a young child's pain: how parents and nurses ‘take care’

Pergamon ht. J. Nurs. Stud., Vol. 33, No. 3, pp. 271-284, 1996

Copyright 1;; 1996 Elsevier Saence Ltd. All rights reserved Printed in Great Britain

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A young child’s pain: how parents and nurses ‘take care’

ROBERTA WOODGATE,* R.N., M.N., Ph.D. Candidate Children’s Hospital, Health Sciences Centre, 840 Sherbrook Street, Winnipeg, Manitoba R3A lS1, Canada

LINDA J. KRISTJANSON, R.N., Ph.D. Faculty ?f‘Nursing. University of Manitoba, Winnipeg, Manitoba, Canada

Abstract-A qualitative study was undertaken to describe how parents and nurses respond to hospitalized young children experiencing pain from surgical interventions. Participant observation was used to identify care behaviours and the care context within which the children experienced, and caregivers witnessed, post-operative pain. Interviews with parents, nurses, and children were also conducted during the observation periods and prior to discharge to augment the observational data. Care provided by parents included comfort measures and vigilant monitoring of the children’s pain. Nurses primarily provided technical care, used limited pain assessment approaches, and were not able to adequately alleviate the children’s pain. Factors, strategies, and feelings associated with these care behaviours are described. The most salient recommendations arising from these findings are that nurses: (a) be provided with education about pain assessment and management, and (b) be empowered by policies that allow them to sensitively and effectively respond to children in pain. Copyright 0 1996 Elsevier Science Ltd.

Introduction

Research focusing on childhood pain has received considerable attention within the last decade. Areas of interest include the development of assessment tools (Beyer and Aradine,

*To whom all correspondence should be addressed: tel.: 204-787-2079; fax: 204-787-4807.

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272 R. WOODGATE and L. J. KRISTJANSON

1986, 1987, 1988) analgesic administration (Beyer et al., 1983; Schechter et al., 1986), and children’s interpretations of pain experiences (Alex and Ritchie, 1992; Ely, 1992; Gaffney and Dunne, 1986; Ross and Ross, 1984). Descriptions and explorations of the context in which pain is experienced by children, however, have not received much attention. More specifically, the affect of approaches by parents and other caregivers on children’s pain experiences has not been described.

Studies to date, are primarily retrospective chart audits and surveys that identify the type and amount of medication administered. It is well documented that children are prescribed less pain medication by physicians and receive less medication from nurses than do adult patients (Beyer et al., 1983; Burokas, 1985; Eland and Anderson, 1977; Schechter et al.,

1986). This is particulary notable in post-operative situations. Although there are accounts of children being too afraid to confide in their nurse about

their pain (Eland and Anderson, 1977; Eland, 1985; Mather and Mackie, 1983), minimal attention has been directed towards staff-child interactions. Similarly there are only a few studies which directly examine measures used by nurses or parents to help children deal with pain during painful or intrusive events (Caty et al., 1989; Davis and Calhoon, 1989; Savedra, 1981).

Crook (1985) has postulated that the communicative nature of pain must be considered in relationship to the two primary systems with which the individual comes in contact- the family and health professionals. Therefore, the need for a deeper understanding of this interaction becomes apparent. Expressions of pain symbolize a need for help (Szasz, 1975). Studies of how parents and nurses respond to children in acute pain are warranted.

A qualitative study was undertaken to examine how children experience pain. More specifically, the study aimed to describe children’s responses to pain and investigate the effect of others in the care environment on children’s pain experiences. An outcome of the study was a model describing the young child’s pain experience, reported elsewhere (Woodgate and Kristjanson, 1995). This paper reports in more detail, one major category of the model, how parents and nurses ‘take care’. Components of this category include descriptions of care behaviours and strategies used by parents and nurses in response to the children’s pain experiences, factors influencing parents’ and nurses’ caring behaviours, and feelings experienced by parents and nurses.

Method

Design

The qualitative method of grounded theory was used to study hospitalized young children and their primary caregivers during a 6 month period. This approach was most suited to the study’s purpose, considering the complex, subjective nature of phenomenon. Moreover, a qualitative design facilitated the examination and description of the processes by which parents and nursing staff respond to children in pain (Glaser and Strauss, 1967; Strauss and Corbin, 1990).

