"You Just Have to Make the Pain go Away" -- Children's Experiences of Pain
This paper reports a study of the descriptions young children use and their expectations for pain management interventions experienced during hospitalization. The alleviation of children's pain has been investigated through the eyes of health care providers and parents, but the children's own perspective has largely been ignored. To date, there is a growing tendency to listen to the children when making final decisions on treatment in child health care. The evidence shows that children should be regarded as experts on their pain to maximize the options for pain management and to provide high-quality care. Forty-four children who were inpatients in four pediatric units in a university hospital participated in the study. The data were collected by means of a qualitative interview with the children until theoretic saturation was reached. The data analysis was based on inductive content analysis. The findings indicate that the children used multiple strategies while trying to deal with their pains during hospitalization and expected professional competence from health care professionals. Moreover, the children valued the care and attention provided by significant others. When managing pain in hospitalized children with a wide diversity of sources, the complexity of pain as a physiologic, psychologic, social, and cultural phenomenon must not be overlooked.
Children's experience of pain is recognized as one of the most complex human stressors, which may have consequences for later pain-related behavior and perception. Despite an increase in research on pain in children, studies still report hospitalized children experiencing unacceptable levels of pain (Cummings et al 1996, Hamers et al 1998, Brennan-Hunter 2001, Kortesluoma and Nikkonen 2004).
Managing hospitalized children's pain is challenging for health care professionals. The ethical principles of the duty to benefit another and the duty to do no harm oblige health care professionals to provide pain management to all patients, including children, who are extremely vulnerable because of their constant developmental changes, being ill, and being hospitalized. However, a growing body of research has shown that nurses do not assess children's pain effectively. Moreover, nurses do not give pain management a high priority (Twycross, 1999). Several studies (Kubecka et al 1996, Salanterä and Lauri 2000, Simons and Roberson 2002, Van Hulle Vincent 2005) have demonstrated that nurses' lack of knowledge to assess and manage children's pain is an international problem. Twycross (2007) states that surprisingly few nurses in her observational study spoke with children about their pain. In a study by Richards and Hubbert (2007) the interviewed expert nurses admitted that it was difficult to accept what the patient says about his/her pain. In the United States, the introduction of pain management standards announced by the Joint Commission (2000) requires the use of patients' self-report in assessing pain for most patient populations. The value of verbal self-reports in assessment and evaluation of pain has been reported by several authors (Anghelescu and Oakes 2002, Calam et al 2000, Gaston-Johansson 1984, Kortesluoma and Nikkonen 2004). This leads us to the conclusion that, when assessing pain, the health care professional should assume that the child's report of pain is valid.
A growing acknowledgment of human rights issues is recognized in adult health care, and children have a right to express their opinions and to have their views taken into account and given due weight in the decision-making process (United Nations, 1989). The right is, however, a moral right, not a legal one, and in pediatrics the key barrier to recognizing these principles is a widespread belief that it is very difficult to get information from young children who have a limited vocabulary and level of cognition. Contemporary studies have begun to change the focus from children's cognitive limitations to their competencies (Rushforth, 1999). On the basis of our previous research, we believe in children's potential to understand far more about their illness and hospitalization experiences than previously thought. Therefore, child health practitioners should recognize children's right to be actively involved in decisions pertaining to their care. Nowadays, when making decisions on treatment in child health care, the tendency to listen to children is a last resort. In view, however, of the subjective nature of the pain experience, children should be regarded as experts on their pain to maximize the options for pain management. The benefits from this inclusion are a reduction of anxiety in children during hospitalization and minimization of the ill effects of an unpleasant experience.
Most clinical studies to date concerning children's pain management, focus primarily on methods used by health care practitioners or parents (Jonas 2003, Twycross 2002, Woodgate and Kristjanson 1996). Previous studies have examined the use of medications (Gauthier et al 1998, Kankkunen et al 2003b) during medical procedures (Rogers & Ostrow, 2004). Only a minority of pain intervention studies have focused on other types of help and refer to specific patient groups, such as postoperative (Pölkki et al 2001, Kankkunen et al 2003a, Idvall et al 2005), juvenile chronic arthritis (Schanberg, et al., 1997), and cancer patients (Jay et al 1985, McCarthy et al 2004). Most of the studies are of children, and there is an increasing interest in the child perspective on pain (e.g., Woodgate and Kristjanson 1996, Cummings et al 1996, Pölkki et al 2003, Huth et al 2004). A few studies have attempted to find simultaneous representations for different states of pain (Perquin, et al., 2000), and very few studies have dealt with the representation of pain among randomly chosen hospitalized children (e.g., Johnston et al 1992, Cummings et al 1996, Kortesluoma and Nikkonen 2004). The data collected in most studies conducted with children are based on behavioral observation, surveys, semistructured interviews, forced-choice questions, questionnaires, or nonblinded experiments. However, Wilkinson (1988) stated that child studies based on questionnaires will reveal minimal information in relation to children's total views.
Numerous studies have addressed children's pain, but research on children's self-help pain relief strategies (Bossert et al 1996, Campbell and McGrath 1999, Pederson et al 2000, Woodgate and Kristjanson 1995) and preferred interventions in assisting children in minimizing their pain from the point of view of children (Alex & Richie, 1992) is limited. The present study extends previous research by setting its focus on children's thoughts about effective strategies used spontaneously during pain episodes and experiences in alleviating and managing pain in children in a hospital setting.
