Assessment of Pain is Complex due to the Personal Nature of the Experience and Other Variables. It is Particularly Problematic in the Pediatric Setting
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Introduction
Humans express many emotions during the span of their lives. Most of these emotions result from different circumstances and from different situations. Humans can express diverse emotions at the same time and change them according to the given condition. One of the distinct characteristics of humans is expressing pain in different ways. Every individual, especially patients, experiences and suffers pain. It is associated with a myriad of causes, and is described depending on the range of its intensity. Pain can be felt and expressed either physically, mentally, and emotionally, and often times, this emotion can lead to serious problems. However, a disease or a sickness causing pain must be the biggest challenge a person will experience. This pain may or may not be endured by the person and may even result to death. This may affect how the person may function and perform on his or her daily activities. With these, many treatments are being improved and used, to at least, alleviate the pain being experienced by many persons inflicted with a disease.
With such information, it can be perceived that assessing the pain that can be experienced by children, particularly in terms of sickness or illness may be one of the most tedious activities to be encountered by healthcare practitioners. As such, this paper aims to present a review of different literatures in support of the argument being presented. A number of articles would be used in order to support the argument. In the end of the paper, a conclusion would be presented in order to highlight the different points emphasized in the paper.
Review of the Literature
As argued, the statement emphasizes that the assessment of pain is complex due to its personal nature and experience. In this sense, it becomes problematic in the pediatric setting. This statement can be deemed true, even without proof, as many healthcare practitioners would perceive treatment of infants, children, or adolescents in pain may provide them less information on how to treat them accordingly, due to (a) lack of effective means of communicating to adults, (b) hesitation to express pain due to shame or fear, (c) confusion as to the location of pain, and (d) fear of treatment, such as through injections or medicines. With such known factors, it can be perceived that the parents, guardians, and healthcare practitioners are equally burdened with the responsibility to find ways on how to assess the pain being felt by children, find ways on alleviating them, and find ways in managing them.
Peden et al. (2005) are supporting the argument or statement stressed, as they state that a longstanding issue within pediatric pain management has been the difficulty of assessing pain in children, in which pain is deemed as a complex, multi-dimensional phenomenon. The objective assessment of children’s pain constitutes a challenge for all healthcare professionals. In this sense, accurate and timely pain assessment has been found to be a key factor in improving pain management of children (as cited in Peden et al. 2005). As such, the statement of the authors supports the argument of this paper, as they emphasize that, the pain in children is complex and multi-dimensional, thus, contributing to the complexity in terms of assessment and treatment.
More importantly, it is essential to define pain. This is because pain is the most vital component of pain assessment and management, and is the dilemma of the child, his or her parents and guardians, and the healthcare practitioners. It has been emphasized that pain is an important component, and at times, the only component of most disease processes. Healthcare professionals have a moral, ethical, and legal obligation to ensure that children in their care are relieved from pain and suffering. It has been reported that over the last decade, practitioners have realized that pain might have profound deleterious effects on children. This is because the pain of children is being perceived as low priority. Pain is an issue in potentially every clinical area, as it is understood that it is everyone’s duty but no one’s responsibility. The lack of pain as a priority could explain a fundamental obstacle to implementing emerging evidence that would require substantial changes to some pain management practices (Simons and MacDonald, 2004). In addition, pain is deemed as unpleasant, delays recovery and adds to the trauma of illness, injury, and clinical procedures (as cited in Simons and MacDonald, 2006). Thus, from the definition and information of pain, it can be understood that the lack of priority, assessment and management of pain in children can provide them with psychological, emotional, and physical effects that they could be taking with them as they grow up. Children endure an array of painful medical treatments starting at birth and continuing through adolescence. Such procedures include heel sticks, circumcision, immunizations, catheter insertion, chest tube placement and removal, lumbar punctures, bone marrow aspirations, venipuncture, dental restorations, burn wound treatments and many others. For each of such painful procedures, children’s fear and anticipatory anxiety increases the likelihood of their experiencing more pain and distress during the actual procedures (as cited in Blount et al., 2006).