Participants

Participants were selected through a theoretical purposive sampling technique. This sampling approach is recommended in qualitative studies to increase the probability of describing the full extent of the phenomenon (Lincoln and Guba, 1985). The concern is

CHILDREN’S POST-OPERATIVE PAIN 213

with the representativeness of emerging themes and concepts (Lincoln and Guba, 1985; Strauss and Corbin, 1990).

Children who took part in this study experienced pain in response to surgical intervention (i.e. plastic, cardiac, and urologic surgery) and were cared for on one of the two paediatric surgical units. Eleven children ranging from 2 to 6 years of age participated. The average length of hospital stay for the children was 6 days. Although surgical intervention was a new experience for most of the children, all had some previous encounter with hospitals (e.g. medical or emergency admissions and outpatient testing).

The surgical units were based on a U-shaped design with patients’ rooms situated outside all along the ‘II’. The patients’ rooms either had single- or double-bed occupancy. Treatment and supply rooms were located inside the ‘U’. The nurses’ desk was located at the bend of the U-shape. The children diagnosed as the most unstable or those with the most extensive surgery were placed in rooms closest to and facing the nurses’ desk. This included children undergoing abdominal or chest surgery. Children requiring surgery to their limbs or face were usually placed in rooms closer to the end of the hallway. Although the nurses strived to meet the needs of all the children, it was sometimes observed that children located in the end rooms were not being checked as frequently as those located in rooms nearer the desk. These children sometimes waited longer to have their pain assessed and managed especially considering the fact that the medication room was located at the nurses’ desk.

Each child had both of their parents visit during their hospitalization. A total of 22 parents took part in the study. Usually one parent stayed with his or her child during most of the hospitalization. In most instances, mothers were the primary caregivers and their reactions and interactions with their children accounted for a good portion of the observation data. However, for two of the children, fathers were more frequently observed than mothers. All parents were married except for one couple who was divorced. All but one parent were Caucasian. Only three of the parents had previous experience with their child’s recovery from surgery.

Nursing staff referred to nurses and nursing assistants. A total of 24 nursing personnel participated: 15 Diploma-prepared Registered Nurses, seven Licensed Practical Nurses, two Baccalaureate-prepared Registered Nurses, and one nurse’s aide. All were females and except for one, all were Caucasian. All nursing staff participants had more than 5 years experience of caring for paediatric patients. All but two identified surgical nursing as their area of expertise.

Data collection

Data collection took place on two surgical units of a university-affiliated children’s hospital in Central Canada. The primary means of data collection involved participant observation. This method optimizes the researcher’s ability to understand motives, beliefs, unconscious behaviours, and customs (Lincoln and Guba, 1985). Children were observed from the immediate post-operative period until their discharge day. Their responses to pain and how caregivers (i.e. parents and nursing staff) reacted to them were noted. To capture the most detailed descriptions of the children’s pain experiences, a variety of care events were observed (e.g. bathing, changing a dressing, ambulating a child) at various time periods (i.e. day and evening shifts). Observation periods lasted from 2 to 8 hours daily. The number of observation hours totalled approximately 250 for all 11 children.

Data were recorded in detailed field notes at the time the observations were made or as


close as possible to the time of the observed event. Approximately 25 hours of observation time was spent with each child over a period of approximately 4-7 days, During this time period, children’s pain experiences varied in length of time from 5 hours to as much as 25 hours of intermittent pain. In some instances the pain severity was intense and brief (e.g. bladder spasms). For other children the pain experienced was less severe, but more continuous (e.g. post-operative incision discomfort). During observations periods notes were kept brief and then were elaborated on in detail by the data collector immediately following the observation period (within 1-8 hours of observation).

Informal interviews with children, nursing staff, and parents during the observation periods took place to extend the observational data and to clarify meanings the subjects themselves attributed to the situation. For the parents and nursing staff, the questions focused on three areas: (a) interpreting what the children’s behaviours implied; (b) considering what factors contributed to the behaviours; and (c) inquiring about the parents’ and nursing staffs behaviours. For the children, the focus was on whether or not they were in pain and what they felt helped to take away the pain.

