Why aren’t clinical guidelines used in practice?

The next EBN TWITTER journal chat will take place on Wednesday 25th June 8-9 pm (UK time) and focus on why clinical guidelines aren’t used in practice focusing on children’s pain management.

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Nurses and other health care professionals have an ethical and professional duty to ensure pain in children is recognised and managed effectively. Effective pain managing is the responsibility of the inter-disciplinary team; having 24 hour contact with children in hospital, nurses often assume the overall responsibility for the management of a child’s pain. Yet, despite advances in our understanding of pain management in children, from assessment, safe and effective use of analgesia in children, and evaluating children’s experiences research findings highlight on-going inconsistencies and inadequate pain management in children.Misconceptions about pain and pain management in children, professional socialisation and deep-rooted organisational cultures remain (1).

Why aren’t clinical guidelines used in practice?

Clinical guidelines are recommendations on the appropriate treatment and care of people with specific diseases and conditions. Clinical guidelines are based on the best available evidence and are designed to make it easier to ensure that evidence based care is provided. The first clinical guidelines relating to pain management were published in the early 1990s but despite this children are still experiencing moderate to severe pain post-operatively (2, 3) and current guidelines are not always adhered to in practice (4, 5). Why is this the case when the evidence to guide practice is readily available in the form of clinical guidelines (e.g. (6-8))? One reason may be the quality of clinical guidelines. A recent review of paediatric clinical guidelines for acute procedural pain concluded that many of them were of average quality (9). Other factors postulated as contributing to sub-optimal practices relate to health care professionals, patients (children and parents), and the organisation (10).

Factors relating to health care professionals

Factors relating to health care professionals include out-dated or inadequate attitudes and knowledge. Evidence that some pain is expected (and accepted) during hospitalisation has been found (11-14). Further, pain management may be seen as synonymous with administering analgesic drugs (4, 11, 15, 16). Pain management may not be given as much priority as other aspects of a nurse’s role (11, 17-19). There is also evidence that the importance nurses attribute to pain management tasks does not reflect the likelihood of the task being undertaken in practice (20) as well as variability in nurses’ aims when managing post-operative pain (13). Gaps have been found in nurses’ knowledge about paediatric pain in relation to: pain assessment (21, 22); analgesic drugs (15, 19, 21-25); pharmacology (21, 22, 24, 25); non-pharmacological methods (15, 19, 23, 25); physiology of pain (15) and the psychology and sociology of pain (15). Research indicates that similar gaps are found among medical staff (26, 27).

Although clinical guidelines are clear in relation to best practice, insufficient theoretical knowledge may not be enough in itself to explain variations in practice. Different forms of knowledge and expertise may shape different professional practices, in varying clinical contexts. It has been suggested tacit knowledge may play an important part in clinician’s approaches to treatment. The current emphasis on evidence-based practice has provoked debate around the role of tacit knowledge in clinical practice (28, 29). The distinction between explicit and tacit knowledge refers to the difference between knowing what and knowing how (30). Explicit knowledge is codified, abstracted and can be transferred through formalised means such as texts, whereas tacit knowledge arises through experience and is personal and contextual as well difficult to make explicit (31). Drawing on this distinction between tacit and explicit knowledge, and their role in shaping clinical practice, may prove valuable in attempting to explain why clinical guidelines are not consistently implemented.

Factors relating to parents and children

Parents are seen by many nurses to be reluctant for their children to receive pain medications (19, 32-34). A lack of cooperation between parents and nurses has also been described (32, 33, 35). Children’s behaviour is seen as a barrier to managing pain effectively; nurses sometimes feel their behaviour did not indicate that the child was in pain (32, 35). A child having a diagnosis suggesting they may be in pain may facilitate optimal pain management (35) while the child’s age is sometimes a barrier particularly for children unable to communicate verbally with the nurses (33, 35). Children were also seen as reluctant to report or rate their pain as well as being unwilling to take analgesic drugs (19, 34).

Factors relating to the organisation

Over the past decade there has been a growing awareness that a unit (ward) has a set of informal rules that determine how pain is managed. This was demonstrated by the results of an ethnographic study on two (adult) units in one hospital in the USA (36). Participants described a clear but different pattern of pain assessment on each ward. The social context of the ward appeared to influence practices. Further, in one Canadian study, paediatric nurses described the unit’s pain management culture as giving pain medications regularly even if they are prescribed prn; this appeared to be the factor that impacted most on practice (4). Another study exploring neonatal pain management also found organisational context affected practices (37).

A key organisational factor that influences pain management practices is the relationship between medical and nursing staff. This was clearly described in Van Niekerk and Martin’s (2003) study where (adult) nurses who did not feel adequately consulted by medical staff were significantly more likely to report encountering barriers such as insufficient cooperation and inadequate prescription of analgesic medications(38). Similar findings about a lack of co-operation between nurses and medical staff have been found in paediatrics(19).

 Summary

There appear to be many reasons why clinical guidelines are not used consistently in practice. Further research is needed to identify strategies that support the use of this evidence in practice.

Questions for consideration:

  • What factors do you think contribute to clinical guidelines not being used in practice?
  • Do you implement all aspects of pain management guidelines in your practice? If not – why not?
  • Current clinical guidelines state that pain assessment tools should be used but research suggests this does not happen consistently. Why is this?
  • When managing a child’s post-operative pain what is your aim?
  • Do you feel you have gaps in knowledge about managing pain in children? If so what are these gaps?
  • What strategies can we use to improve the use of clinical guideline recommendations in practice?
  • Why does research continually highlight that children perceive there pain is not managed well, and their views are not listened to?
  • What skills are required by nurses to effectively manage pain in a child who is in pain?

Alison Twycross

Head of Department for Children’s Nursing and Reader in Children’s Pain Management,

London South Bank University

 Editor: Evidence Based Nursing  

Join in the blog discussion @EBNursingBMJ

Tweet me: @alitwy

 

References

  1. Twycross A. Managing pain in children: Where to from here? Journal of Clinical Nursing. 2010;19(15-16):2090–9.
  2. Kozlowski LJ, Kost-Byerley S, Colantouni E, Thompson CB, Vasquenza KJ, Rothman SK, et al.Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Management Nursing. 2014;15(1):22-35.
  3. Twycross A, Finley GA. Children’s and parents’ perceptions of postoperative pain management: A mixed methods study. Journal of Clinical Nursing. 2013;22(21-22):3095–108.
  4. Twycross A, Finley GA, Latimer M. Pediatric Nurses’ Postoperative Pain Management Practices: An Observational Study. Journal for Specialists in Pediatric Nursing. 2013;18(3):189-201.
  5. Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, et al.Pain assessment and intensity in hospitalized children in Canada. The Journal of Pain. 2012;13(9):857-65.
  6. Royal College of Nursing. The recognition and assessment of acute pain in children – Recommendations: Revised. London: RCN Publishing; 2009.
  7. Association of Paediatric Anaesthetists. Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Pediatric Anesthesia. 2012;22(S1):1-81.
  8. American Academy of Pediatrics, American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793-7.
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