REVIEW

Managing pain in children: where to from here?

Alison Twycross

Aims and objectives. The aims of this study are to review research published in the past 15 years to provide insight into the
factors impacting on the management of pain in children and identify strategies that can be used to improve pain management
practices.
Background. The evidence to guide nurses pain management practices is readily available, in the form of clinical guidelines.
However, childrens nurses pain management practices continue to fall short of the ideal with children experiencing moderate
to severe unrelieved pain. Several factors have been suggested as providing an explanation for this. There is a need to explore the
impact each of these factors have on pain management practices further. With this in mind, a literature review was undertaken.
Design. Literature review.
Methods. A computerised literature search was carried out using CINAHL, Medline and the British Nursing Index. The search
terms used were as follows: pain, pain assessment, pain management, education, quality and nurses. Articles published in the
last 15 years were included in the review.
Results. Several themes emerged from this review of the literature as possible explanations for why childrens pain is still not
managed effectively. These include knowledge deficits; incorrect or outdated beliefs about pain and pain management; the
decision-making strategies used and organisational culture.
Conclusions. Improving pain management requires a multifactorial approach encompassing: education, institutional support,
attitude shifts and change leaders. Issues that need addressing include education, decision-making strategies and organisational
practices. Further research needs to be carried out to determine other factors that impact on pain management practices.
Relevance to clinical practice. Despite the evidence to guide practice being readily available children continue to experience
unrelieved pain. The strategies identified in this article may help to ensure that pain is relieved effectively.
Key words: children, decision-making, nurses knowledge and attitudes, organisational culture, pain management
Accepted for publication: 4 February 2010

Introduction
The evidence to guide nurses pain management practices is
readily available, in the form of clinical guidelines. Childrens
nurses pain management practices, however, continue to fall
short of the ideal (Polkki et al. 2003; Vincent & Denyes
2004, Twycross 2007a) with children experiencing moderate
to severe unrelieved pain (Health Care Commission 2004;
Vincent & Denyes 2004, Johnston et al. 2005, Health Care
Commission 2007; Taylor et al. 2008). Indeed, the (English)
Author: Alison Twycross, PhD, MSc, DMS, CertEd, RGN, RMN,
RSCN, Faculty of Health and Social Care Sciences, Kingston
University St Georges University of London, Grosvenor Wing, St
Georges Hospital, London, UK
Correspondence: Alison Twycross, Faculty of Health and Social Care
Sciences, Kingston University, St Georges University of London,

2090

National Service Framework for Children and Young People

(Department of Health 2004) states that childrens pain
management is often suboptimal and stresses the need to
provide evidence-based care. This issue has also been
highlighted by the International Association for the Study
of Pain (IASP) who declared October 2005October 2006
the Global Year Against Pain in Children (Finley et al. 2005).
There is a need to explore the factors impacting on pain
management practices further. With this in mind, a literature
review was undertaken.
Grosvenor Wing, St Georges Hospital, London UKSW17 0RE, UK.
Telephone: 0778 552 5986.
E-mail: a.twycross@sgul.kingston.ac.uk

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

doi: 10.1111/j.1365-2702.2010.03271.x

Review

Objectives and methods

This study aims to establish through a review of the literature
the reasons why the management of pain in children remains
suboptimal and the strategies that can be put in place to
facilitate best practice. A computerised literature search was
carried out using CINAHL, Medline and the British Nursing
Index. The search terms used were as follows: children, pain,
pain assessment, pain management, education, quality and
nurses. These search terms were used individually and in
combination to derive a list of pertinent articles. Further
relevant articles were identified from the reference lists of
articles detected by this literature search. Articles published in
the last 15 years were included in the review. The majority of
the articles included in this study relate to childrens nursing
but where there is insufficient evidence available research
relating to adult nursing is drawn upon.

Results
The review of the literature revealed several factors that have
been suggested as reasons why childrens pain is still not
managed effectively including knowledge deficits; incorrect
or outdated beliefs about pain and pain management; the
decision-making strategies used and organisational culture.
Each of these themes will be discussed in turn.

Knowledge deficits
Limited theoretical knowledge about managing pain in
children has been suggested as one reason nurses do not
manage pain effectively. Seven studies were found that have
examined childrens nurses theoretical knowledge about pain
in children. A study carried out with paediatric oncology
nurses (n = 106) in the USA found a lack of understanding
of basic pharmacological principles in relation to analgesic
drugs (Schmidt et al. 1994). However, Schmidt et al. do not
provide any information about statistical testing and so these
results should be treated with caution although as they
concur with the results of similar studies they may provide an
accurate insight into knowledge in this area.
Salantera developed a pain management knowledge questionnaire based on a review of the research literature about
pain in children and adults. This questionnaire was completed by paediatric nurses (n = 265) in Finland; gaps were
found in nurses knowledge about managing pain in children
in relation to analgesic drugs and non-drug methods of painrelief (Salantera et al. 1999). Final-year student nurses
(n = 73) also completed the questionnaire and demonstrated
knowledge deficits in relation to analgesic drugs and pain