In addition, formal open-ended interviews of the children and parents were conducted near discharge day to further validate the data collector’s observations. Parents and children were asked to describe the pain experiences and factors that influenced the experiences. The open-ended technique allowed the researcher to focus on areas deemed significant by the participants or not anticipated by the researcher. Examples of questions for the parents’ interviews included “what do you think helps to take away your child’s pain?“. Examples of questions for the children’s interviews included “tell me what helped to take away the hurt”. All interviews and field notes were transcribed verbatim and checked for accuracy.

Although younger children have limited cognitive and linguistic abilities, their thoughts and feelings can still be uncovered by applying research methods that are understood by them (Kotzer, 1990). Therefore, the children’s interviews were combined with play (i.e. the children played with hospital equipment and dolls while the data collector asked questions). Play has been described as an excellent medium for young children to communicate their perspectives because play helps them to assimilate, comprehend, and master their experiences (Deatrick and Faux, 1989). The data collector also used simple words, sentences and concrete facts compatible with the young child’s level of cognitive development.

Information was also gathered from the child’s hospital record related to demographic factors, procedures performed, type and amount of analgesic prescribed and administered, and notes specific to the children’s pain experiences.

Data analysis

Field notes and interview transcripts were analyzed utilizing the constant comparative method (Glaser and Strauss, 1967). Data was simultaneously coded and analyzed as it was collected. The coding process involved writing a phrase/statement that captured the meaning of the units of information. A unit of information could be a word, phrase, paragraph or description of an incident. Comparisons were made among units of analysis and similar events and incidents were labelled and grouped to form categories. As categories surfaced, each category was then compared with other categories and units of information for each subject and between subjects. The use of analytic memos representing the written form of the researchers’ abstract thoughts about the data, codes, and categories was ongoing. When no new information emerged data collection and analysis were considered complete. All


categories were independently reviewed by three researchers with expertise in qualitative analysis to confirm the organization and relationships of the derived properties and categories. For a categorization to be validated all reviewers were required to agree. Analysis of themes that did not meet this criterion were re-examined and re-classified until consensus was achieved.

Descriptive measures were also applied to summarize and describe the data from the children’s records (i.e. demographics and analgesic administration), and involved measures of central tendency and frequency distributions.

Establishing trustworthiness

In assessing the rigour of the study, Lincoln and Guba’s (1985) criteria for establishing trustworthiness were used (i.e. verifying credibility, transferability, dependability, and con- firmability). Triangulation of research methods, persistent observation, memoing, and continuous validation of data sought from subjects helped to increase the trustworthiness of the findings. To increase the study’s consistency, only one person collected and recorded data (Lincoln and Guba, 1985).

A major threat to the truth value of a qualitative study lies in the closeness of the researcher-subject relationship (Sandelowski, 1986; Miles and Huberman, 1984). Specifi- cally, there was the potential of the researcher or data collector becoming so enmeshed with subjects that she would not have been able to distinguish her own experiences from those of the subjects. A reflexive journal was maintained to help verify that the findings were a condition of the participants and not the data collector’s biases (Lincoln and Guba, 1985).

Participant observation research may create ‘reactive effects’ which are defined as artificial conditions imposed on respondents by virtue of the data collector’s presence (Deatrick and Faux, 1989). To help decrease this effect on the subjects interactions, prolonged engagement in the field (6 months) occurred.

Findings

‘How parents and nurses take care’ was the major category that emerged describing how parents and nurses responded to and cared for children in pain due to surgical interventions. Subcategories also emerged and relate to the strategies and factors influencing parents’ and nurses’ care behaviours as well as feelings experienced by parents and nurses as they coped with the children’s pain.

How parents and nurses ‘take care’

A specific examination of the parents’ actions revealed that the parents played a pivotal role in the children’s care. Parents were the bridge between nurses and children, especially during periods of severe pain. Besides actually performing most of the children’s basic care such as bathing and feeding, two other principal categories of care were identified: monitoring and comforting. Although monitoring and comforting were observed throughout hospitalization, these care practices were especially necessary when children were in pain. In contrast to care practices of parents, nurses focused on carrying out technical aspects of the children’s care. A closer examination of these care practices is described below.

