An illustration of a child holding their stomach, seemingly in pain.An illustration of a child holding their stomach, seemingly in pain.Every child experiences pain. But pain is too often silenced and appropriate relief not given frequently enough. So what has been done to improve the management of children’s pain?Although the figures above are surprisingly high there has been a significant amount of work carried out in an attempt to reduce the prevalence of pain. Some examples are two well-evidenced guidelines developed by the Royal College of Nursing (2009) and the Association of Paediatric Anaesthetists (2012) developed to guide how pain management should be delivered to children in hospital in the UK. Despite these well-developed guidelines children’s pain prevalence remains high. Good communication, effective information sharing and clarity about roles can all positively influence the effectiveness of pain management as well as health care practitioners (HCPs) taking a proactive stance on the relief of children’s pain. However, nurses may not take as active a role as they could do in managing children’s pain, seeing it as the parents and child’s responsibility to inform them when they are experiencing pain (Twycross 2013). 1.1 Way forwardHaving looked at the size of the problem and some of the contributory factors of ineffective pain management, let’s look at some ways forward. A study by Vasey et al (2019) which included parents (n=41), children (n=30) and nurses (n=11) found that the involvement of parents can improve the child’s pain experience, as well as reduce parental anxiety and increase parents’ satisfaction in care. Nurses in the study had good intentions to involve parents in pain management, but in practice did not always do so. This finding is supported by other studies that found even when parents attempt to be involved and advocate for their child’s pain care, a lack of communication and information provision and poor negotiation of roles can result in missed opportunities for nurses to work in partnership with parents (Vasey et al 2019; Carter et al 2017; 2016).In a recent publication Chabot and Ferlanda (2020) who reviewed 10 studies on children’s pain found nurses need to provide parents with more information such as analgesia use. Parents are keen to be involved in their child’s pain management and have been found to use pain relief strategies when nurses share them (Chng et al 2015; Lim et al 2012). However, when their child is in pain parents either hesitate or delay in asking for help from nurses (Valizadeh 2016) but to date there is little evidence of nurses proactively engaging parents in managing their children’s pain whilst in hospital. There is no apparent explanation for this lack of engagement in the literature. Although a study by Twycross (2013) found that nurses may not take as active a role as they could do in managing children’s pain, seeing it as the parents and child’s responsibility to inform them when they are experiencing pain.
Figure 2: A way forward
An illustration of a person having a phone conversation with a medical practitioner.An illustration of a person having a phone conversation with a medical practitioner.One obstacle for some parents, in approaching a nurse, is the belief that they are too busy already, or that they know their child is in pain and there is nothing that can be done about it. Parents may not know how to ask for more pain relief, and may need some support and guidance, even encouragement, to do so The need for better communication and information to enable parents to effectively participate in managing their child’s post-operative pain, have been identified by Zhu et al (2018) as necessary to involve parents in the management of their child’s pain. Where parents (and children) are given information on pain management, studies have shown that this results in satisfaction with care (Twycross and Finlay 2013).1.2 A pain management frameworkAn international study by Simons (2015) of 28 practitioners in the UK, Sweden and Australia explored innovations in pain management practice. The findings identified five key elements that contributed to the delivery of effective pain management to children in hospital, these being:distributed pain management with visioneffective pain management with less stresspain management delivered with confidenceindividual approach to child and parentraising parents’ expectations of effective pain management.Having identified these key elements for the delivery of effective pain management, a further study by Simons et al (2020) explored their relevance and practical application with UK based pain practitioners (n=43). The result of this multistage work is a central focus of this short course.The 43 practitioners included Band 5 nurses, Advanced Nurse Practitioners (ANP), pain nurses and pain consultants working in the NHS. The findings demonstrated that the following elements were considered to be important: delivering pain management with confidence, supporting colleagues with protocols and guidance, adopting an individual approach to a child and family, and empowering parents to be involved in pain management.These elements form the basis of a framework for children’s pain management, as illustrated in Figure 3. Each quadrant in Figure 3 is linked with the next but not necessarily a prerequisite of the subsequent quadrant. The four sections contribute to the effective management of children’s pain in hospital. You will explore the framework in more detail in Section 2 and 3 of this course.
