Pain management is a complex area of patient care, especially when it involves children. This qualitative study undertaken in Dublin and Cork in Ireland set out to identify any barriers to effective pre-hospital paediatric pain management as perceived by a group of advanced paramedics (AP).
The researchers wanted to explore practitioners’ experiences in order to better understand their perspectives. To facilitate this a qualitative approach employing focus groups was adopted. Two focus groups were held, with 12 APs in one group and four in another. No explanation was given as to the differing size of focus groups.
The focus group interview guide is included in the paper which usefully informs readers that the discussion was structured around topics such as participants’ experiences of paediatric pain management; views about current clinical practice guidelines and the role of both pharmacological and non-pharmacological approaches; and opinions as to alternatives to current practice.
The interviews were recorded, transcribed verbatim and analysed using thematic network analysis moving through a sequence of developing ‘codes’, identifying ‘basic themes’, constructing ‘organising themes’ and ending up with a ‘global theme’.
The researchers identified a global theme of ‘understanding barriers to the pre-hospital management of acute pain in children’ which emerged from three organising themes: AP education and training, current clinical practice guidelines for paediatric pain management, and realities of pre-hospital practice.
The overall findings suggest that participants consider that there is inadequate focus on paediatric pain management in both undergraduate programmes and also in activities targeted at continuing professional development. Recommendations to address this problem included an increased number of placements in paediatric emergency departments plus greater use of simulation and e-learning to correct this deficit.
In relation to the current clinical practice guidelines, participants identified difficulties both in assessing pain levels in young children as well as in administering either oral or inhaled analgesia to distressed and uncooperative children. Some participants believed that intranasal drugs are easier to administer with minimal patient discomfort and therefore may be more useful when attempting to manage a child's pain.
Within the theme relating to the realities of pre-hospital practice, it was clear that participants lacked confidence in managing sick children and attributed this to their infrequent exposure to these patients.
If paediatric patients geographically were not far from hospital or were in pain due to a ‘medical’ undiagnosed cause, rather than from a clear injury, then they were less likely to be given analgesia, with the AP preferring to wait until they get to hospital.
Some participants reported having experienced conflicting ideas of patient management between different professions, with APs reporting that some GPs still promote the ‘myth’ that analgesia should not be given to patients in abdominal pain for fear of ‘masking’ symptoms. Desire to avoid this type of conflict appeared, on occasion, to influence APs’ decisions as to whether to administer analgesia or not.
The authors recognise that this is a small-scale study and as such its findings are not generalisable. In the future, they intend to undertake a survey informed by the findings of this study in order to gain a broader perspective from a wider range of the emergency medical services’ workforce on this topic.
This is a timely study as pain management is increasingly being seen as a key performance indicator within ambulance Trusts. Identifying the barriers to delivery of optimal pain management is a very necessary first stage in the process of working towards improvements in the treatment of acute pain in this vulnerable patient group.