Monitoring. Monitoring referred to supervising the children’s pain experience and hos-


pitalization in general. This included observing for signs of pain as well as ensuring that some action was taken to relieve the pain. Parents were always alert to signs of pain and would respond immediately to any movement or noted change in their children. They often were the ones to initiate the process of obtaining an analgesic for their child. As one parent commented, “I just watch closely and when the time for the pain killer comes I run and ask...“. This statement illustrated how vigilantly most parents monitored their children’s pain. For one parent, monitoring the child’s care was perceived to be essential because she believed that her child would not be cared for at all if she was not there to supervise his care.

Comforting. Comforting activities referred to those behaviours associated with providing both physical and psychological support to the children. These included assisting children with their activities, holding or rubbing a body part, talking to children in a comforting and reassuring tone, and distracting the child from pain with activities such as reading. Of all activities, just being with the child was perceived by parents to be the most important activity they performed. Children also stated that their parent’s presence was the major care practice useful in relieving the pain.

Carrying out technical care activities. Examples of these activities included changing dressings or monitoring intravenous machines. Comforting children was not a major activity for the nursing staff. In fact, some nurses assumed it was the parents’ duty to calm or soothe children and when parents were unable to do so, the parents were negatively evaluated by the nurses. This was reflected by one nurse’s comment: “the mother did not seem to help, she could not get him to settle down”. When dealing with the children’s pain, non- pharmacological nursing measures such as teaching the child relaxation techniques were rarely used by the nurses. Instead, providing analgesic medication was the most frequent practice carried out by nursing staff. Although nurses gave more narcotics than non- narcotics, often at intervals of every 3-4 hours during the first 48 hours post-operatively, this pain relief practice was not adequate for many of the children. Often children experienced pain within 2 hours of receiving their last medication.

An associated observation was the finding that after administering analgesia, nurses frequently did not reassess the patient’s pain to determine if the medication was effective. When nurses did reassess the child’s pain, they often did not revise the pain treatment plan if analgesia was found to be ineffective, therefore the children’s pain experience continued.

Strategies used to help care for children in pain

Knowing. Both parents and nurses expressed possessing a certain knowledge related to the children and their pain experiences was what helped them to respond to the children in pain. For parents, this specifically related to knowing how their child’s pain was to be managed. “Just knowing what was going on”, as described by one parent, was important to them. However, most parents had limited knowledge with respect to analgesia (i.e. what type and how often it should be given). Many of the parents were surprised to learn that their child would receive a narcotic.

Knowing when the children were experiencing pain was also important to how parents cared. Parents’ knowledge of their child’s pain was influenced by their past experiences in caring for their child in pain. Except for three families, surgical intervention was a new


experience and parents had more difficulties assessing and responding to the children’s pain. It was a “whole different ball game” as one of the parents described it. Parents who had not seen their children in pain before, reported difficulties knowing how to interpret their child’s behaviour.

Indicators of pain identified most often by parents included: facial expressions indicating pain, change in personality or mood, rubbing or pointing to a painful body area, and crying or verbal expressions of pain. Knowing the circumstances related to the child’s behaviour was beneficial and was often included in the parents’ descriptions of the children’s pain experiences (e.g. time of day, the child’s level of activity, and what was being done to the child). Some parents reported that they “just knew” their child was in pain. This knowledge appeared to be based on an intuitive type of understanding or a familiarity with their child that made specific articulation of behavioural cues unnecessary.

Although all parents were able to identify signs of pain, they also expressed difficulties either with this hospitalization or with past hospitalizations because they felt they were not always able to ascertain the presence of pain. Some parents reported that their child showed no signs of pain, or as they described, it “was hard to figure out”, or “it wasn’t always clear-cut”. Even parents who felt relatively secure in identifying pain still expressed difficulty describing their perceptions.

For nurses, ‘knowing the child’ in general as opposed to knowing when the child was in pain, was a theme consistently identified by nurses as being significant to their pain assessment and management approaches. When questioned about a child’s level of pain, nurses would frequently respond with the following comments “I don’t know, I don’t know him or her, I haven’t taken care of him or her, or I haven’t seen Tommy (pseudonym) that much”.