In order to illustrate the extent of pain in children and its difficulty in terms of assessment and management, several clinical situations can be cited. One of the three situations to be cited is the incidence of headache, which can demonstrate pain in children. It has been demonstrated that headache is a common disorder in children and adolescents. Chronic daily headache or CDH is a collective term for primary headaches, with an estimated prevalence of 0.9% in children. In the second revised edition of the International Classification of Headache Disorders, 4 types of CDH have been included, namely, chronic migraine or CM, chronic tension-type headache or CTTH, new daily persistent headache, and hemicrania continua, which are only developed for adults. However, there are no specific criteria for children, making it difficult to classify their headaches. In conclusion, it has stated that CDH is a serious disorder that can occur at any age and leads to significant school absenteeism and sleeping problems in children (Wiendels et al., 2005). Another clinical situation is when a child has been subjected under the process of tonsillectomy, which is a procedure most often done in the same-day surgery setting. It has been reported that children having a tonsillectomy have been observed to experience moderate to severe pain levels in the days following the surgery. As a pain reliever, analgesics were given to the participants, and data were taken through diaries (Van Kuiken et al., 2007). In relation to this, pediatric day surgery is another situation wherein pain in children can be demonstrated. It has been emphasized that rapid-acting anesthetic and analgesic drugs, which hasten recovery from anesthesia with fewer side effects, accomplish the goals and desirable ends of day surgery by facilitating early discharge. However, the management of post-operative pain remains a continuing problem, both for the child and his or her parents. Apparently, increasing the use of non-sedating drugs, such as Paracetamol, non-steroidal anti-inflammatory drugs, and local anesthetic blocks ensure that a large proportion of children are leaving hospital pain-free following day surgery. However, children can experience extreme pain when the local anesthetic block wears off if no other analgesia has been given, which may be in the middle of the night when parents have limited access to health professionals (Jonas, 2003). As such, such situations or experiences would mean difficulty in managing the pain being felt by children, with the burden of the responsibility on their parents or guardians.
Given such difficulty, a number of measures or tools are used in healthcare settings in measuring pain in children, namely, self-report observational, and physiological. Self-report methods are preferred and referred to as the ‘gold standard’ within pediatrics due to the subjective nature of pain. Faces scales and visual analogue scales are available for children to use, as some children are unable to self-report for a variety of reasons (Peden et al., 2005). The FLACC scale includes five categories of pain behaviors, namely, facial expression, leg movement, activity, cry, and consolability (Willis et al., 2003). Others include the TPPPS or The Toddler Preschooler Postoperative Pain Scale, and the CHEOPS or the Children’s Hospital of Eastern Ontario Pain Scale.
With such scales, it can be deemed that assessing and managing pain in children can be easier. However, this is not the case. This is because an important reason for the lack of utilization has to do with the issue of practicality and versatility of the instruments for use in the practice setting. Although many pain measures have been developed and validated, the clinical relevance of many of the tools has not been adequately tested, thus, hindering their integration into clinical practice (Gharaibeh and Abu-Saad, 2002). This has been supported by the fact that all the other studies mentioned, cited, and included in this paper speaks of the limitations in relation to the studies done, involving the different pain management tools. According to the study done by Peden et al. (2005), pain management tools can be evaluated in terms of their internal consistency, thus, it must be homogenous to the extent that all sub-parts are measuring the same characteristics. This was not performed in their study and would require consideration in future studies. Another study is the study done by Van Kuiken et al. (2007), which considered using the paper diary as inconsistent in data collection. This is because the number of entries on each diary and the interval between entries are varied. In this regard, relying on written reports, such as through using the paper diary may be one good source of error in pain management. In relation to this is the study done by Wiendels et al. (2005), which used a retrospective study design. Through the design, the study had to rely on data recorded by different physicians with varying expertise in headache. Missing data could not be retrieved, thus, leading to erroneous classification of participants. In this sense, relying on personal, manual, and subjective recordings of results may lead to errors and inconsistent findings.