Figure 3: Framework for delivering effective pain management
An illustrated diagram focusing on effective leadership and pain management.A diagram with Effective leadership titled at the top. In the centre, there is the label: Effective pain management, and there are four sections surrounding the centre. From the top right, there are two boxes: Supporting staff with relevant practice guidance.Use evidence-based pain management protocols & guidance & tailor these as appropriate.Then below this, bottom right, there are two boxes:Adopting an individual approach to child and family.Generate individual plans that consider experience, needs & situation of each child & family.To the left of this, bottom left, there are two boxes:Empowering parents to be effectively involved.Communicate effectively & encourage parental participation in pain management.Above this, top left, there are two boxes:Creating knowledgeable and confident practitioners.Provide regular education & training to build confidence & reduce stress from induction onwards.Having stated earlier that there are guidelines that have been well researched and carefully developed it is important to ask: How can the framework above bring about change? The framework has a number of interconnected elements that focus on supporting health care staff, helping them become confident, adopting an individual approach to children and families, and empowering parents to become more actively involved in their child’s pain management All of these processes are dependent on effective leadership and robust education. You may ask what difference will the framework make? It is intended to make children’s experience of pain in hospital better, and it is therefore aligned with The Lancet Child and Adolescent Health Commission (Ecclestone et al 2020) on delivering transformative action in paediatric pain, which has four transformative goals: Make pain matter; make pain understood; make pain visible; make pain better. Addressing these goals ‘will improve the lives of children and adolescents with pain and their families’ (Ecclestone et al 2020:1).2 Creating knowledgeable and confident practitioners<?oxy_delete author="sm36828" timestamp="20220314T122920+0000" content=" and supporting staff to access and use relevant practice guidance"?>In this section you will explore the first two sections of the framework; creating knowledgeable and confident practitioners and supporting staff to access and use relevant practice guidelines.
Figure 4: Section 1 of the Framework: Creating knowledgeable and confident practitioners
There are two boxes, from right to left:Creating knowledgeable and confident practitioners.Provide regular education & training to build confidence & reduce stress from induction onwards.Experiencing pain can be stressful, especially as a child, and this is compounded if the pain is not relieved and the child doesn’t know or understand the reasons for the pain persisting. One of the key elements of effective pain management was that when pain was managed well, stress was reduced. The first element of the pain framework focuses on the reduction of stress and the need for health care practitioners to be knowledgeable and confident in managing children’s pain. 2.1 <?oxy_delete author="sm36828" timestamp="20220314T123006+0000" content="M"?><?oxy_insert_start author="sm36828" timestamp="20220314T123006+0000"?>The stress of m<?oxy_insert_end?>anaging children’s painManaging children’s pain can be stressful for children, parents and practitioners. In a study with 43 HCPs the following was reported. Click through the boxes and read the findings. Alternatively, click ‘toggle plain view’ or ‘long description’ for a more accessible version.
Figure 5 (interactive): Pain relief or caring for a child in pain
A click and reveal diagram with the following text:Feeling helplessBeing asked for pain relief or caring for a child in pain, and not be able to relieve that pain, could lead to issues negatively affecting their relationship with parents: ‘Parents lose confidence if their child is left in pain.’Losing confidenceHaving a parent lose confidence in the nurse caring for their child was reported as stressful for nurses: ‘Staff get stressed when they look powerless in front of patients and relatives.’Feeling frustratedFrustration was also expressed in stating that there was: ‘No time to spend time with the child and families. No time to listen.’Proposing solutionsOn the other hand a potential solution was suggested as: ‘Being there, being approachable.’ This is an interesting finding which hints that practitioners are not always approachable, which would deter parents calling on them to help manage their child’s pain.Being informedMost participants talked of the importance of keeping children and their families informed, as this could help mitigate stress for parents and children related to pain management: ‘discussing with the families ahead of a painful episode and letting them know what to expect … people available … people assessing the pain management, and … make adjustments if required.’2.2 Alleviating stress for practitionersHaving identified that pain management could involve stress, practitioners also identified aspects of practice that could help alleviate stress with the intention of increasing practitioners’ confidence. This finding fits well with previous work on the positive impact confidence has on pain management, with confident nurses giving more analgesia to children in pain. Figures 6 and 7 shows some findings. Click through the circles and read the findings. Alternatively, click ‘toggle plain view’ or ‘long description’ for a more accessible version.