When nurses were asked how they could tell the child was in pain, they usually had great difficulty articulating this assessment. Their responses were usually brief-usually no more than three cues given by each nurse. There were often periods of silence when nurses were questioned. Indicators of pain varied between the nursing staff members, but crying or other forms of verbal behaviours were the most frequent responses noted by nurses. The second most frequent pain response identified by nurses was overt forms of non-verbal behaviours such as fighting or restlessness. The only physiological cue identified by nurses was a change in vital signs. Also, like parents, nurses often did not recognize quietness as a sign of pain. When these quiet children were asked by the data collector to rate their pain they would describe it as “very bad”. Unlike parents, nurses rarely relied on children’s facial expressions or on changes in their mood.

Nurses frequently referred to how children in general responded to pain, and seldom referred to the child that they were caring for when asked to indicate pain cues. The uniqueness of each child’s behaviour was not emphasized by nurses. Although knowing the children was identified to be important to nursing staff, nurses reported knowing few children. The consequence of not knowing the child resulted in some nurses being unaware of the child’s pain or particulars about a child’s care (e.g. what position children favoured).

The quality and quantity of time nursing staff spent with the children seemed to effect the nursing staffs knowledge of the child. It was common for a nurse to walk in to a child’s room for a few minutes when the child appeared comfortable, and then as the nurse left, the child would show signs of pain. Nurses would frequently miss SOme of the most painful periods experienced by the children further delaying analgesic administration, For example, children who experienced severe pain from bladder spasms following urologic surgery were


often not observed at the peak of their painful experiences. The spasms were intermittent and therefore, when the nurses spent brief periods in the children’s rooms they often missed observing pain in the children caused by the spasms.

Factors affecting parents’ and nurses’ caring

Parents’ and nurses’ abilities to perform pain relief actions were influenced by their value judgements, misconceptions, and expectations toward the children’s pain experiences and hospitalization, as well as their interactions with each other.

Value judgements. Many value judgements guided the parents’ and nursing staffs reason- ing and actions. Children were judged by parents and nurses as either ‘good’ or ‘bad’. For parents, they perceived their child to be ‘good’ if the child was able to cope with the pain and would view the ‘good’ child as having to tolerate more pain compared to other children. Not only did the parents at times expect the children to experience some degree of uncontrolled pain, at least half of the parents expressed the belief that dealing with the pain was partly the child’s responsibility. Many parents described their hospitalized child as stoic in comparison to their other children, and expected that the ill child could tolerate more pain and cope with the pain better than other children. This expectation was often reported by parents when they also believed that children in pain are more overt in their responses to pain.

For nurses, ‘good’ children were those who were quiet or did not complain. Nurses deemed certain behaviours as desirable and others as undesirable. The more overt the children’s behaviours were, the more likely nurses would perceive these children as hysteri- cal, whining, or miserable. Although some nurses associated these behaviours with pain, there were others who related overt expressions of pain to the child’s personality. Some nurses even reported that ‘whiny’ children were sometimes ‘acting’ and they blamed parents for the child’s overt expressions of pain. The ‘noisy’ children or the children who had parents who intervened frequently received more pain medication compared to the quiet children or children with passive parents.

There was a perceived hierarchy of suffering identified based on the child’s diagnosis. Children who had undergone abdominal or chest surgery received more narcotics than children who had surgery to face or limb. Children who were identified as being more ill or who had more visible injuries, were also expected to experience more pain than children whose injuries were not as visible or extensive. The type of pain the children experienced also affected how parents and nurses responded. Nursing staff concentrated more on the children’s incision pain. Any other types of pain not associated with the incision pain (e.g. treatment-related), were not perceived with the same degree of seriousness by nursing staff even though most children rated all their pains as ‘bad. One nurse even referred to all pains other than the incision pain as “unusual pain”.

Parents concentrated on distinguishing pain from discomfort. Parents would sometimes describe their child as experiencing “discomfort” as opposed to pain. Although not clearly differentiated, discomfort was considered by some parents to be an “inconvenience type of pain”, not “real pain”. Parents who labelled their child’s pain as discomfort would not always request that their child be given an analgesic.