Managing pain in children

assessment (Salantera & Lauri 2000). A. Twycross (University of Central Lancashire, Preston, unpublished PhD
thesis) used a modified version of Salanteras questionnaire
(as part of a larger study) and found that nurses (n = 12) had
gaps in their knowledge and these were particularly noticeable in relation to analgesic drugs, non-drug methods and the
physiology of pain as well as the psychology and sociology of
pain.
The Pediatric Nurses Knowledge and Attitudes Regarding
Pain Survey was completed by nurses (n = 274) in Manworrens (2000) study. The mean score for the questionnaire
was only 66% (range = 3198%), with knowledge deficits
apparent in many areas including pain assessment, the pharmacology of analgesic drugs, the use of analgesic drugs and
non-drug methods. Nurses (n = 67) completed an adapted
version of the Nurses Knowledge and Attitudes Regarding
Pain Survey in Vincents (2005) study. Nurses had knowledge
deficits in relation to non-drug methods of pain-relief, analgesic drugs and the incidence of respiratory depression.
Rieman and Gordon (2007) surveyed paediatric nurses
(n = 295) working in Shriners Hospitals in the USA using a
revised version of the Pediatric Nurses Knowledge and
Attitudes Regarding Pain Survey. The questionnaire was
modified to ensure that items related to the areas participants
worked in. One item relating to the application of heat/cold
was removed as it was not considered applicable to the
management of pain resulting from burn injuries, and the
wording for 39 questions was altered to ensure they applied
to the children being cared for (Rieman et al. 2007). The
mean survey score was 74%. The 10 questions answered
incorrectly by most participants related to pharmacology and
the incidence of respiratory depression. Significant differences
were found between the scores of nurses with two years or
less experience in nursing compared to more experienced
nurses (p < 005). Nurses who were active in professional
nursing organisations also had significantly higher scores
than other nurses (p < 005).
The results of these studies suggest that gaps remain in
nurses knowledge about pain in children and in particular in
relation to pain assessment, analgesic drugs and non-drug
methods. Indeed, limited knowledge about many aspects of
analgesic drugs was also found by Ellis et al. (2007). These
gaps in knowledge provide, at least, a partial explanation for
suboptimal pain management practices. However, looking at
nurses theoretical knowledge alone does not provide information about the impact of knowledge deficits on practice.
Two studies have examined the impact of deficits in
childrens nurses theoretical knowledge on the quality of
actual pain management practices. Vincent and Denyes
(2004) examined the relationship between knowledge and

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

2091

A Twycross

attitudes about childrens pain-relief and nurses analgesic

administration practices. They observed the care for children
(n = 132), aged 317, by nurses (n = 67) and found that
nurses with a better theoretical knowledge about pain were
not more likely to administer analgesia. In the second study
by Twycross (2007b), nurses (n = 13) on one childrens
surgical ward were shadowed for a five-hour period for 24
shifts. Data about postoperative pain management practices
were collected using a pain management checklist and field
notes. Nurses (n = 12) also completed the revised pain
management knowledge test. Questionnaire scores were
compared to the observational data. No positive relationship
between individual childrens nurses level of knowledge and
how well they actually managed pain was found. Even when
the nurses had a good level of theoretical knowledge, this was
not reflected in their pain management practices.
The findings of Vincent and Denyes (2004) and Twycross
(2007b) support those of Watt-Watson et al. (2001) who
collected data from 80 (adult) nursepatient pairs. No
relationship was found between nurses knowledge and
patients ratings of pain and the amount of analgesia
administered, even though the nurses had moderately good
knowledge levels about pain management. Nurses do not
appear to apply their theoretical knowledge in practice. This
is, perhaps, attributable to a lack of knowledge about pain
assessment meaning that nurses are unable to assess pain
accurately and thus unable to apply their knowledge in
practice. Further research is needed in this area; attributing
suboptimal practices to a lack of theoretical knowledge
appears too simplistic an explanation.

Beliefs about pain in children

Nurses beliefs about pain and, particularly, the priority
nurses attribute to pain management have been suggested as
reasons for suboptimal pain management practices. Nurses
beliefs about pain management have been examined in
several studies. Nurses (n = 22) completing a training needs
questionnaire about several aspects of nursing attributed a
significantly lower priority to pain management than to other
aspects of their role, such as communication and teamwork
and management and supervision (p < 0001) (Twycross
1999). Hamers et al. (1994) describe the results of two
identical studies which examined the factors affecting nurses
assessment of pain and implementation of pain-relieving
interventions in the Netherlands. Data were collected using
semi-structured interviews with nurses (n = 20), by observing
participants and examining nursing records. Nurses seemed
to assume (incorrectly) that some pain was to be expected
during a hospital stay and used their past experiences (both
2092

bad and good) to determine what to do when managing pain.