Figure 6 (interactive): Confidence
The interactive figure shows five circles that each contain information. From top-right, going clockwise:‘there’s a tendency to under-dose, and as I say it is a confidence issue’, ‘giving less paracetamol.’ Some practitioners reflected on sub-optimal analgesic prescribing and dosage for children due to a lack of confidence.‘in terms of morphine, people are still very, can be very cautious with it.’ Some practitioners reflected on sub-optimal analgesic prescribing and dosage for children due to a lack of confidence.‘the more you do it the more confident you get.’ Participants reported the factors that can influence practitioner confidence, such as experience.‘the experience, the education, device training as well.’ Participants reported the factors that can influence practitioner confidence, such as experience. This was a key factor.‘You can’t be confident with your pain delivery unless you’ve had the training to know that what you’re doing is right.’ Participants reported the factors that can influence practitioner confidence, such as experience. This is another point to note.
Figure 7 (interactive): Building confidence
The interactive figure shows five circles that each contain information. From top-right, going clockwise:‘knowing the norm’ Practitioners shared their views of what engendered confidence such as knowledge and experience.‘readily, easily accessible’ Practitioners shared their views of what engendered confidence such as knowledge and experience.‘clear easy to understand guidelines and protocols’ Practitioners shared their views of what engendered confidence such as knowledge and experience.‘use of language and their demeanour … on patients’ Participants talked of the need for confident delivery to be underpinned by good communication and for colleagues to understand the impact of their behaviour. This suggestion relates closely to the earlier suggestion of being approachable to parents as a factor that would help reduce stress, calling for an element of self-awareness for practitioners, being cognisant of the impact of their behaviour on parents.‘need to have confidence in the nurse’, ‘the basic package … doesn’t fit’ The impact of practitioners behaviour was reported as: Families ‘need to have confidence in the nurse’ and this confidence could also be facilitated by working with the support of the pain team’s expertise when ‘the basic package … doesn’t fit’2.3 Supporting staff<?oxy_delete author="sm36828" timestamp="20220314T123131+0000" content=" with relevant guidance and protocols"?>The second section of the framework focuses on supporting staff with relevant guidance and protocols and builds on the first section by aiming to reduce stress and increase confidence. Managing children’s pain can be complex and HCPs need support to be able to do so effectively. There was also the suggestion that improving access to protocols, dosing guidance, as well as training at induction would help to reduce stress. Protocols are well researched, and quality assured evidenced based guidance on specific aspects of care, one example being a protocol for the management of pain post tonsillectomy. The ANPs noted that support was available to help with the stress of pain management: ‘support of the pain team, alongside protocols and procedures, result in less stress and an increase in confidence’.Practitioners have recognised the complexity of pain and in particular certain painful situations that have been challenging. Examples are the pain post tonsillectomy, or acute sickle cell crisis. Both situations have had numerous studies undertaken to devise a regime in response the acute pain experience (Gostian et al 2020; Persino et al 2017) and academics have undertaken systematic reviews to identify the best approach to deliver effective pain management. Hospital trusts have clinical procedure guidelines that are used in-house to interpret and apply such guidance locally.
Figure 8: Section 2 of the Framework: Supporting staff with relevant practice guidance
There are two boxes, with the following text, from left to right: Supporting staff with relevant practice guidance.Use evidence-based pain management protocols & guidance & tailor these as appropriate.Some participants called for additional in-service education on children’s pain, as seen in the findings from other research (Alotaibi et al 2019).Stress could also be reduced if effective interventions were available for every individual child and being able to: ‘provide the right answers or the best answers that you can, or the best care and practice and alter things to reduce that stress’.Activity 1: Effective pain management10 minutesWatch this short video that explains the framework. Whilst you are watching it, you will see that there are four areas all of which link together to provide effective pain management.While watching the video, consider the following questions and make some notes in the text box. These notes can only be accessed by you and you can refer back to these at any time (as long as you have enrolled on the course and have saved your response). Do you agree with the elements of the pain framework? What would need to happen where you work for all elements to be present in the management of children’s pain?