For both parents and nursing staff the duration of time the child was in pain as opposed to intensity, was often perceived to be most important. For example, one parent stated that


“my child was in bad pain, but at least it didn’t last too long”. Many other symptomatic states experienced by the children received more attention than pain symptoms. For example, treating a fever was given priority over managing pain. Nurses would not hesitate to give acetaminophen around the clock for a fever, yet not for pain. Nurses would sometimes become so concerned or engrossed with one symptomatic state (e.g. emesis), that they would ignore or not acknowledge other conditions.

Misconceptions. Both parents and nurses held misconceptions about safe use of analgesics. Although all parents believed analgesia was necessary for their child, they only wanted enough medication to relieve the pain without making their child too drowsy. As one parent put it, “only if it warrants it”. The parents assumed or expected a certain degree of recovery daily. To some parents this meant that their child would require less medication.

Fear of addiction or “becoming too strung out” was a concern of some nurses. Although acknowledging the importance of controlling pain with analgesics, one nurse also admitted that “it just takes one bad incident with a medication” to cause an individual to hesitate in administering certain analgesics.

Expectations. Both parents’ and nursing staffs expectations with respect to pain relief were minimal. Although most parents believed that the nurses would “try their best” to relieve the children’s pain, they still anticipated that the children would have “to put up with some pain”. Some of the parents also expected the nurses to inflict more pain than they would relieve because administration of painful procedures was assumed to be part of the nurses’ role. One parent who had past experience with hospitals even suggested that if it was up to the nurses, “they would sooner not give any pain medication at all”. Except for giving pain medications, parents initially also had minimal expectations with respect to the type of pain-relief and comfort measures nurses could initiate. They only expected the nurse to give pain medications to the children.

Parents’ expectations, however, changed near the end of hospitalization. Their expectations were higher, more detailed, and specific. This included: giving analgesics more frequently (especially prior to bedtime), providing more information about analgesics and non-pharmacological pain relief measures, allowing for more rest periods, and providing more physical and psychological support to children and parents during painful periods. Parents reported that they wished the nurses had inquired more frequently about their child’s level of pain. Some stated that nurses should take pain in children more seriously and not make hurtful comments such as referring to children as “typical” or “role playing”.

Nurses’ past experiences with pain relief measures greatly affected how they responded to the children. If, in the past the nurse did not have much success with a particular pain relief measure, she would often not attempt using it with other children. “I’ve tried it, it doesn’t work” was a common response. It appeared that nurses expected a certain level of uncontrolled pain or that nurses did not expect that they could relieve all the children’s pain. This was especially evident with pain associated with bladder spasms experienced after a particular urologic surgery (i.e. ureteral re-implantation). Although nurses perceived this type of surgery as ‘miserable’ and expressed frustration about managing the spasms, they did not attempt other approaches to manage this type of pain. The prevalent attitude among nurses was that not much could be done. One nurse reported that the only thing that could be done was to be honest with parents and tell them about the spasms in advance.

Nurses also expected that pain medications would be reduced daily, even if the children’s


pain had not subsided. The majority of medications were given by the second or third post- operative day. Nurses were more intent on managing the moderate to severe pain post- operatively within the first 48 hours, and appeared less concerned about managing sub- sequent mild to moderate pain. More medications were given during evenings and days, with fewer medications given at night, even when children experienced restless sleep.

Interactions. Another factor affecting the nurses’ and parents’ ability to care for children was the level of communication between parents and nurses with respect to the children’s pain experiences. There was minimal dialogue between nurses and parents about how to manage the children’s pain. Discussion focused on whether or not the children were hurting and when they last received an analgesic. Such things as the quality and intensity of the pain, pain behaviours, and types of medications were rarely discussed. This lack of communication sometimes resulted in parents incorrectly assuming an analgesic had been administered. Discourse among nursing staff with respect to the children’s pain experiences was also minimal. Information such as how much pain medication children received within the last 12 hours was not always known by nurses coming on duty. Adjectives such as ‘fine’ or ‘good’ were often used by nurses to indicate that generally, children were stable or not in any distress. The children’s level of pain was not always part of the nurses’ verbal reports. Charting was especially limited and except for the medication record, there were no plans recorded with respect to managing pain. Nurses more frequently relied on parents to tell them if the child was in pain, but did not always probe and directly ask the child or confer with other nurses. Many nurses stated that they believed the parents would say something or tell the nurse if their child was in pain.

