A1: Describe a healthcare problem The problem presented is pain control in children postoperatively. Currently there are no proven ways to accurately measure postoperative pain in children. Hospital staff tend to under estimate the pain of children. Staff have only the word of patients and caregivers, combined with pain scales, which can be less than reliable due to the fact that many of them are utilizing opinions and visual cues. It is more difficult to gauge the pain of a child, especially under the age of 5, and in nonverbal children.
So, the real problem is that many children do not have properly managed pain postoperatively. A2: Explain the significance of the problem The main problem with uncontrolled postoperative pain is lack of communication among staff, patients and caregivers. Children should not be in unnecessary pain. This also causes increased anxiety for the parents and children. In turn this causes friction and mistrust between the staff and parents/ caregivers. Another significant problem is parents are forcing children to tolerate pain.
According to Valizadeh, “Some parents considered postoperative pain as normal and anticipated” (Valizadeh, Ahmadi, & Zarea, 2016, p. 445). If staff members are unable to control a child’s pain the patient and caregiver will not rest, relax or heal properly. In addition to poorly managed pain control the patients and parents are unprepared perioperatively. According to Rabbitts, “families felt that surgical preparation did not accurately reflect the experience” (Rabbitts et al. , 2016, p. 4-5).
There are some physicians who are apprehensive about prescribing narcotics to pediatric patients. A3: Describe the current practice related to he problem Often times the patient is given the lowest dose possible for their weight or non-narcotic medications that are not enough to control the pain. This practice leaves the nurse to utilize all that we have available before we call the physician to prescribe another medication or increase the dosage. In the meantime, the patient is suffering and the parent is frustrated. Currently for pain assessment in our hospital we utilize several methods. We use FLACC (face, legs, activity, cry and consolability), FACES, Numeric, and CRIES (Crying, required oxygen, increased vital signs, expression, sleepless).
Along with these staff also rely on the parents/caregivers to inform us. Many time the parent/ caregiver is not available and the staff have to rely on patient if they are old enough, assessment tools and the staffs’ visual assessment. The surgical floor in our hospital is occupied with many developmentally delayed children. This poses an additional problem with pain assessment due to the fact that the patients are nonverbal or cognitively delayed and are not able to express pain in a way that staff can legitimately use selfassessment tools for them.
When Parents/caregivers are available, they will tell staff when they feel patient is in pain. Many times, staff members feel parents/caregivers over react and just want child sedated so they can sleep. According to Thel Khin Hla, “Parental pain scores showed a strong correlation with children’s scores. As such, parental scoring of pain is a reliable proxy to use when children cannot score their own pain” (Khin Hla et al. , 2014, p. 1130). Parents know their children and should be listened to. A4: Discuss how the problem impacts the organization and/or patient’s cultural background
The current practice in the organization is slightly different for each group of physicians. The surgical floor is home to all noncritical, non-cardiac surgical patients. This includes urology, ENT, general pediatric surgery, nephrology, orthopedics and craniofacial. Each discipline has certain order sets they follow. Pain control is also different for each discipline. This causes much confusion for the nursing staff to go between disciplines and not have a hospital wide pain protocol. Perioperative preparation is also an issue.
Many of the disciplines do not properly prepare the parents/caregivers or the patients on what to really expect postoperatively. C1: Identify the keywords used for the search/C2: Describe the number and types of articles that were available for consideration Utilizing the WGU library, a search was done using the key words: postoperative pain in pediatrics. Search dates were 2013 – 2017 to make sure the guidelines of 5 years were followed. All articles were peer reviewed and in Academic journals. The number of articles that populated was 23,633.
This number was still too large so the phrase “parent expectations’ was added and also ‘nursing experience’. Using these added phrases got the article count down to 753. Scrolling through the articles I chose 15 to review. Of those, 7 were qualitative, 2 were quantitative, 3 were reviews of mixed research papers, 1 was Quality Improvement, 1 was Guidelines and the final was a pilot study. E: Recommended Practice Changes This author currently works in an establishment that does not incorporate beside reporting as a general practice. According to Valizadeh, “parents believe that healthcare professionals. .. o not involve them in children’s postoperative pain management” (Valizadeh et al. , 2016, p. 440). Incorporating beside nurse to nurse reporting would start involving the parents in the plan of care and pain management. This author feels this practice would be well received by the parents. Postoperative pain can last well beyond the hospital stay. Increased education for staff and parents/caregivers is essential to decrease postoperative pain.
One researcher states “families experience surgery as stressful, and felt underprepared for pain and recovery” (Rabbitts et al. , 2016, p. 1). Utilizing increased raining on postoperative pain for staff would help improve communication with patients and families for the days of recover. “Results show that regular training of the health care professionals and improvement of clinical processes led to a significant improvement in the quality of postoperative pain management” (Heinrich, Mechea, & Hoffmann, 2015, p. 592). This author recommends, beside reporting to include parents in pain management and plan of care in addition to increased training of the staff for pain management. This training would include the use of assessment tools and increased acknowledgement of parent’s perception of pain.
According to the authors of the paper on perception of pediatric pain, “Parental pain scores shoed a strong correlation with children’s pain scores. As such, parental scoring of pain is a reliable proxy to use when children cannot score their own pain” (Khin Hla et al. , 2014, p. 1130). F1: Key Stakeholders The key stakeholders for these changes would be the nurses, families, patients and educators. The educators would be utilized to train the nurses on how to do bedside reporting and continued education on postoperative pain control and how to assess it properly.
The nurses and families would benefit from bedside reporting due to the fact that the families would be involved in the plan of care for that shift and both nurses would have the same plan of care set with the patient and family. The patient would benefit the most. With these few changes, postoperative pain control would be able to be improved. F2: Barriers The first barrier this author sees is resistance from the nursing staff to do bedside reporting. Nurses are often times resistant to changes. Another barrier would be increased demand on the educators.
No money is needed to make these changes. F3: Strategies for Barriers Making the nursing staff aware of the neglect of postoperative pain management in the patient population would be a step in the right direction to making a change. Ensuring the staff that doing bedside reporting would not take any longer to accomplish than report at the nursing station. The nursing staff will also have to be made aware that getting the parents involved while reporting and confirming the plan of care they had during the day and what the plan of care is for the evening will make for a smoother shift.
This also alleviates the ever so present accusations from one shift to another. Teaching pain management is already a practice, but not to the extent of involving the parents and making sure we listen to them. Refreshers on how to use our assessment tools correctly. The educator could delegate some of the responsibilities to a team of nurses that she trains. This would take much of the responsibility off of the educator and help get the staff more involved in the changes that need to be made.
F4: Indicator to Measure Outcome Outcomes would be measured by utilizing the results of the NRC Picker, which is a survey the hospital utilizes post hospitalization. Staff could also put together a short survey of just a few questions to be asked at the time of discharge. This author would have two questions about the parent involvement and pain control during the hospital stay. The questions could be started one month prior to implementing changes and then the same questions asked for one month after implementation and compare the two.