This paper reports a study of the descriptions young children use and their expectations for pain management interventions experienced during hospitalization. The alleviation of children's pain has been investigated through the eyes of health care providers and parents, but the children's own perspective has largely been ignored. To date, there is a growing tendency to listen to the children when making final decisions on treatment in child health care. The evidence shows that children should be regarded as experts on their pain to maximize the options for pain management and to provide high-quality care. Forty-four children who were inpatients in four pediatric units in a university hospital participated in the study. The data were collected by means of a qualitative interview with the children until theoretic saturation was reached. The data analysis was based on inductive content analysis. The findings indicate that the children used multiple strategies while trying to deal with their pains during hospitalization and expected professional competence from health care professionals. Moreover, the children valued the care and attention provided by significant others. When managing pain in hospitalized children with a wide diversity of sources, the complexity of pain as a physiologic, psychologic, social, and cultural phenomenon must not be overlooked.
Children's experience of pain is recognized as one of the most complex human stressors, which may have consequences for later pain-related behavior and perception. Despite an increase in research on pain in children, studies still report hospitalized children experiencing unacceptable levels of pain (Cummings et al 1996, Hamers et al 1998, Brennan-Hunter 2001, Kortesluoma and Nikkonen 2004).
Managing hospitalized children's pain is challenging for health care professionals. The ethical principles of the duty to benefit another and the duty to do no harm oblige health care professionals to provide pain management to all patients, including children, who are extremely vulnerable because of their constant developmental changes, being ill, and being hospitalized. However, a growing body of research has shown that nurses do not assess children's pain effectively. Moreover, nurses do not give pain management a high priority (Twycross, 1999). Several studies (Kubecka et al 1996, Salanterä and Lauri 2000, Simons and Roberson 2002, Van Hulle Vincent 2005) have demonstrated that nurses' lack of knowledge to assess and manage children's pain is an international problem. Twycross (2007) states that surprisingly few nurses in her observational study spoke with children about their pain. In a study by Richards and Hubbert (2007) the interviewed expert nurses admitted that it was difficult to accept what the patient says about his/her pain. In the United States, the introduction of pain management standards announced by the Joint Commission (2000) requires the use of patients' self-report in assessing pain for most patient populations. The value of verbal self-reports in assessment and evaluation of pain has been reported by several authors (Anghelescu and Oakes 2002, Calam et al 2000, Gaston-Johansson 1984, Kortesluoma and Nikkonen 2004). This leads us to the conclusion that, when assessing pain, the health care professional should assume that the child's report of pain is valid.
A growing acknowledgment of human rights issues is recognized in adult health care, and children have a right to express their opinions and to have their views taken into account and given due weight in the decision-making process (United Nations, 1989). The right is, however, a moral right, not a legal one, and in pediatrics the key barrier to recognizing these principles is a widespread belief that it is very difficult to get information from young children who have a limited vocabulary and level of cognition. Contemporary studies have begun to change the focus from children's cognitive limitations to their competencies (Rushforth, 1999). On the basis of our previous research, we believe in children's potential to understand far more about their illness and hospitalization experiences than previously thought. Therefore, child health practitioners should recognize children's right to be actively involved in decisions pertaining to their care. Nowadays, when making decisions on treatment in child health care, the tendency to listen to children is a last resort. In view, however, of the subjective nature of the pain experience, children should be regarded as experts on their pain to maximize the options for pain management. The benefits from this inclusion are a reduction of anxiety in children during hospitalization and minimization of the ill effects of an unpleasant experience.
Most clinical studies to date concerning children's pain management, focus primarily on methods used by health care practitioners or parents (Jonas 2003, Twycross 2002, Woodgate and Kristjanson 1996). Previous studies have examined the use of medications (Gauthier et al 1998, Kankkunen et al 2003b) during medical procedures (Rogers & Ostrow, 2004). Only a minority of pain intervention studies have focused on other types of help and refer to specific patient groups, such as postoperative (Pölkki et al 2001, Kankkunen et al 2003a, Idvall et al 2005), juvenile chronic arthritis (Schanberg, et al., 1997), and cancer patients (Jay et al 1985, McCarthy et al 2004). Most of the studies are of children, and there is an increasing interest in the child perspective on pain (e.g., Woodgate and Kristjanson 1996, Cummings et al 1996, Pölkki et al 2003, Huth et al 2004). A few studies have attempted to find simultaneous representations for different states of pain (Perquin, et al., 2000), and very few studies have dealt with the representation of pain among randomly chosen hospitalized children (e.g., Johnston et al 1992, Cummings et al 1996, Kortesluoma and Nikkonen 2004). The data collected in most studies conducted with children are based on behavioral observation, surveys, semistructured interviews, forced-choice questions, questionnaires, or nonblinded experiments. However, Wilkinson (1988) stated that child studies based on questionnaires will reveal minimal information in relation to children's total views.
Numerous studies have addressed children's pain, but research on children's self-help pain relief strategies (Bossert et al 1996, Campbell and McGrath 1999, Pederson et al 2000, Woodgate and Kristjanson 1995) and preferred interventions in assisting children in minimizing their pain from the point of view of children (Alex & Richie, 1992) is limited. The present study extends previous research by setting its focus on children's thoughts about effective strategies used spontaneously during pain episodes and experiences in alleviating and managing pain in children in a hospital setting.
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