Parents also expressed a concern which they phrased as “not wanting to cause any trouble”. Parents would ask politely for medications, but rarely asserted themselves when medications were not forthcoming and infrequently asked for help for their children. An example of this involved one mother whose child had been admitted more than five times to the same unit. The mother never informed the nursing staff that the analgesic routinely prescribed for her child rarely was effective. Parents wanted to avoid bothering nurses. They did not want to be seen as a ‘nuisance’. Feeling comfortable with nurses was important to them. In addition, most parents seemed to have great trust in the nurses indicated by the following comments: “I know they (i.e. nurses) will try to do everything they can” or “they know what is best”. There was also a tendency for parents to make excuses for staff when they were not available (e.g. “it is a busy day”). Parents generally reported that their child received ‘good’ care even though many children experienced periods of uncontrolled pain.

Just as parents did not want to disturb the system, nurses too, were careful not to disrupt relationships. Although many nursing staff believed that some of the children could have received more pain medication, they made excuses for their nursing and medical colleagues and rarely challenged their actions.

Feelings experienced by parents and nurses in caring for children in pain

Feelings of helplessness were experienced by most parents. Although parents accepted the role of primary caregiver during hospitalization, many still expressed frustration in not knowing how to do things without hurting their child (e.g. lifting or moving them). There were instances when parents had indeed caused pain in their child due to a lack of knowledge. Even the more independent parents stated that they needed more help or support


especially when the parents experienced fatigue. Parents also expressed a need to be told more about how to handle their child’s pain at home. Nurses often expressed feelings of helplessness and frustration in managing pain that was difficult to control. “I think..., I don’t know but, I guess..., what do you think”, were comments expressed by nurses when dealing with the pain. Awareness of how often a drug could be given, the types of routes, and new management regimes such as patient-controlled analgesia, were not always known by nursing staff. Nurses also reported difficulties trying to secure changes in analgesic orders, which they stated limited their abilities to relieve the children’s pain. A sense of powerlessness or hopelessness was expressed by nurses when they could not obtain the medical orders that they believed were necessary for adequate pain relief. Typical responses expressed by nurses included: “it will not do any good to ask, I hope you are there to see their response” or “no, this is how Dr.-likes it, this is what he prefers” or “there is nothing that can be done”. One nurse reported an incident that involved a young child with a ruptured appendix who required intravenous morphine, but due to the insistence of the physician, it took 3 days before the required order was written. The nurse recalled this incident with anger, expressing frustration with the lack of control nurses had over pain management approaches.

Feelings of guilt and sadness were also expressed by parents. Although most parents rationalized their child’s pain by stressing that the surgery was necessary, parents never- theless questioned if they had done the right thing in consenting to the surgical procedure. Most parents stated that the pain their child suffered was more than what most people experience in a lifetime and they hoped their child would never have to go through this again.

Discussion

Observations of care given to children indicated that there were definite differences between the duties performed by nurses and parents. Although research has revealed that comforting hospitalized children is one part of the parent’s role (Algren, 1985; Caty et al., 1989) monitoring children’s pain has not been previously identified. One suspects that because parents stayed with their child most of the time, it was assumed by nurses that monitoring the child’s pain was the parents’ role, and that parents would notify the nurses if there was a problem.

The findings are consistent with research that has shown the use of non-pharmacological interventions by paediatric nurses to be limited (Bradshaw and Zeanah, 1986; Burokas, 1985; Gadish et al., 1988). Although there are many descriptions of such strategies in the literature (Campos, 1988; Eland, 1985; Hunsberger et al., 1984; McCaffery, 1990) it seems that nurses make limited use of such treatments.

