Children's nurses' pain management practices: theoretical knowledge, perceived importance and decision-making

Abstract

Children continue to experience unrelieved moderate to severe pain post-operatively. Previous studies have suggested several factors to explain this. However, the impact of these factors on practice has not been explored. Nor have children's nurses clinical decision-making strategies been examined.
This case study set out to explore the influence of various factors on individual nurses' post-operative pain management practices, and to answer the following questions:
• How does the perceived importance of a pain management task impact on
practice?
• How does theoretical knowledge and its application impact on practice?
• How does what nurses say they do compare to what they actually did?
• How do nurses make decisions when managing pain in children?
The case study used qualitative (participant observation and the think aloud technique) and quantitative methods (questionnaires) to obtain an in-depth picture of children's nurses' post-operative pain management practices. As well as examining some aspects of pain management for the first time, such as nurses' pain-related clinical decision-making, new perspectives were explored in relation to other well researched issues, including whether theoretical knowledge about pain management is applied in practice.
The perceived importance of a pain management task did not affect the likelihood of it being undertaken. A good level of theoretical knowledge appeared not to affect the quality of a nurse's pain management practices. A lack of congruence was found between what the nurses said they do and what the nurses actually did. Observational data indicated that nurses generally did not follow current recommendations fully when managing pain. In several areas, the practices of the ward sisters appeared to be of a lower standard than more junior nurses. Nurses appeared to use non-expert decisionmaking
strategies regardless of their years of experience or level of academic attainment. A hypothetico-deductive (analytical) model of decision-making seemed to be used.
Several strategies, which might facilitate the application of theoretical knowledge in clinical decision-making and practice are considered, including the use of teaching rounds and clinical scenarios. These need evaluating, and further research is needed to identify other factors that affect pain management practices and decision-making strategies. How children's nurses make clinical decisions also needs further exploration.
A revised conceptual framework is presented which suggests that, for post-operative pain management practices to be effective, nurses need to have not only the right attitude and the right knowledge but also the ability to make the right decision. However, it is probable that other factors, both individual and collective, are also involved, including ward culture, role-modelling and lack of motivation to change. The revised conceptual framework provides a basis for future research.