Why is pain still not managed effectively?

Due to unforeseen circumstances this week’s Twitter Chat focusing on the care of people with learning disabilities has had be postponed. Watch this space for details of its rescheduled date. Given this I am taking the opportunity to report on some of my reflections while at the World Congress on Pain.

Along with several thousand other people I am currently at the World Congress on Pain in Buenos Aires, Argentina. One of the things I have been reflecting on whilst here is why, if so many people are interested in pain, patients are still experiencing moderate to severe unrelieved pain. We know what we should be doing but this knowledge doesn’t seem to be used in practice. For example, for paediatric acute and postoperative pain there are clinical guidelines available (Association of Paediatric Anaesthetists 2012) yet we know that children continue to experience moderate to severe pain in hospital postoperatively (Kozlowski et al. 2014, Stevens et al. 2012, Twycross et al. 2013).

The workshop I am involved in tomorrow explores this in relation to acute pain for children in hospital. My paper reports on a systematic review that explored nurses’ postoperative pain management practices over the past 20 years. The results of the systematic review revealed some improvements. For example, there is some use of self-report tools and opioids are administered more often. However, these practices are not consistent. There is still a lot of room for improvement. Many of the papers included in the systematic review were chart audits. This means much of what we know is based on documented practices rather than what actually happens in the clinical setting. Three observational papers did provide a greater understanding of current practices (Byrne et al. 2001, Shrestha-Ranjit & Manias 2010, Twycross 2007).

One of the key things that needs exploring is the reasons suboptimal practice continues and which strategies are most effective at changing practice. I am presenting a second paper on behalf of an ex-PhD student (Dr Anna Williams) that looks at nurses’ conceptualisations of children’s pain. This paper draws on sociological principles to help us understand nurses’ thinking about different types of pain (routine pain; pain versus fear; complex pain). The management of a child’s pain seems to depend on how nurses conceptualise the pain. Professor Bonnie Stevens from Toronto Sick Kids Hospital and the University of Toronto is presenting a paper reporting on the success of knowledge translation strategies in changing practices in hospitals across Canada. Some of the preliminary results have already been published (Stevens et al. 2014).

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 (Lauzon Clabo 2008). 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 (Twycross et al. 2013). Another study exploring neonatal pain management also found organisational context affected practices (Stevens et al. 2011).

We perhaps also need to explore the reasons why clinical guidelines aren’t used in practice. One reason may be the quality of some guidelines. A recent review of paediatric clinical guidelines for acute procedural pain concluded that many of them were of average quality (Lee et al. 2014). However, just having a good quality guideline does not mean it will be implemented in practice. In Lee et al.’s review the vaccination guideline (Taddio et al. 2010) scored the best for quality, yet is still not being using in practice.

The current emphasis on evidence-based practice has provoked debate around the role of tacit knowledge in clinical practice (Gabbay & LeMay 2004, Thornton 2006). The distinction between explicit and tacit knowledge refers to the difference between knowing what and knowing how (Polanyi 1966). 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 (Greenhalgh et al. 2008). Clinicians in multidisciplinary teams have been shown to draw on tacit knowledge in their use and interpretation of standardised outcome measures, adjusting patient scores in accordance with their tacit knowledge of individual patients (Greenhalgh et al. 2008). In pain assessment, the impact of clinical judgement and tacit knowledge has begun to be addressed in work that suggests a self report score is only one factor health care professionals consider when deciding how much pain children are in (Voepel-Lewis et al. 2012). Additional research is needed to explore if and how tacit knowledge impacts on pain assessment practices and how this impacts on the quality of pain management practices.

Dr Alison Twycross

Head of Department and Reader in Children’s Pain Management

Department of Children’s Nursing

London South Bank University

Email: a.twycross@lsbu.ac.uk



Association of Paediatric Anaesthetists (2012): Good Practice in Postoperative and Procedural Pain Management, 2nd edition. Pediatric Anesthesia 22, 1-79.

Byrne A, Morton J & Salmon P (2001): Defending against patients’ pain: A qualitative analysis if nurses’ responses to children’s postoperative pain. Journal of Psychosomatic Research 50, 69-76.

Gabbay J & LeMay A (2004): Evidence based guidelines or collectively constructed ‘mindlines?’. Ethnographic study of knowledge management in primary care. British Medical Journal 329, 1013.

Greenhalgh J, Flynn R, Long AF & Tyson S (2008): Tacit and encoded knowledge in the use of standardised outcome measures in multidisciplinary team decision making: A case study of in-patient neurorehabilitation. Social Science and Medicine 67, 183-194.

Kozlowski LJ, Kost-Byerley S, Colantuoni E, Thompson CB, Vasquenza KJ, Rothman SK, Billett C, White ED, Yaster M & Monitto CL (2014): Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Management Nursing 15, 22-35.

Lauzon Clabo LM (2008): An ethnography of pain assessment and the role of social context on two postoperative units. Journal of Advanced Nursing 61, 531-539.

Lee GT, Yamada J, O B, K.,, Shorkey A & Stevens B (2014): Pediatric Clinical Practice Guidelines for Acute Procedural Pain: A Systematic Review. Pediatrics Online early.

Polanyi M (1966) The Tacit Dimension, 3rd edition edn. Routledge & Kegan Paul, London.

Shrestha-Ranjit JM & Manias E (2010): Pain assessment and management practices in children following surgery of the lower limb. Journal of Clinical Nursing 19, 118-128.

Stevens B, Riahi S, Cardoso R, Ballantyne M, Yamada J, Beyene J, Breau L, Carnfield C, Finley GA, Franck L, Gibbins S, Howlett A, McGrath PJ, McKeever P, O’Brien K & Ohlsson A (2011): The influence of context on pain practices in NICU: Perceptions of health care professionals. Qualitative Health Research 21, 757-770.

Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, Stinson J, Le May S & Pain. atCTiCs (2012): Pain assessment and intensity in hospitalized children in Canada. The Journal of Pain 13, 857-865.

Stevens BJ, Yamada J, Estabrooks CA, Stinson J, Campbell F, Scott SD, Cummings EA & CIHR Team in Children’s Pain (2014): Pain in hospitalized childre: Effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes. Pain 155, 60-68.

Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp. M., Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Riddell RP, Rieder M, Scott J & Shah V (2010): Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. Canadian Medical Association Journal 182, E843-855.

Thornton T (2006): Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement. Philosophy, Ethics, and Humanities in Medicine 17, 1.

Twycross A (2007): Children’s nurses’ post-operative pain management practices: An observational study. International Journal of Nursing Studies 44, 869-881.

Twycross A, Finley GA & Latimer M (2013): Pediatric Nurses’ Postoperative Pain Management Practices: An Observational Study. Journal for Specialists in Pediatric Nursing 18, 189-201.

Voepel-Lewis T, Piscotty RJ, Annis A & Kalisch B (2012): Empirical Review Supporting the Application of the “Pain Assessment as a Social Transaction” Model in Pediatrics. Journal of Pain and Symptom Management 44, 446-457.

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