Experience of Registered Nurses of Postoperative Pain Assessment Using Objective Measures among Children at Effia Nkwanta Regional Hospital in Ghana

Introduction

Surgical operations are inevitable in alleviating certain disease conditions, however, surgical procedures are associated with pain. Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”.¹ Postoperative pain refers to the pain experienced after surgery.² Studies show that children feel pain just like the adult population.^3-5 Every individual is entitled to pain management. Pain assessment must first be performed before treatment commences.^6-9

Pain assessment involves the use of subjective and objective measures and the subjective measures involve the use of self-reports where patients verbalize or describe their pain. Objective measures comprising behavioural and physiological measures are commonly used to assess children’s pain. Behavioural measures involve observing how a child behaves in response to pain such as facial expressions, crying, body postures and movements.¹⁰ Physiological measures include assessment of heart rate, blood pressure, respiration, oxygen saturation, palmer sweating and temperature.¹¹ For pain, assessment to be practical, and consistent pain assessment tools and guidelines are used. Some of the common pain assessment tools used among children include Faces Pain Scale-Revised (FPS-R), the Wong-Baker Faces Scale and the Oucher Scale, the Face, Legs, Activity, Cry and Consolability (FLACC), the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), the Toddler-Preschooler Postoperative Pain Scale (TPPPS), and the Parents’ Postoperative Pain Rating Scale (PPPRS).

It has been established that inadequate assessment of post-operative pain leads to inadequate management which can lead to severe complications such as delayed wound healing, deep vein thrombosis, atelectasis, pneumonia and even death.^12-15 Despite the knowledge and importance of pain assessment and availability of guidelines and assessment tools,^16-18 there are reports in many countries that nurses do not assess pain before administering pain medication after surgery.¹⁹

There is an extensive body of literature globally on children’s pain assessment. However, the majority of the studies focus on children four years and older with limited studies among children three years and younger. A number of these studies are on procedural pain such as pain from intravenous insertions and venipuncture and have mainly been conducted in emergency units ^20,21 and neonatal intensive care units.^22-24 Most of these research studies are quantitative,^25-27 and parents have mainly been the target population.^28-30

It is apparent that many gaps exist in the current literature regarding postoperative pain among children 0-3 years. In addition to limited research on these population, limited studies exist among nurses in surgical units. As nurses play a critical role in pain management, it is important to understand the experiences of nurses regarding pain assessment among these population to serve as a platform for more research to inform evidence-based pain management services for these population. This concept needs to be investigated further by qualitative methods. Children 0- 3 years usually are not considered when it comes to assessing pain and also most of the studies conducted are quantitative. It is in this view that the researchers attempt to fill the gaps in the literature. Therefore, the purpose of this study was to explore the lived experiences of registered nurses in assessing postoperative pain among children (0-3 years) using objective measures at the surgical unit at the ENRH in Ghana.

Materials and Methods

Descriptive phenomenology was adopted since it is beneficial in uncovering a phenomenon that has been incompletely conceptualized by prior research.³¹

The study was conducted in ENRH which is the biggest hospital in the Western Region of Ghana. It is a general hospital that takes care of all age groups. Nurses in this facility run a three shift system making nurses always available to care for patients. The participants consisted of registered nurses who had experience with nursing children after surgery. All potential participants that were approached agreed to participate in the study. Nine participants were recruited using maximum variation purposive sampling.

Face to face in-depth interview was used to collect the data with the help of an interview guide. The questions asked were: 1-Can you share with me from your experience some of the behaviours of the child after surgery that helps you to know the child is in pain? 2-Can you share with me some of the physiologic parameters that help you to know a child is in pain after surgery?

The participants were interviewed at their own time of convenience in the English language. The interviews lasted for approximately 45 minutes per person. Data were audiotaped and the participants were made aware of the audio recording. Field notes were also taken in addition to the audiotaping. The data saturation was observed after the seventh interview when there was data redundancy but we interview two more participants to confirm the saturation. Repeat interviews were conducted for two participants to data clarification. All the interviews were conducted by the principal investigator (SOOD). The strategies used to enhance the quality of the study followed recommended principles for enhancing trustworthiness in phenomenology.³² The trustworthiness of qualitative research is an indication of methodological soundness, and it includes credibility, dependability, transferability, confirmability and bracketing. Credibility was ensured by the researcher returning to the participants to ensure that the themes generated from the interviews are the nurses’ authentic experience of postoperative pain assessment in children consistent with step seven of the Colaizzi’s analysis framework used for this study. Dependability and confirmability were ensured in the data collection and analysis by the development of an audit trail. The researcher achieved transferability by providing a full description of the study. Bracketing requires researchers to set aside personal theories, research presuppositions, inherent knowledge, and assumptions as separate from what the researcher observed in the process.^33,34 A diary was kept to ensure bracketing. In the diary, the researcher wrote her presumptions and personal value systems. This was necessary as the researcher was a nurse and had experience with postoperative pain assessment among children.

After each day’s interview, the data recording was transcribed verbatim by the researchers in a Microsoft word document and analyzed following the Colaizzi’s methodological approach to a phenomenological inquiry which consists of the following seven steps³⁵:

Step 1: Each transcript was read several times in order to obtain a sense of the full content. During this stage, any thoughts, feelings and ideas that came from the researcher due to her previous work with postoperative children were added to the bracketing diary.

Step 2:During this stage, significant statements and phrases that reflect the methods and processes of objective measures that the nurses reported to have used to assess postoperative pain were extracted from each transcript. Initial coding was conducted by SOOD and confirmed by AAD, and EA. Disagreements were resolved through a consensus.

Step 3: After the completion of step two, there was the framing of the formulated meanings from each of the significant statements. The researchers arranged each significant statement in the left-hand column of a table in the word document with a column on the right for recording the formulated meaning.

