads on the ward

10. Nurses have responsibility in dealing with children pain but it seemed to give low priority to administering pain relief to children

Findings

This study showed that some nurses always administered prescribed analgesics and had applied non-pharmacological interventions such as distraction, relaxation technique and comfort ways for dealing with children’s pain, especially for postoperative pain. However, the results also indicated that pain in children seemed not to be managed optimally. Results of this study showed that even though the majority of nurses believed that non-pharmacological approaches reduce pain in children, unfortunately these strategies were not always used consistently in dealing with children’s pain because they were considered time consuming. In addition, the nurses tended to be more confident when using analgesic drugs because they believed that pharmacological approaches provide simpler and quicker relief of pain.

Similarly, even though the nurses had tried to assess children’s pain and there were appropriate methods for assessing and measuring pain in children, they were not applied in clinical practice. Reasons for this being, nurses felt that pain assessment in children was a difficult task and because of the lack of the assessment tools. This study therefore, suggested that lack of standardised methods for assessing pain in children may influence inadequate pain assessment and management in pediatric patients. Limited education about pain assessment may also contribute to inadequate pain assessment in pediatric patients. Indeed the nurses have a responsibility to ensure whether or not children’s experience of pain should be treated and if relief is achieved. This is especially pertinent as nurses provide twenty-four hour care to the pediatric patients and have frequent contact with patients and know the patients’

This study found that some Indonesian nurses administered pain relief to pediatric patients in accordance with their own perception and judgment of the child’s pain. The nurses administered pain medications only if they assumed that patients were ‘really’ in pain. This highlights the use of personal attitudes, values of the nurses and lack of knowledge about analgesia that may account for the undertreatment of the pediatric patients’ pain. All the nurses realised that their knowledge about pain and its assessment and management was limited and lacked confidence in regard to this. The results showed that limited resources and facilities in the hospital and heavy workloads also may have contributed to ineffective pain management in children. Nurses have a pivotal role in managing children’s pain. It is important that they develop appropriate skills, knowledge and awareness to enable them to fully fulfill their role and function effectively in managing children’s pain, and that adequate pain management can be achieved in clinical practice.

Recommendation Education

1. In-service education programs may be needed to refresh and increase nurses’ knowledge of pain theories, pain assessment and management. In particular in-service education is needed to expand and explain the range of non-pharmacological and complementary interventions that can be used by the nurses. Continuing education should also be provided in clinical practice to improve the nurses’ knowledge of pain assessment and its management. Lastly, pain management knowledge should be implemented in clinical practice. It means that assessing and managing pain in the pediatric patients should be based on theoretical knowledge of pain and its assessment and

management, as unrelieved pain has negative physiological and psychological impacts on children. Most importantly, pain assessment should not only be based on the nurses’ subjective values and beliefs in regard to pain.

Institution

1. The hospital should provide adequate facilities to support effective pain management for patients. For instance, tools for measuring pain, pain relief modalities, such as non-pharmacological interventions, for example, music interventions, play therapies and thermal regulation (heat and cold) should be made available. The hospital should provide a standardise pain measurement tool that will be used in clinical practice, for example, the Faces Scales, the Oucher scale, the Visual Analog Scale, the Numeric Scale or the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS). These pain scales have been proved to be reliable and valid. The nurses would be able to measure children’s pain accurately if they used these assessment tools. In addition, the hospital should also provide a pain relief protocol for clinical practice for the nursing staff to follow.

2. The hospital needs to develop strategies to improve knowledge, skills and attitudes of nurses and other health care professionals regarding pain and its assessment and management. An educational intervention program would be useful to correct misconceptions and inaccurate knowledge related to pain management for all health care teams involved in pain management. A pain management program would assist to improve health care services and to achieve effective pain management pediatric patients.

Future research

1. Specific recommendations for future research would be to repeat this study other paediatric nursing wards with different patients and nurse populations. Further research is needed involving paediatric patients and parents to explore their perceptions of the effectiveness of pain assessment and management of pain in children, and to identify other factors that contribute to inadequate pain management in children.

2. In addition, further research is needed in observing nursing practice to gain an exact picture of the patients’ and nurses’ experience regarding assessment and management of pain. This research would allow assured conclusions about pain management on the ward.

3. Pain is a complex issue and there are multidimensional problems that should be considered from a variety of perspectives. All health care professionals play an important role in managing children’s pain. Optimal pain management requires an interdisciplinary approach (Clarke et al 1996). It would be beneficial to encourage physicians, as well as other health care providers to conduct similar research about the beliefs, knowledge, attitudes and practices regarding pain in children in clinical practice. This would be useful to achieve adequate pain management of pediatric patients’ pain. Moreover, pain management begins and ends with the nurse acting as a patient’s advocate, through constant assessment and reflection on the pediatric patient’s pain. Assisted by a hospital pain protocol, education and hospital policy, nurses can bring about effective pain management in pediatric patients.

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Jacob, E & Puntillo, K. A. 1999 (B), ‘A survey of nursing practice in the assessment and management of pain in children’, Pediatric Nursing, vol. 25, no. 3, pp. 278-286. Kotzer, A. M. 2000, ‘Factors predicting postoperative pain in children and adolescents following spine fusion’, Issues in Comprehensive Pediatric Nursing, vol. 23, no. 2, pp. 83-102.

LaFleur, C. J. & Raway, B. 1999, ‘School-age child and adolescent perception of the pain intensity associated with three word descriptors’, Pediatric Nursing, vol. 25, no. 1, pp. 45-55.

LoBiondo-Wood, G. & Haber, J. 1994, Nursing research: methods, critical appraisal, and utilization, 3rd edn, Mosby, St Louis.

McCaffery, M. & Beebe, A. 1994, Pain clinical manual for nursing practice, Mosby, London.

McCaffery, M. & Beebe, A. 1989, Pain - Clinical manual for nursing practice, C.V. Mosby Company, Boston, MA.

McCaffery, M. & Pasero, C. 1999, Pain clinical manual, 2nd edn Mosby Company, St Louis, pp. 4-98.

McGrath, P.A. 1990, Pain in children: Nature, assessment and treatment, The Guilford Press, New York.

McGrath, P. J. & Unruh, A. M. 1994, ‘Measurement and assessment of paediatric pain’, in Textbook of Pain 3rd edn. eds, P. D. Wall & R. Melzack, Churchill Livingstone, Edinburg, pp. 303-312.

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