If nurses believe pain is to be expected during a hospital stay,
it is perhaps not surprising that relieving it is given a low
priority.
The lack of priority attributed to pain management by
childrens nurses is supported by the findings of two
observational studies. In Woodgate and Kristjansons
(1996) study, nurses (n = 24) were shown to concentrate on
technical aspects of care and saw comforting the child as the
parents role. Further, Byrne et al. (2001) observed nurses on
an orthopaedic ward in the United Kingdom communicating
with parents and children in the ward setting. Data were
collected about the verbal interaction of nurses (n = 13) with
children (n = 16). Standardised open-ended interviews were
also carried out with the nurses, children and parents.
Discourse analysis demonstrated that nurses appeared to
negate (ignore) childrens pain. Children were required to
conform to ward routines and schedules of recovery. Rather
than asking the child how much pain they were in, nurses
appeared to manage pain using a set of behavioural
milestones. Nurses beliefs about managing pain in children
and how these impact on practice clearly need exploring
further.
One study has explored the link between the perceived
importance of pain management and the priority nurses
actually attribute to managing pain in practice (Twycross
2008). Participant observational data were collected about
childrens nurses (n = 13) postoperative pain management
practices on a childrens surgical ward in the English
Midlands. Nurses (n = 12) also completed a questionnaire
to provide a measure of the importance they attributed to
pain management tasks. The importance nurses attributed to
the pain management task did not reflect the likelihood of the
task being undertaken in practice. Indeed, the perceived
importance of a pain management task bore little relationship
to observed practices. There is evidence from the studies
reviewed in this section that out-dated and incorrect beliefs
about pain management and not making pain a priority
contribute to suboptimal practices, but they do not provide a
complete explanation.

Decision-making strategies
Little is known about how childrens nurses make decisions.
Two studies have explored this in relation to managing pain
in children. Twycross and Powls (2006) examined childrens
nurses decision-making when managing postoperative pain
in children using the think aloud technique. Nurses (n = 12)
appeared to use an analytical model of decision-making. All
the nurses used backward reasoning strategies (in forward

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

Review

reasoning an individual works forward from a hypotheses to

find a problem solution, while in backward reasoning an
individual works backwards from an hypothesis to evaluate
different options or find a solution (Lamond et al. 1996).
Participants also collected similar types and amounts of
information before making a decision about appropriate
nursing care. This is indicative of non-expert decisionmaking. No differences were noted between nurses with five
or more years experience in paediatric surgery and less
experienced nurses. Nor were there any differences apparent
between graduate and non-graduate nurses. These results
may be attributable to the data collection method used;
nurses decision-making may differ when in the clinical area.
The complexity of managing pain could have impacted on
nurses decision-making, although as similar results were
found among nurses working in a paediatric medical ward
this is unlikely to be the case (Twycross & Powls 2006).
The influence of expertise on nurses pain assessments and
decisions regarding analgesia administration in children was
explored by Hamers et al. (1997). First-year nursing students
(n = 271), fourth-year nursing students (n = 222) and registered nurses (n = 202) were presented with video vignettes.
Participants were asked to rate on a 100-mm Visual
Analogue Scale: the pain experienced by the child in the
case; how sure they were that their pain assessment was
correct and whether they would administer analgesia to the
child. The results indicated that while registered nurses were
most confident and more inclined to administer analgesics
than less experienced nurses, expertise (that is, years of
experience) did not influence the assessment of pain intensity.
It could perhaps be anticipated that registered nurses would
be more confident than student nurses. However, it is of
concern that the accuracy of pain assessments did not differ
between the groups.
Clinical scenarios were used to explore influences on
nurses (n = 334) decision-making about which analgesic
drugs and non-drug methods to implement when managing
childrens pain (Griffin et al. 2008). The personal attributes
of nurses (n = 334) such as education level, race/ethnicity,
age, years of clinical experience, or having had continuing
education about pain did not appear to impact on decisionmaking. Indeed, nurses in the study indicate that they would
administer the maximum prescribed dose of analgesic drugs.
This contradicts the results of other studies (Hamers et al.
1998, Vincent & Denyes 2004). This is perhaps attributable
to a social desirability response affecting participants
responses; alternatively the introduction of the Joint Commission of the Accreditation of Hospital Organisations
(JCAHO) pain standards in 2001 may have had an impact
on pain management practices in the USA. This studies

Managing pain in children

discussed in this section provide some insight into how nurses

make decisions and the factors that affect this process.
Further research is needed in this context. However, suboptimal decision-making strategies might explain, at least in
part, why children continue to experience unrelieved pain.

