Back to square one? Pain management in children

Jackie Vasey, Senior Lecturer Children’s Nursing, University of Huddersfield

Effective pain management is a human right and health professionals have a responsibility to ensure that all children receive effective pain management (Twycross & Williams, in; Twycross, Dowden & Stinson, 2014). However, evidence suggests that effective pain management is lacking, with children continuing to experience moderate to severe pain (Twycross and Finlay, 2013). A recent incident when working as an agency nurse highlights the stagnant nature of pain management. Prior to embarking on a career in education 8 years ago, previous roles included a children’s pain nurse and a practice development nurse with a passion for children’s pain care. Along with other nurses and colleagues across health professions, I implemented a range of pain management strategies improving outcomes for children and their families. I naively assumed that pain management in children had continued to develop; after all there is an abundance of evidence promoting effective pain management. The incident involved a young person I was caring for who required a minor but potentially painful procedure. In my absence and despite initiating a pain management plan, the procedure proceeded without analgesia. The nurses involved in the procedure stated that the doctors perceived that analgesia was not necessary. On discussing the procedure with the young person, the young person stated that it ‘made his toes curl’. While the incident was reported and dealt with effectively by the manager, it highlighted a continued outdated tradition of doctors making paternalistic decisions and nurses not challenging those decisions when they are not in the best interests of the child. Nurses are required to be advocates for their patients (Nursing and Midwifery Council, 2008) and having 24 hour contact with children and their families and are best placed to ensure effective pain management.

There are a number of factors that may have influenced this incident occurring such as workload pressures, lack of perceived importance and prioritisation of pain management, lack of education or absence of practice development in relation to pain management. The incident occurred in a district general hospital where children’s services are often marginalised as ‘small fish in a big pond’, impacting on how services and roles are configured. There also appears to be remnants of a hierarchal system whereby nurses feel unable to challenge poor practice. The question remains, whose court is the pain management ball in? In the vision for nursing, nurses are being encouraged to consider the 6 c’s in their practice (Cummings, 2012). Perhaps pain management could be further improved if nurses had more compassion for children experiencing pain and the resulting distress if not managed effectively. Nurses need courage to speak up on behalf of the child when pain management is not meeting their needs, the competence to drive practice forward and care about managing pain. Nurses must communicate effectively in order to be an advocate for children and their families and have a commitment to ensuring that when health professionals perform painful procedures on children (as in this incident) that we take responsibility for minimising the effects. However, the support of a leader with a specific role to promote effective pain management is essential to ensure pain management at the forefront of nurse’s work. The challenge is having a recognised role to support the ongoing development of pain management practices, empowering nurses to promote effective pain management, and ensure nurses take individual responsibility for the children they are caring for and that pain care is an integral and essential aspect of the care.

Lack of effective pain care should perhaps not have been a surprise as feedback from child nursing students suggests that effective pain management continues to be challenging in clinical areas. My research interests relate to children’s pain management, and specifically parental involvement. One of the reasons that I decided to explore parental involvement in pain management of children, was the plethora of research about children’s pain management. I assumed that this would continue to be translated into practice and therefore, there was less need to add further evidence to the current mass of studies. Preliminary findings from my research indicate that nurses do not always involve parents in their child’s pain care. Perhaps, this is partly related to nurse’s lack of confidence in promoting effective pain care for the reasons illustrated in this incident.

What are your thoughts about the progress of children’s pain care?

Are practice development/children’s pain nurses essential to progress pain care, or should nurses be self-directive in ensuring pain care is effective?

Is education enough?

References

Cummings, J. (2012) Compassion in practice. NHS England. http://www.england.nhs.uk/nursingvision/

Nursing and Midwifery Council (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC

Twycross, A,. & Williams, A. (2014) Why managing pain in children matters. in Twycross, A,. Dowden, S,. & Stinson, J. (2014) Managing pain in children. Oxford: Wiley Blackwell

Twycross, A. & Finley, G.A. (2013) Children’s and parent’s perceptions of post-operative pain management: a mixed methods study. Journal of Clinical Nursing. 22: 3095- 3108. DOI: 10.1111/jocn.12152

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