Step 4: In this stage of the analysis, Colaizzi recommends the sorting formulated meanings into categories (sub-cluster themes), clusters of themes and themes. After describing all formulated meanings, there was organisation and grouping of the formulated meanings into thematic categories. Each category title reflected the cluster of themes that emerged from the formulated meanings under each category. Each formulated meaning could belong to only one category.

Step 5:In this stage of the analysis, Colaizzi advocates writing summaries for each of the clustered themes. The study presents these summaries in the next chapter. In order to continually link back to the importance of the participants’ descriptions of their experiences, quotations from their narratives were used during the exhaustive description in order to expand upon the themes with ‘real-world examples.

Step 6: This final stage involves formulating an exhaustive description of the investigated phenomenon as a statement of its fundamental structure. The results and discussion represent this type of exhaustive description and facilitate an in-depth understanding of the fundamental structure of the phenomenon being explored in this study.

Step 7: Colaizzi suggested a final validating step that could be achieved by returning to each participant in an interview setting to ask their opinion of the findings. The researcher returned to the participants after getting advanced approval during the in-depth interview to validate the findings. All participants confirmed that the results were a true reflection of their experiences of postoperative pain assessment among children.

Results

Table 1 presents the demographic characteristics of the nurse participants involved in the study. All the participants were registered nurses who had experience of nursing children with postoperative pain and were all females as there were no male nurses in the surgical ward where the participants were recruited. All the participants were assigned ID codes to ensure anonymity. The ages of the majority of the participants ranged between 30 to 40 years, with the average age being 32 years. The highest educational level of six participants was a diploma, five had a first degree, and one had a master’s degree. A majority had worked between two to sixteen years with the average years being 9 years as registered nurses. Concerning experience with children after surgery, the number of years of experience ranged from 8 months to 7 years and averagely, 3 years 8 months.

Discussion

The study revealed that with the objective measures, the participants reported having more experience in utilizing behavioural measures with limited use of physiological measures which is contrary to a previous study conducted by LaFond et al, who found that nurses used more physiological measures in the pediatric postoperative assessment.³⁶ This revelation could be because the nurses in this study did not have adequate knowledge of the various physiological measures that could be used to assess pain. This finding indicates a need to address this gap.

For behavioural measures, most of the participants in this study mentioned that they have experience in using the facial expression of the child to assess pain as reported previously.^37,38 However, the participating nurses failed to name the specific facial movements associated with pain that has been reported in the literature including brow bulge, eye squeeze, nasolabial furrow and open mouth as explained in earlier works.³⁹ Instead, they gave some of the descriptions of facial expression to be the child “squeezing the face”, “making funny faces” and also “making their faces as if they want to cry”. Using the exact facial movements as documented in literature helps in providing evidence-based care and also useful in distinguishing the facial expression in pain and those made in other conditions such as hunger. The findings indicate the need to teach the nurses on specific words to use for facial recognition of pain. Crying was used by the participants in this study to assess children’s pain, as reported in an earlier study conducted in Brazil by Silva et al.⁴⁰ The cry of the child in pain was different from the usual cry of the child ³⁸ since children specifically infants communicate through crying. The study revealed that children who experience pain cry profusely and do not respond to comfort measures such as feeding, swaddling and holding. Similar findings were described by James et al.⁴¹ Preverbal children in pain also pointed to the site for nurses to know which part of their body was in pain. The nurses in this study also said they had experience in using irritability and restlessness among children to detect pain. As reported in earlier literature, children in pain become irritable¹¹ and restless.³⁸

With the physiological measures, the temperature was widely used to assess pain. The nurses also stated that elevated body temperature in a child after surgery was an indication of the presence of pain which were stated in earlier litteature.^42,43 However, there is limited research on the use of body temperature as an indicator of pain. Just one participant each mentioned the use of pulse and respiration to detect pain, but none of them mentioned the use of oxygen saturation. A study stated that an increased pulse and respiration and decreased oxygen saturation as physiological measures used in pediatric pain assessment.⁴⁴ Though the participating nurses were aware that blood pressure could be used to detect pain, none of them reported having used it due to logistic challenges. Interestingly, one of the participants reported using the reddish appearance of the surgical wound to detect pain. This finding has not been reported in existing literature and calls for further research.

It was somewhat surprising to find that the nurses did not report the use of pain assessment tools despite the availability of pain assessment tools.^19,45 These findings indicate the need to train nurses to use such evidenced-based tools.

The subjectivity of data gathered poses limitations with phenomenology. The researcher overcame subjectivity by returning to the participants for them to validate the findings to ensure that it was a true reflection of their experiences of postoperative pain assessment among children.

Conclusion

The findings of the study have established that although the nurses have some experiences in children’s postoperative pain assessment, they do not formally use consistent approaches to assess pain among children. Opportunities should be made available for nurses to enhance their skills and utilize evidence-based approaches to formally assess postoperative pain among children.

Acknowledgement

The authors are grateful to all nurses who participated in this study for their immense contribution.

Ethical Issues

The study received ethical clearance from the Institutional Review Board of the University of Cape Coast with ethical clearance ID (UCCIRB/CHAS/2018/25), after which the researchers sought approval from the Effia Nkwanta Regional Hospital. The study adhered to all ethical research principles for human subjects.

Conflict of Interest

The authors declare no conflict of interest in this study.

Authors’ Contributions

Conception of the study and design, data collection, analysis and discussion. Drafted manuscript and critically revised the article: SOOD; Conception of the study and design, supervision of data collection, analysis and discussion. Also drafted and critically revised the article: AAD; Supervision of data collection, analysis and discussion. Also drafted the article: EAA.

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