Organisational culture
Organisational culture also needs to be considered in relation
to improving pain management practices. This has been
identified as the key to changing practices (Bucknall et al.
2001, Treadwell et al. 2002, Botti et al. 2004, Jordan-Marsh
et al. 2004, Bruce & Franck 2005) but can be difficult to
achieve (Megens et al. 2008). Indeed, participants in a webbased project to disseminate information about managing
pain in children identified organisational culture as a barrier
to changing practices (Bruce & Frank 2005). Several studies
have examined the impact of implementing organisational
pain management strategies on practice.
Quality improvement strategies were used to improve pain
assessment practices in Treadwell et al.s (2002) study. Staff
in a paediatric haematology/oncology unit in the United
States were educated about the use of pain assessment tools,
and a standardised pain assessment protocol was implemented. Data were collected from children and parents (Time
1: n = 36; Time 2: n = 49) before and 12 months after the
implementation of the protocol; staff (nurses, physicians and
psychosocial staff) also completed a questionnaire at similar
times (Time 1: n = 68; Time 2: n = 82). Children, parents and
staff all reported increased pain assessment (p = 005) and
improved staff responsiveness to pain (p < 0001) following
the intervention. A chart audit demonstrated compliance
with the assessment protocol. A strength of this study is that
change was measured over a 12-month period providing
some indication that changes in practice had become
embedded in the unit.
An action research study was carried out to improve the
management of acute pain in children through the systematic
assessment of pain and the administration of appropriate
analgesia in one US hospital (Jordan-Marsh et al. 2004). Pain
management procedures for postoperative and procedural
pain were implemented; a pain assessment tool was implemented; and analgesic drug regimes were standardised.
Patient care rounds focusing on pain management also took
place. Chart audits were carried out and demonstrated an
increase in documented pain assessments; reassessment of
pain and the amount of analgesia administered.
An organisation-wide comprehensive pain management
programme was implemented in one Canadian hospital (Ellis
et al. 2007). The elements of the programme are identified in

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

2093

A Twycross
Box 1 Elements of pain management programme (Ellis et al. 2007)

Pain management standards

Standard care plan
Pain assessment tools
Pain documentation paperwork
Pain experience history record
Education workshops
Pain information folders
Pain resource nurse programme
Pain information boards

Box 1. Data were collected preimplementation and six

months after implementation. A statistically significant
increase was found in the use of pain assessment tools
(p = 0005) and documentation of pain assessment in nursing
notes (p < 0001). No improvements were found in other
areas, including recording pain scores on a flow chart and
evaluating the effectiveness of pain-relieving interventions.
Improvements in pain management practices have also
been found in other studies (Megens et al. 2008, Oakes
et al. 2008). These studies, together, provide evidence that
making pain management an organisational priority can
improve pain management practices. However, many of
these studies are small scale, and change is not always
evaluated over a prolonged period. Further evidence of the
impact of organisational culture on pain management
practices can be found in Lauzon Clabos (2008) ethnographic study on two (adult) wards in one hospital in the
USA. Participants described a clear pattern of pain assessment on each ward; these patterns were different to each
other. The social context appeared to heavily influence
nurses pain assessment practices. The impact of organisational culture on pain management practices needs exploring
further. Indeed, it has recently been suggested that there is a
need to investigate how the social (ward) setting impacts on
individuals pain management practices (Craig 2009, Franck
& Bruce 2009).

Discussion: the way forward

Clearly, there is no easy answer to improving the management of pain in children. However, if the factors identified are
addressed simultaneously practices may improve. Strategies
for improving practices will be discussed in this section.

Educational issues
There will always be a need to educate nurses about pain
management. However, there is increasing evidence that
childrens nurses are not using their theoretical knowledge in
2094

practice (Vincent & Denyes 2004, Twycross 2007b). A

review of literature in this context by Twycross (2002) found
that:
Nurse education does not appear to be preparing nurses to
manage pain in the clinical area.
Nurses continue to have educational deficits about pain
management.
Not all educational interventions result in improvements in
pain management practices.
Several studies have found evidence that gaps in nurses
theoretical knowledge may mean that they do not understand
the rationale for pain-relieving interventions (Schmidt et al.
1994, Salantera et al. 1999, Manworren 2000, Salantera &
Lauri 2000, A. Twycross, University of Central Lancashire,
Preston, unpublished PhD thesis, Vincent 2005, Rieman &
Gordon 2007), which may explain why nurses do not use
their knowledge in practice. If this is the case, pre- and
post-registration course content needs evaluating to ensure
that nurses have a thorough knowledge of pain (for example,
pain as bio-psycho-social phenomenon, anatomy and
physiology of pain, pain assessment, pharmacological and
non-drug pain-relieving interventions and understand the
rationale for pain-relieving interventions).
One reason for the limited use of theoretical knowledge in
practice could be that because of their knowledge deficits,
nurses do not understand the rationale for using specific
interventions. Indeed, a review of pain content in preregistration diploma courses in England found that most child
branch curricula included <10 hours education on pain,
providing students with little more than a whistle-stop tour
of pain management (Twycross 2000). This concurs with the
findings of a study carried out in the USA by Graffam (1990)
which found that the amount of time devoted to pain in
nursing curricula ranged from two hours to more than
15 hours. It is perhaps not surprising that knowledge deficits
remain. Further research is needed to ascertain the optimum
time and content required on pain management in preregistration nursing curricula.
There is a need to develop educational initiatives that
promote the use of theoretical knowledge in practice. Several
educational strategies have been suggested in this context.
Ochieng (1999) describes the use of reflective practice as a
method of changing pain management practices. Three
months after the start of the project, practices did appear to
have changed but there was no evaluation of whether this
was sustained long term. Other suggestions for improving the
use of knowledge in practice, which have not yet been tested,
include:
The clinical discussion of individual patients and their care
(Graffam 1990).