In contrast to prior reports (Gadish et al., 1988), nurses in this study were more likely to administer a narcotic rather than a non-narcotic. However, all the children still experienced pain indicating that the analgesic treatments were insufficient and post-operative pain was poorly controlled. These findings are consistent with other reported research studies that have documented substandard management of pain in paediatric patients (Beyer et al., 1983; Mather and Mackie, 1983). A major factor contributing to inadequate pain management may have been the fact that nurses rarely reassessed the effectiveness of their actions; it was as if they assumed giving an analgesic would guarantee pain relief.

The finding that suggested pain control was not a priority is consistent with previous


research examining nurses’ management of pain in hospitalized patients (Burokas, 1985; Fagerhaugh and Strauss, 1977; Strauss et al., 1979). Fagerhaugh and colleagues (Fag- erhaugh et al., 1987) attributes this lack of priority for pain control to the fact that expanding, complex therapeutic tasks compete with nurses’ comfort work and result in nurses delegating comfort tasks to other personnel. Brown (1992) believes nurses have become so absorbed with the technical side of nursing that more nurturing aspects are neglected.

Knowing the children was significant to how parents and nurses responded to the children’s pain. Those individuals who relied on many indicators of pain (verbal, non- verbal) were more confident and accurate in their assessments, supporting the notion that a multidimensional approach to pain assessment is useful (McCaffery and Beebe, 1989).

Misconceptions and the lack of knowledge about pain assessment and management experienced by both parents and nursing staff greatly contributed to feelings of helplessness. However, even though parents and nurses both lacked certain information, they did not always communicate this deficit to one another. Communication about pain assessment and management was in general, limited and supports other research findings that suggest both verbal and written communication between patients, families, and nurses is lacking (Bradshaw and Zeanah, 1986; Camp and O’Sullivan, 1987).

Morse (1992) found that limited nurse-patient interaction reduced the chance for nego- tiations related to patient care. Wuest and Stern (1990) also reported that the extent to which families learn the rules in a hospital setting also determines their ability to negotiate. Parents in this study may have had a limited understanding of the rules, preventing them from negotiating more effectively for pain relief for their children. Parents in this study rarely complained openly about the children’s pain management. Strauss and colleagues (Strauss et al., 1979) also revealed that an important aspect of pain work was balancing of priorities which involved making choices between alternative options based on what is deemed more or less important. For parents, perhaps settling for uncontrolled pain at times was necessary to ensure that the their child received continuing care and was not negatively labelled by staff.

Implications and recommendations for practice

Even though there has been an increase in paediatric pain research within the last decade, findings from this study indicate that nurses still know little about paediatric pain control. Further research is needed to assess if these findings are reflective of current practice in other settings. These findings point to the need for increased curriculum content related to paediatric pain in nursing education. As well, measures that empower nurses to respond attentively and appropriately to the child’s pain are needed. For example, hospitals that use a pain management protocol that allows nurses a range of dosages and routes of analgesic administration has been shown to result in more effective pain relief for patients than do hospitals without this type of protocol (Cherny, 1993). Actions such as updating guidelines for paediatric pain management and establishing a paediatric pain team to guide management of paediatric pain would be valuable. Regular patient rounds should be held to allow health personnel to discuss complex pain cases.

Parents too, need to be provided with more information on managing pain. A pamphlet or booklet on childhood pain for families addressing types of pain, misconceptions, medi-


cations, and measures parents could utilize to help relieve their child’s pain would be helpful.

Recommendations for research

Further examination of how parents and nurses manage children’s pain is needed. This includes examining: (1) how comfort work is integrated by nurses into the daily care; (2) how paediatric nurses make care decisions related to pain management; and (3) how parents care for their child in pain at home. Research to identify barriers that prevent nurses from knowing or comforting children in pain is warranted.

Acknowledgements-This study was supported in part by a University of Manitoba Fellowship and a Manitoba Association of Registered Nurses Graduate Bursary to the first author and funding from the Manitoba Health Research Council to the second author. The advice and consultation of Drs Erna Schilder and John Matthiasson are gratefully acknowledged. A special thanks to the children, parents, and nurses who participated in the study.

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(Received 16 February 1995; acceptedforpublication 4 September 1995)

a young child's pain: how parents and nurses ‘take care’

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