Exploration of nurses' pediatric pain management experiences in rural hospitals: A qualitative descriptive study

Highlights

• Rural nurses may not have standard pediatric pain specific knowledge.

• Rural nurses experience unique challenges within their context.

• Opportunity exists to improve pediatric pain management in Northern Ontario.

• Need for rural context specific strategies to improve pain management that move beyond education

• Discussion of use of electronic documentation strategies were suggested as facilitators.

Abstract

Background

Hospitalized children continue to experience inadequate pain management. Children in the rural hospital setting may be at risk due to unique challenges experienced by Registered Nurses (RNs) in this context.

Objectives

To understand the experience of pain care from RNs who work in rural hospitals with inpatient pediatric patients.

Design

Qualitative description that used semi-structured interviews to explore RNs' inpatient pediatric pain care experiences.

Participants

RNs who: 1) worked directly with pediatric in-patients; 2) spoke English; 3) and who worked in rural Northern Ontario. Hospital sites were selected based on population density, from one province in Canada. To reduce heterogeneity, only sites with dedicated pediatric beds were eligible (n = 9).

Methods

This qualitative descriptive study used semi-structured interviews over Skype and telephone. Data were analyzed using inductive content analysis.

Results

Ten participants were recruited from seven sites. Five main categories were identified, with one category that influenced all other categories. Rural RNs needed to practice as generalists as they care for many types of patients. Resource challenges included a lack of specialist expertise and educational opportunities. Pediatric pain was not perceived as a priority within their organizations. Most participants perceived there were no explicit standards for pain care. Moving forward the adoption of built in assessments in electronic documentation was suggested as a solution to standard pain care.

Conclusions

Opportunity exists to improve pediatric pain management, however, without a systematic approach that considers the rural context, pain care for children will continue to be based on individual's beliefs and knowledge.

Introduction

Pain is a subjective phenomenon that must be prevented and treated, as there are short and long-term negative consequences when left untreated (Schechter, Finley, Bright, Laycock, & Forgeron, 2010). These negative consequences of poorly treated pain in children include such things as suffering and fear, future avoidance of healthcare (Twycross & Williams, 2014) and the potential for changes in central nervous system pain processing that predispose a child to increases in pain sensitization (Dahl & Moiniche, 2004; (Taddio, Katz, Ilersich, & Koren, 1997). The need for more attention to children's pain management was marked by the first “Global Year Against Pain in Children” in 2005 (Finely, Franck, Grunau, & von Baeyer, 2005), yet hospitalized children all over the world continue to experience pain regardless of whether they are in pediatric teaching hospitals in first-world countries (Harrison et al., 2014; Stevens et al., 2011) or hospitals in low and middle income countries (Forgeron, Finley, & Arnaout, 2006; Linhares et al., 2012). This is despite evidence of effective management strategies being readily available.

Registered nurses (RNs) play a key role in a hospitalized child's pain management given their role in pain assessment, treatment, and communication of findings to other clinicians. Linhares et al. (2012) found that although nurses were more likely than medical doctors (MDs) to document their pain assessment using a validated pain assessment tool, most children's charts (74%, n = 87) had no documentation on pain, meaning that nurses may not have assessed this parameter and certainly failed to communicate their findings effectively. When pain assessment is not conducted, or the findings are not communicated to other clinicians, children may not receive appropriate pain treatment. Furthermore, knowledge and attitudes towards pain management has been repeatedly found to influence nurses' approach to pain management (Habich et al., 2012; Latimer, Ritchie, & Johnston, 2010; Lunsford, 2015). Thus, when nurses and other clinicians hold inaccurate beliefs about pain, children are at risk for their pain to be ineffectively addressed.

One factor that has been found to influence the use of research into practice is context (Kitson, Harvey, & McCormack, 1998), which is defined as the environment or setting in which nurses' work (Kitson et al., 1998). Evidence suggests that context can positively or negatively influence nurses' practice behaviours, (Cummings, Hutchinson, Scott, Norton, & Estabrooks, 2010; Latimer et al., 2010; Squires et al., 2013) and therefore may play a critical role in nurses' use of evidence in practice. When investigating context and pain, research suggests that interprofessional collaboration is a strong influencing factor for effective pain management practices (Stevens et al., 2011). For example, when nurses are supported through policies or MDs orders to provide pain analgesics around the clock, children receive more analgesia (Simons & Moseley, 2008). However, the types of context resources available within the rural context to support RNs pain care practices have received little attention.

The impact of rural context on Canadian nurses' pediatric pain management practices have only been previously explored in one study (Caty, Tourigny, & Koren, 1995). This study highlighted that nurses in rural contexts may hold incorrect knowledge of pediatric pain management. For example Caty et al. (1995) found that nurses reported children were not in pain if there was an absence of crying or movement and chose intra-muscular injection as the usual route of opioid administration in children. Other studies conducted in rural contexts which focused on low and middle-income countries (i.e. Thailand) also found that clinicians held myths and misconceptions about children's pain management and that continuing educational opportunities are limited (Forgeron et al., 2009). One of these studies in a resource-restricted country suggested that practice change to improve pain management requires organizational support (e.g., policies, protocols, guidelines) (Forgeron et al., 2009). Although these studies have been conducted in rural settings these results may not be transferable to a rural Canadian context where resources are known to differ from the studies mentioned above. Understanding of the interplay between rural context and nurses' pediatric pain management practices is limited and is the focus of this study.