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

Review

Incorporating clinical scenarios and simulations into

teaching (Lee & Ryan-Wenger 1997, Cioffi 1998, Jones &
Sheridan 1999, Cioffi 2001).
Teaching rounds (Segal & Mason 1998).
Journal clubs (Kessenich et al. 1997, Khalid & Gee 1999).
Some methods of learning (for example, confluent education) emphasise the importance of integrating left brain
knowledge with right brain creativity. These teaching methods may help ensure the integration of theory and practice.
The importance of reflection in integrating theory and
practice has also been emphasised (Atkins & Murphy 1994;
Rolfe 1996). The use of scenario based or problem-based
learning seems to support the integration of theoretical
knowledge into practice; however this needs further research.
Educational strategies need to be used that incorporate
theoretical knowledge into practice.

Supporting decision-making
A review of the decision-making literature provides no
definitive answers about ways to improve nurses decisionmaking strategies or how to ensure that current best practice
guidelines are used when making clinical decisions. One
possible method would be the use of a decision-making
algorithm. The effectiveness of an algorithm in conjunction
with the administration of regular multimodal analgesia was
tested by Falanga et al. (2006). Data were collected relating
to the care for children (n = 112), aged 517, before and after
the implementation of the algorithm. When the algorithm
was used, children received more analgesia and had lower
pain intensity scores, suggesting that this is an effective way
of improving pain management. However, it was unclear
how long after the implementation, the second set of data
were collected. Several algorithms are available to support
decision-making (see, for example, Craze et al. 2005, Megens
et al. 2008, Dowden 2009, Stinson & Bruce 2009). Developing and using algorithms from best practice guidelines
would remove much of the stress associated with decisionmaking and would guide nurses through the process in a stepby-step way. This might help ensure that best practice
guidelines are adhered to and thus improve pain management
practices. Further research is needed in this area.

Making pain an organisational priority

An increasing number of research studies have concentrated
on the impact of including pain management in an organisations quality improvement programme (Treadwell et al.
2002, Jordan-Marsh et al. 2004, Ellis et al. 2007, Megens
et al. 2008, Oakes et al. 2008). The JCAHO standards

Managing pain in children

(2001) in the USA and the English National Service Framework for Children, Young People and Maternity Services
(DH 2004) also promote the need for an organisational
commitment to pain management. Several ways of ensuring
pain as an organisational priority have been identified
including setting and auditing pain standards (JCAHO
2001; Department of Health 2004); having a pain management service (UNICEF 1999; Royal College of Anaesthetists
(2001) and introducing pain link nurses (Ferrell et al. 1993,
McCleary et al. 2004). A pictorial representation of the
strategies required to make pain an organisational priority
can be seen in Fig. 1.

Setting and auditing pain standards

The first step in making effective pain management an
organisational priority is to audit current practice against
selected best practice guidelines. These pain management
standards should be audited on a regular basis (at least every
six months). Following completion of the audit, an action
plan should be drawn up. Once sufficient time has been given
for changes to be implemented, practice should be re-audited.

Pain management services

Another organisational strategy for improving pain management is the development of a pain service. Guidance on the
provision of paediatric anaesthetic services by the RCA in the
United Kingdom emphasises the need for a properly staffed
and funded acute pain service covering the needs of children
(RCA 2001). The RCA recommend that a member of the
acute pain service should visit all childrens surgical wards
every day and see all children having major surgery. This is
supported by the UNICEF child-friendly hospital initiative,
which states that a team should be established whose remit is
to establish standards and guidance in the control of pain and
discomfort in children (UNICEF 1999). Many childrens
hospitals have such teams; however, the effectiveness of these
services does not appear to have been evaluated.
A pain nurse visiting the wards each day can provide
support to the nurses caring for children in pain. This could
reduce the stress associated with decision-making when
caring for children in pain and may also increase nurses
confidence regarding pain management. No evaluation of
paediatric pain services was found while undertaking this
review. However, several studies have examined the effect of
introducing an adult pain service. A study in Wales found
that the introduction of an acute pain service led to a
statistically significant improvement (p < 001) in the level
of adults postoperative pain (assessed by visual analogue

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

2095

A Twycross

Pain management considered a high priority by

organisation

Pain management policy

and quality standards
National, e.g. JCAHO; pain: the
5th vital sign; clinical guidelines,
NSF.
Applied at a local level

Education
Orientation/induction
On-going
All levels/disciplines of
clinical staff
Decision-making strategies
Encouraging reflection on
practice
Problem-solving approach

Standards are
audited regularly
(seen as organisational
performance indicator)

Pain management service

For all patients with pain
Having a nurse as a
clinical role model/clinical
leader is important
Multi-disciplinary

Algorithm(s)
Pain link nurses

To support decision-making

Provide link between Pain

Management Service and wards
Act as role models
Adequately resourced; time,
education, support, etc

Action plan
To address areas in need
of improvement

Improvements in
practice encouraged

Figure 1 Improving pain management practices: organisational aspects.

scores) (Gould et al. 1992). Further, Bardiau et al. (2003)

found a significant improvement in patients pain scores
(p < 0001) when a pain management service was introduced in one hospital in Belgium. This concurs with the
findings of other studies (Stratton 1999, McDonnell et al.
2005).