Video 1: Paediatric pain Wellchild
NarratorWhen children are in hospital, managing any pain they experience is essential, but it’s not always done effectively. Many parents leaving hospital report that their child experienced a lot of pain during their stay. But they also feel positive about the care they received, which means something isn’t working.Following extensive research with pain specialists across the UK and internationally, we’ve developed a framework for delivering effective pain management for children. There are four components.The first is creating knowledgeable, confident practitioners. Many nurses can feel nervous about giving too much pain medicine. And when nurses are not feeling confident, they may administer less than what’s being prescribed to be on the safe side.The second element is the support given to those staff. Making sure they have access to relevant protocols ensures that they rely less on their own judgement and more on proven best practice. Pain protocols with well-evidenced guidelines for predictable scenarios are usually created by dedicated teams after a lot of hard work. But when the whole hospital implements them, they are shown to make effective pain management easier to achieve.Thirdly, nurses need to involve parents and treat them as partners. After all, they have unique expertise when it comes to their child. But parents are often reluctant to point out that their child’s pain is not going away. So they need to be encouraged to speak up. Practitioners want to help. But if they don’t know a child is in pain, they can’t do anything about it.Lastly, it’s important to take an individual approach to both the child and their family. Talking and listening to each child and finding out about their experience, understanding, fears, likes, and dislikes makes it more likely that their pain can be managed effectively.To be effective, all four components need to happen with everyone at all levels playing their part. If all practitioners start using this framework together, it can contribute to managing children’s pain a lot more effectively.[MUSIC PLAYING]3 Adopting an individual approach<?oxy_delete author="sm36828" timestamp="20220314T123247+0000" content=" to child and family"?>To deliver effective pain management to a child there is a need to recognise their individuality, which in turn warrants an individual approach to addressing how to relieve their pain. Many studies have focussed on this approach. Tailored or individualised pain management for children needs to encompass tailored analgesic medication (Lundeberg 2015) as well as non-pharmacological approaches, and managing anxiety and pain (Gai et al 2020; Fortier and Kain 2015).
Figure 9: Section 3 of the Framework: Adopting an individual approach to child and family
There are two boxes, with the following text, from left to right:Adopting an individual approach to child and family.Generate individual plans that consider experience, needs & situation of each child & family.When asked about taking individual approach to a child and family in relation to managing a child’s pain HCPs reported that: ‘everyone’s different, every family is different and every social circumstance is different’.Most practitioners agreed that an individual approach was an important aspect of managing children’s pain, acknowledging that: ‘it should be paramount in all aspects of care, but certainly within pain management’.You will remember that in section two we covered the need to provide guidance and protocols to support effective pain management. But as one size doesn’t fit all, such an approach could be deemed to be the opposite of managing a child’s pain through an individualised approach. However, practitioners who were asked about individualised care were clear that this should not be the case.It was reported that even when working with a protocol, ‘tailoring it to that child or family’ was important, meaning that flexibility was important: ‘We won’t rigidly stick with a regime just because that’s the regime that we do for X. So, I think we’re quite flexible.’This level of flexibility being reported here may come with experience, as these responses came from pain specialist practitioners. A pain nurse stated the following: ‘we have a plan there. But within the plan there could be plan A, B and C depending on the individual child’. Participants talked of the importance of both ‘involving them (child and family) in the conversations at the bedside’ and treating the ‘family as a whole, making sure that they have plenty of information so that they know what to expect’.3.1 Parent leafletAn obvious place to start in providing evidence-based care to a child and family is with the child’s parent, by enquiring from them how their child has dealt with pain in the past and using that information to manage a child’s pain.
