Ouch! Why is it so hard to assess children's pain?

The simple answer it is difficult to assess pain full stop, because pain is by definition subjective, the classic definition being that it is whatever the experiencing person says it is.  With children of course there is the added complication of developmental issues, in particular the inability to verbalise pain.

To get round this, there are a large number of different pain assessment tools and scales, ranging in complexity from a straight line with no pain at one end and the worst imaginable pain at the other; to quite sophisticated behavioural tools, which try to identify behaviours associated with pain.  The problem remains though; how do you know when someone who can't verbalise pain is in pain, and how do you know your treatment is working?

A new study has looked at two tools that are fairly commonly used, a 'faces' scale and a colour intensity scale.  The first has faces that reflect differing degrees of discomfort; the second a graduated colour scale, where more intense colour is associated with greater pain.  In my travels around hospitals in the UK, I have to say that I see these scales a lot, but I rarely see them actually used.  Never mind lets press on with the study.

They looked at the reliability and validity of these tools in children aged between 4 and 17 years in the United States who had painful and non-painful conditions; and compared the two tools.  When you are assessing how useful tools such as this are, there are two key things that people look for:

1. Validity - is it actually measuring what you think it is (in this case is it measuring pain, or might it be measuring something else, such as mood?)
2. Reliability - how consistent is it, in other words if you measured the same thing twice at the same time, would you get the same answer?

They actually did some quite sophisticated tests here, and found that overall the tools seemed to work quite well.  However, there is a but..

Firstly, the children were quite old; and there was least agreement between the tools in the youngest age-group, which is the very children in which it is hardest to measure pain.  Secondly, validity is context specific.  Just because it works with these children in this place at this time, it does not mean it is going to work elsewhere.  Watch for this one, the famous 'validated tool' which people talk about without often knowing the circumstances of the validation.  For example, a tool validated among old people in New York is not likely to be valid for children in Bolton.  You may think this sounds far fetched (and it is a bit) but I have seen similar claims made.  Lastly just because two tools agree, it doesn't make them right - they could both be wrong.  Often people refer to a 'gold standard' measure and compare a new measure to this, but even then there can be problems, for example the existing standard may itself not be very good.  Everyone 'agreed' about banking 5 years ago - it is just a shame that they were all wrong.

For parents my suggestion is to know your child's pain behaviours, and make sure that when you are with healthcare professionals you make them know that you know!

Tsze (2013) validation of self-report pain scales in children.  Pediatrics 132 e971-979

So you want to be a children's nurse?

Most Universities will be full for September now, but before you know it they will be interviewing for 2014, so if you want to be a children’s nurse, what might you think about in preparing for your application?  Here are some thoughts; but note I am not an admissions tutor (if I were I would not be able to do this!) and there are no guarantees, these are just some thoughts.  

Before you apply, think about where you want to go to University, but also remember that you will have placements that may start/finish at unsocial hours.  Find out where you will be doing placements and can you get there and home early in the morning and late at night, and at weekends?

Having done this, what about your statement and interview?  The first thing is, and I don’t want to sound patronising, but being a children’s nurse is not like being a nursery nurse, be clear that you know the difference.  I am not going to tell you what these differences are, if you want to be a nurse you should know or find that out, a hint however is that saying ‘I want to be a children’s nurse so that I can look after/because I like children’ is probably not going to be enough.  

Secondly, remember that although a lot of children’s nursing is done in hospital, even more is done out of hospital.  Nurses don’t just work with sick children, but increasingly with well children; trying to prevent disease as well as to treat it.  Even for children who are sick, they are looked after at home as far as possible.  This is where the future really lies, to find out more look up health visiting or community nursing on the search engine of your choice.

Thirdly, have some idea of what is going on both in the world, the nation, and in the NHS.  Look up a few recent reports and have some idea of what they said; for example try the Kennedy Report.   Don’t read the whole thing (unless you want to), when you get reports such as this look for something called the Executive Summary – it is all you need to know in a few pages.

Fourth, if you have trouble with maths, get some help.  You will have to do a maths test at some point – it will usually be at the interview stage, but you will also have to demonstrate your ability to do basic maths throughout the course.  This is crucial for the delivery of safe care; most children’s drugs for example are given according to weight (usually) or surface area, and so you need to be able to calculate these doses.

Fifth, remember children are not ‘little adults’; but developing individuals.  Think about children of different ages, and how they develop both physically and cognitively (how they think and understand the world).  For example, the heart rate of a baby is much higher than an adult; and a rash will seem different to a 3 year-old than to a 14 year-old.

Six, try and think about things from the child and families point of view; what do you think matters to them?  You might get some clues from this blog and other websites - but just think logically, even better, ask some children!

Finally, you need to be competent to practice as a nurse, but you also need to be nice.  Show this side: be assertive, but be polite; be professional, but smile; take part in group exercises, but don’t be too pushy.

Good luck!