Pain link nurses

Pain link nurses enable nurses working in a pain management
service to have better links with the wards. Pain link nurses
provide educational support and advice on pain-related issues
in their ward/department (Ferrell et al. 1993, Ellis et al.
2007). Human sources of information have been shown to be
important in changing practices and in the dissemination of
research evidence into practice (Thompson et al. 2001;
McCaughan 2002). Indeed, facilitators have been described
as having a key role in relation to getting evidence into
practice (Harvey et al. 2002, Rycroft-Malone et al. 2002).
The use of link nurses has been suggested as a way of
increasing the application of research in practice both
generally (Thompson et al. 2001) and in relation to pain
management (Ferrell et al. 1993, McCleary et al. 2004), but
such roles need to be resourced adequately. The use of
facilitators was taken a step further in a clustered randomised
trial carried out by Johnston et al. (2007) in Canada. One-on2096

one coaching with audit feedback was used to improve

individual nurses pain assessment and management practices. The rate of pain assessment, nurses knowledge and
non-drug interventions increased in the coaching group, but
not all the differences could be attributed to the coaching.
The authors conclude that institutional factors need to be
considered alongside the role of individual nurses. Further
research is needed in this area.

Conclusion
Factors that contribute to continuing poor pain management
practices include knowledge deficits; incorrect or outdated
beliefs about pain and pain management; the decisionmaking strategies used and organisational culture. Improving
pain management thus requires a multifactorial approach
encompassing institutional support, attitude shifts and
change leaders (for example, nurses working in the pain
service and pain link nurses in ward areas).
Issues that need addressing include education, decisionmaking strategies and organisational practices. Educational
strategies need to promote the integration of theory and
practice as well as ensuring that nurses understand the
rationale for pain-relieving interventions. Nurses need support in their decision-making about managing childrens
pain; the use of algorithms may be useful in this context. Pain

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

Review

management needs to be an integral part of an organisations

quality improvement programme. This includes setting and
auditing standards. The use of adequately educated and
resourced pain link nurses has also been suggested as a means
of providing good role models and for disseminating
evidence-based information in a non-threatening way. Further research needs to be carried out to determine other
factors that impact on pain management practices.

Relevance to clinical practice

The literature reviewed in this paper suggests that ensuring
children receive optimal pain management while in hospital
will require several factors to be addressed simultaneously.
These factors include:
Ensuring that nurses have the requisite knowledge about
pain in children and are able to apply this in practice.
Addressing nurses beliefs and attitudes about managing
pain in children.
Using algorithms to support nurses in their decisionmaking processes.
Making pain management an organisational priority.

Contributions
Study design: AT; data collection and analysis: AT and
manuscript preparation: AT.

Conflict of interest
None.

References
Atkins S & Murphy K (1994) Reflective practice. Nursing Standard
22, 4956.
Bardiau FM, Taviaux NF, Albert A, Boogaerts JG & Stadler M
(2003) An intervention study to enhance postoperative pain management. Anesthesia and Analgesia 96, 179185.
Botti M, Bucknall T & Manias E (2004) The problem of postoperative pain: issues for future research. International Journal of
Nursing Practice 10, 257263.
Bruce E & Franck LS (2005) Using the worldwide web to improve
childrens pain care. International Nursing Review 52, 204209.
Bucknall T, Manias E & Botti M (2001) Acute pain management:
implications of scientific evidence for nursing practice in the
postoperative context. International Journal of Nursing Practice 7,
266273.
Byrne A, Morton J & Salmon P (2001) Defending against patients
pain: a qualitative analysis of nurses responses to childrens
postoperative pain. Journal of Psychosomatic Research 50, 69
76.