Figure 10: Parent leaflet
An illustration of hands holding a leaflet and the exclamation mark (!) above. An illustration of hands holding a leaflet and the exclamation mark (!) above. We designed a leaflet to be used by parents if their child is in pain in hospital after surgery. The leaflet has space for a parent to record how their child usually responds to pain, what words they use for pain, as well as what usually helps when their child is in pain.It also explains to parents what health care professionals find helpful to know about their child and how they respond to pain, therefore providing parents with insight as to how to link what they know about their child, with what health care professionals need to know, to help to provide individualised care. The second page of the leaflet goes on to ask a parent to record how much pain their child is experiencing, and how satisfied they are with the pain care. You can access the parent leaflet here: Helping your child with pain.Activity 2: Parent leaflet15 minutesRead the parent leaflet: Helping your child with pain and answer the following questions in the text box below. What are the key messages being conveyed to parents?How would you introduce the leaflet to a parent to explain its purpose and encourage them to use it?List statements you would make?What use could you make of this leaflet in practice?4 Empowering parents<?oxy_delete author="sm36828" timestamp="20220314T123259+0000" content=" to be effectively involved in the management of their child’s pain"?>The fourth section of the framework focuses on empowering parents to be effectively involved in the management of their child’s pain by encouraging their participation.
Figure 11: Section 4 of the Framework: Empowering parents to be effectively involved
Two boxes, with the following text, from right to left:Empowering parents to be effectively involved.Communicate effectively & encourage parental participation in pain management.Earlier we learned that parents want to be involved in helping to alleviate their child’s pain, but are not sure how to go about it. Twenty years ago parents who were asked if they were involved in their child’s pain care said they heard what was discussed about their child’s pain management, suggesting that their involvement was passive (Simons et al 2001). However, more recently it was reported that when parents’ expectations were raised, pain management practice on the part of nurses improved (Simons 2015).Activity 3: Parents expectations15 minutesHow would you explain this finding?How do you think the raising of parents expectations had a positive impact on nurses pain management practice?Make a note of what you think the explanation could be.This finding came from interviews with health care practitioners in Sweden who found that when parents became more confident in approaching the nurses when their child was experiencing pain, nurses responded by being more responsive to parents and this change in practice improved the management of children’s pain.The pain leaflet you have just looked at attempts to facilitate parents feeling more confident to approach nurses when their child is experiencing pain.Sharing information with parents as well as valuing their knowledge of their child and communicating in an equal partnership can establish parents’ and nurses’ expectations of parent involvement in the management of their child’s pain.A lack of communication, information provision and poor negotiation of roles can result in missed opportunities for nurses to work in partnership with parents (Vasey et al 2019). Sometimes information provision can be inconsistent, resulting in parents having sufficient information about some aspects (e.g., the surgical procedure) but not others (e.g., pain medication) (Gai et al 2020). Although some participants were cautious about raising parents’ expectations, most talked of this as a key element to effective pain management. The skill lies in how practitioners engage and communicate with parents and the information they share with them. One obstacle for some parents in approaching a nurse is the belief that the nurse is too busy already, or that they know their child is in pain and there is nothing that can be done about it. Also, parents may not know how to ask for more pain relief, and may need some support and guidance, even encouragement, to do so.Preparation and information giving to parents were identified as key components. As with other studies (Zhu et al 2018), we identified the need for better communication and information to enable parents to effectively participate in managing their child’s post-operative pain. Where parents (and children) are given information on pain management, studies have shown that this results in satisfaction with care (Twycross and Finley 2013) and parents have been found to be satisfied with their child’s care, even when they report that their child experienced pain. (Twycross and Finley 2013). This seeming contradiction has been explained by parents having low expectations of their child’s pain being managed well, and therefore reporting that they were satisfied with the care, even though their child had pain.Clearly, empowerment can only really be achieved with consistent and high-quality information that supports parents’ expectations of good care and gives them the confidence to complain about poor pain management (Twycross 2013: Sutters et al 2007). Paradoxically, research has found that strategies to improve pain management and encouraging greater engagement from parents can result in more complaints from parents (Simons 2015); this may be the outcome of parents being more informed, confident and having higher expectations of what can be achieved. Empowering parents makes considerable sense, as they are their child’s most consistent caregivers, and therefore an obvious source of personalized knowledge to assist in identifying and implementing strategies to optimize better pain care (Bettle et al 2018). However, it is important to recognise when a parent or carer can’t or wont advocate on the part of a child. The onus then is on the nurse to proactively evaluate that child’s pain regularly. 4.1 Practitioners views<?oxy_delete author="sm36828" timestamp="20220314T123409+0000" content=" of raising parents’ expectations"?>In our study to develop the pain framework we asked practitioners how they felt about raising parents expectations of pain management.Some practitioners were sympathetic stating parents’ expectations ‘may not be voiced, may not be asked’, suggesting that there is first a need to ‘understand’ parents’ expectations. Some practitioners however, expressed reservations about the possibility of setting unrealistic parental expectations, such as reducing pain to zero, that would then be difficult to meet.