Moreover, analysis of the statement would lead one to consider the issues involved to answer the question, as to why pain assessment and management in children is one of the most tedious tasks in the provision of healthcare. One of such issues is passing the burden of healthcare practitioners in terms of pain management and assessment to the hands of the parents, particularly, after the child’s discharge from the hospital. The study done by Jonas (2003) emphasized that the problems associated with day surgery are not over when children and their parents leave the hospital, thus, a constructive written and verbal information must be given by a healthcare practitioner. Another issue is the lack of opportunity to spend time delivering information, which would only benefit the patients, but the nursing or healthcare staffs as well. The study done by Simons and MacDonald (2006) demonstrated that when a new intervention in pain management is necessary, there are very real obstacles to implementing change. In this sense, the use of the pain management tools becomes difficult to correct, including the perceptions of the ones administering them. This was supported by the study done by the same authors in 2004, wherein they stated that limitations in providing effective pain management and assessment in children involves the needed education of nurses to help them implement pain tools and the lack of a culture, which is supportive of change. As such, it has been emphasized that the lack of experience, lack of support, and lack of communication among staff members (Contro et al., 2004), and between the staff members and the family of the patient are considered primary factors of the lack of effective pain assessment and management in the practice setting. Such factors also support the fact that some healthcare practitioners lack the needed and adequate knowledge over pain and pain assessment methods, need educational preparation, the lack of instrument appeal to the child, the age of the child, and difference between the cultural background of the child and the healthcare practitioner (as cited in Gharaibeh and Abu-Saad, 2002).
Conclusion
From the discussion and analysis of the articles, it can be deduced that the lack of effective and appropriate pain assessment and management among children can be attributed to a variety of factors. Such factors depend on the skills, knowledge, and competencies of the healthcare practitioner, the ability and the willingness of the child/children to cooperate, and the knowledge, skills, and cooperation from the parents or guardians of the child/children. Based on the different limitations and issues discussed, it can be perceived that such issues are the main reasons why pain assessment in children is difficult. Despite the variety of pain assessment tools available to the utilization of healthcare practitioners, their lack of experience and proper skills, knowledge, and competencies may hinder them from providing effective care for their patients.
References
Blount, R.L., Piira, T., Cohen, L.L. and Cheng, P.S. (2006). “Pediatric Procedural Pain”. Behavioral Modification, 30(1): 24-49.
Contro, N.A., Larson, J., Scofield, S., Sourkes, B. and Cohen, H.J. (2004). “Hospital Staff and Family Perspectives Regarding Quality of Pediatric Palliative Care”. Pediatrics, 114(5): 1248-1252.
Gharaibeh, M. and Abu-Saad, H. (2002). “Cultural Validation of Pediatric Pain Assessment Tools: Jordanian Perspective”. Journal of Transcultural Nursing, 13(1): 12-18.
Jonas, D.A. (2003). “Parent’s Management of their Child’s Pain in the Home Following Day Surgery”. Journal of Child Health Care, 7(3): 150-162.
Peden, V., Choonara, I. and Vater, M. (2005). “Validating the Derbyshire Children’s Hospital Pain Tool in Children Aged 6-12 Years”. Journal of Child Health Care, 9(1): 59-71.
Simons, J. and MacDonald, L.M. (2004). “Pain Assessment Tools: Children’s Nurses’ View”. Journal of Child Health Care, 8(4): 264-278.
Simons, J. and MacDonald, L.M. (2006). “Changing Practice: Implementing Validated Paediatric Pain Assessment Tools”. Journal of Child Health Care, 10(2): 160-176.
Van Kuiken, D.M., Lin, L. and Huth, M.M. (2007). “The Difficulties of Studying Children’s Pain at Home”. Western Journal of Nursing Research, 29(4): 432-447.
Wiendels, N.J., van der Geest, M.C., Neven, A.K., Ferrari, M.D. and Laan, L.A. (2005). “Chronic Daily Headache in Children and Adolescents”. Headache, 45: 678-683.
Willis, M.H., Merkel, S.I., Voepel-Lewis, T. and Malviya, S. (2003). “FLACC Behavioral Pain Assessment Scale: A Comparison with the Child’s Self-Report”. Pediatric Nursing, 29(3): 195-198.
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