Managing pain in children

Cioffi J (1998) Decision making by emergency nurses in triage
assessments. Accident and Emergency Nursing 6, 184191.
Cioffi J (2001) Clinical simulations: development and validation.
Nurse Education Today 21, 477486.
Craig KD (2009) The social communication model of pain. Canadian
Psychology 20, 2232.
Craze J, Turner C, Taylor J, Adam R & Jacobs K & the Multidisciplinary Procedural Distress Group (2005) Guidelines for the
Prevention and Management of Procedural Distress. Multidisciplinary Procedural Distress Group, Oxford Radcliffe Hospital,
Oxford.
Department of Health (2004) National Service Framework for
Children, Young People and Maternity Services. The Stationery
Office, London.
Dowden SJ (2009) Management of acute pain in children. In Managing Pain in Children: A Clinical Guide (Twycross A, Dowden SJ
& Bruce EA eds). Wiley-Blackwell, Oxford, pp. 109144.
Ellis JA, McCleary LM, Blouin R, Dube K, Rowley B, McNeill M &
Cooke C (2007) Implementing best practice pain management in a
pediatric hospital. Journal for Specialists in Pediatric Nursing 12,
264277.
Falanga IJ, Lafrenaye S, Mayer SK & Tetrault J-P (2006) Management of acute pain in children: safety and efficacy of a nursecontrolled algorithm for pain relief. Acute Pain 8, 4554.
Ferrell BR, Grant M, Ritchey KJ, Ropchar LM & Rivera LM (1993)
The pain resource nurses training program: a unique approach to
pain management. Journal of Pain and Symptom Management 8,
549556.
Finley GA, Franck LS, Grunau RE & von Baeyer CL (2005) Why
childrens pain matters. Pain: Clinical Updates XIII, 16.
Franck LS & Bruce EA (2009) Putting pain assessment into practice:
why is it so painful? Pain Research and Management 14, 1320.
Gould TH, Crosby DI, Harmer M, Lloyd SM, Lunn JN, Rees GAD,
Roberts DE & Wenster JA (1992) Policy for controlling pain after
surgery: effect of sequential changes in management. British
Medical Journal 305, 11871193.
Graffam S (1990) Pain content in the curriculum A survey. Nurse
Educator 15, 2023.
Griffin RA, Polit DE & Byrne MW (2008) Nurse characteristics
and inferences about childrens pain. Pediatric Nursing 34, 297
307.
Hamers J, Abu-Saad H, Halfens RJG & Schumacher JNM (1994)
Factors influencing nurses pain assessment and interventions in
children. Journal of Advanced Nursing 20, 853860.
Hamers JPH, van den Hout MA, Halfens RJD, Abu-Saad HH &
Heijltjes AEG (1997) Differences in pain assessment and decisions
regarding the administration of analgesics between novices, intermediates and experts in pediatric nursing. International Journal of
Nursing Studies 34, 325334.
Hamers JPH, Abu-Saad HH, van den hout MA & Halfens RJG
(1998) Are children given insufficient pain-relieving medication
postoperatively?. Journal of Advanced Nursing 27, 3744.
Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A,
McCormack B & Seers K (2002) Getting evidence into practice:
the role and function of facilitation. Journal of Advanced Nursing
37, 577588.
Health Care Commission (2004) Patient Survey Report 2004
Young Patients. Health Care Commission, London.

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

2097

A Twycross
Health Care Commission (2007) Improving Services for Children in
Hospital. Health Care Commission, London.
Johnston CC, Gagnon AJ, Pepler CJ & Bourgault P (2005) Pain in the
emergency department with one-week follow-up of pain resolution. Pain Research and Management 10, 6770.
Johnston CC, Gagnon AJ, Rennick J, Rosmus C, Patenaude H, Ellis J,
Shapiro C, Filion F, Ritchie J & Byron J (2007) One-on-one
coaching to improve pain assessment and management practices of
pediatric nurses. Journal of Pediatric Nursing 22, 467478.
Joint Commission for the Accreditation of Healthcare Organizations
(2001) Pain Assessment and Management Standards. Oakbrook
Terrace, JCAHO, Illinois.
Jones DC & Sheridan ME (1999) A case study approach: developing
critical thinking skills in novice pediatric nurses. The Journal of
Continuing Education in Nursing 30, 7578.
Jordan-Marsh M, Hubbard J, Watson R, Deon Hall R, Miller P &
Mohan O (2004) The social ecology of changing pain management: do I have to cry? Journal of Pediatric Nursing 19, 193
203.
Kessenich C, Guyatt G & DiCenso A (1997) Teaching nursing students evidence-based nursing. Nurse Educator 22, 2529.
Khalid SK & Gee HA (1999) A new approach to teaching and
learning in journal clubs. Medical Teacher 21, 289293.
Lamond D, Crow RA & Chase J (1996) Judgements and processes in
care decision in acute medical and surgical wards. Journal of
Evaluation in Clinical Practice 2, 211216.
Lauzon Clabo LM (2008) An ethnography of pain assessment and
the role of social context on two postoperative units. Journal of
Advanced Nursing 61, 531539.
Lee JEM & Ryan-Wenger N (1997) The think aloud seminar for
teaching clinical reasoning; A case study of a child with pharyngitis. Journal of Pediatric Health Care 11, 101110.
Manworren RCB (2000) Pediatric nurses knowledge and attitudes
survey regarding pain. Pediatric Nursing 26, 610614.
McCaughan D (2002) What decisions do nurses make? In Clinical
Decision Making and Judgement in Nursing (Thompson C &
Dowding D eds). Churchill Livingstone, Edinburgh, pp. 95108.
McCleary L, Ellis JA & Rowley B (2004) Evaluation of the pain
resource nurse role: a resource for improving pediatric pain management. Pain Management Nursing 5, 2936.
McDonnell A, Nicholl J & Read S (2005) Focus. Exploring the
impact of Acute Pain Teams (APTs) on patient outcomes using
routine data: can it be done?. Journal of Research in Nursing 10,
383402.
Megens JHAM, van der Werff D & Knape JTA (2008) Quality
improvement: implementation of a pain management policy in a
university pediatric hospital. Pediatric Anesthesia 18, 620627.
Oakes LL, Anghelescu DL, Windsor KB & Barnhill PD (2008) An
institutional quality improvement initiative for pain management
for pediatric cancer inpatients. Journal of Pain and Symptom
Management 35, 656669.
Ochieng BMN (1999) Use of reflective practice in introducing change
on the management of pain in a paediatric setting. Journal of
Nursing Management 7, 113118.
Polkki T, Pietila A-M & Vehvilamen-Julkunen K (2003) Hospitalized
childrens descriptions of their experiences with postsurgical pain
relieving methods. International Journal of Nursing Studies 40,
3344.