Figure 12: Practitioners views
An illustration of six people lined up in two rows of three.An illustration of six people lined up in two rows of three.Nonetheless, most thought that sharing realistic expectations was helpful, explaining that ‘use of (a) pain pathway helps with parents’ expectations of how their child’s pain will be managed’. Participants felts parents’ expectations varied between ‘think[ing] their child will be in pain, and they think it’s normal’, and ‘expect their child won’t have any pain or shouldn’t have any pain’. So, although ‘we can’t get rid of all pain at all times’ there should be a commitment to ‘try and sort it out’.Practitioners reflected that ‘parents’ understanding (of pain) should be checked, not assumed’, and noted that a ‘lack of assertiveness on the part of parents leads to frustration and perhaps avoidable poor pain management’, although parents should not be blamed for this. Parents’ expectations could be raised and managed through pain plans and outlining ‘how pain will be dealt with [and] be realistic and honest with parents’ and ‘educating them that pain management is not just about the drugs’.Practitioners suggested ways of raising expectations including education and communication, giving parents ‘permission’ to ask about pain and stressing the need for nurses to talk to parents, for example: ‘pre-operative information for parents is seen as important to start the cycle of effective pain management. This can reduce the potential for stress and clarify expectations – which would lead to a good start to the admission’.Other ways of raising expectations included signs or ‘posters or something in the parents’ room’ to prompt parents to ‘contact the pain team if you feel your child’s pain isn’t as well controlled’.A consistent approach was deemed important in meeting or raising expectations although it was agreed that this was often dependent on the ‘individual nurses on the floor on that particular day unfortunately’. A pain consultant reported: ‘We can never over-deliver on pain management’ – suggesting the onus is the responsibility of the clinicians, rather than the parents with regards to setting the standard of care.You can see from these responses that many practitioners are supportive of including parents in the management of their child’s pain. However, there seems to be recognition of the need for a shift in health care practitioners interactions with parents that actively encourages parents to become more involved in the management of their child’s pain in hospital.Having covered all four sections of the pain management framework, you are now coming to the end of the course.Activity 4: Six-minute briefing15 minutesBefore you take the quiz, you might like to review your learning in the Children’s Pain Management Framework six-minute briefing. You can use the text box below to make notes of key points. Click on the link to access the leaflet which will provide an overview of the Pain Framework.Six Minute Briefing: Children’s Pain Management Framework5 End-of-course quizCheck what you’ve learned in this course by taking the End-of-course quiz.Open the quiz in a new window or tab then come back here when you’ve finished.ConclusionYou have come to the end of this short course – well done. You have learned about the various aspects of the pain management framework that has been developed over a number of years involving the views of over 60 practitioners and has been shaped by the experiences of children and parents following surgery. The result is a holistic body of work that now needs to be used to engage with best practice and facilitate and deliver effective pain management for children. So with your new knowledge of the framework, consider what one thing would need to change where you are currently working, or have worked, to enable the key elements of the framework to be delivered. What role could you play in that change and who would support you to deliver it?