2098

Rieman MT & Gordon M (2007) Pain management competency

evidenced by a survey of pediatric nurses knowledge and attitudes.
Pediatric Nursing 33, 307312.
Rieman MT, Gordon M & Marvin JM (2007) Pediatric nurses
knowledge and attitudes survey regarding pain: a competency tool
modification. Pediatric Nursing 33, 303306.
Rolfe G (1996) Closing the Theory Practice Gap: A New Paradigm
for Nursing. Butterworth-Heinemann, Oxford.
Royal College of Anaesthetists (2001) Guidance on the Provision of
Paediatric Anaesthetic Services. Royal College of Anaesthetists,
London.
Rycroft-Malone J, Kitson A, Harvey G, McCormack B, Seers K &
Estabrooks C (2002) Ingredients for change: revisiting a conceptual framework. Quality and Safety in Health Care 11, 174
180.
Salantera S & Lauri S (2000) Nursing students knowledge of and
views about children in pain. Nurse Education Today 20, 537
547.
Salantera S, Lauri S, Salmi TT & Helenius H (1999) Nurses
knowledge about pharmacological and non-pharmacological pain
management in children. Journal of Pain and Symptom Management 18, 289299.
Schmidt K, Eland J & Weller K (1994) Pediatric cancer pain management: a survey of nurses knowledge. Journal of Pediatric
Oncology 11, 412.
Segal S & Mason DJ (1998) The art and science of teaching rounds.
The Journal for Nurses in Staff Development 14, 127136.
Stinson J & Bruce E (2009) Management of acute pain in children. In
Managing pain in children: A clinical guide (Twycross A, Dowden
SJ & Bruce EA eds). Wiley-Blackwell, Oxford, pp. 145170.
Stratton L (1999) Evaluating the effectiveness of a hospitals pain
management project. Journal of Nursing Care Quality 13, 818.
Taylor EM, Boyer K & Campbell FA (2008) Pain in hospitalized
children: a prospective cross-sectional survey of pain prevalence,
intensity, assessment and management in a Canadian pediatric
teaching hospital. Pain Research and Management 13, 2532.
Thompson C, McCaughan D, Cullum N, Sheldon T, Mulhall A &
Thompson D (2001) The accessibility of research-based knowledge
for nurses in the United Kingdom acute care settings. Journal of
Advanced Nursing 36, 1122.
Treadwell MJ, Franck LS & Vichinsky E (2002) Using quality
improvement strategies to enhance pediatric pain assessment.
International Journal for Quality in Health Care 14, 3947.
Twycross A (1999) Pain management: a nursing priority? Journal of
Child Health Care 3, 1925.
Twycross A (2000) Education about pain: a neglected area? Nurse
Education Today 20, 244253.
Twycross A (2002) Educating nurses about pain management: the
way forward. Journal of Clinical Nursing 11, 705714.
Twycross A (2007a) Childrens nurses postoperative pain management practices: an observational study. International Journal of
Nursing Studies 44, 869881.
Twycross A (2007b) What is the impact of theoretical knowledge on
childrens nurses postoperative pain management practices? An
exploratory study. Nurse Education Today 27, 697707.
Twycross A (2008) Childrens nurses pain management practices:
theoretical knowledge and perceived importance. Journal of Clinical Nursing 17, 32053216.

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

Review
Twycross A & Powls L (2006) How do childrens nurses make
clinical decisions? Two preliminary studies. Journal of Clinical
Nursing 15, 13241335.
UNICEF (1999) Global millennium targets: UNICEF child-friendly
hospital initiative. Paediatric Nursing 11, 78.
Vincent CVH (2005) Nurses knowledge, attitudes and practices
regarding childrens pain. MCN 30, 177183.
Vincent CVH & Denyes MJ (2004) Relieving childrens pain: nurses
abilities and analgesic administration practices. Journal of Pediatric Nursing 19, 4050.

Managing pain in children

Watt-Watson J, Stevens B, Garfinkel P, Streiner D & Gallop R (2001)
Relationship between nurses pain knowledge ad pain management
outcomes for their postoperative cardiac patients. Journal of
Advanced Nursing 36, 535545.
Woodgate R & Kristjanson L (1996) A young childs pain: how
parents and nurses take care. International Journal of Nursing
Studies 33, 271284.

 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 20902099

2099

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.
Users should refer to the original published version of the material.