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Clinical situation
In a critical care setting such as the Pediatric Emergency Department (PED), I gained a
deep appreciation early on of the importance of pain management and distraction techniques.
These therapies play a valuable role in preventing long-term medical trauma. Our goal is to
implement a family-centered approach to all procedures as most procedures are new to this
population and can have negative connotations if not approached properly. This approach
consists of educating the patient and his family in an easily understandable language, devoid of
medical jargon. During this shift, my preceptor and I were assigned to a total of four patients,
one mental health patient, two patients with asthma exacerbation and one patient with fever due
to sickle cell crisis. The sickle cell patient was experiencing a pain crisis which can be
nociceptive, neuropathic or both and is described as a sudden recurring episode of severe pain
(Abdo et al., 2019). This patient was a 4-year-old African American child who arrived on the
main side of the PED with his father. The family had gone to the PED the day before, where
they had received minimal care for hours, resulting in a slight improvement before being
discharged. However, they returned as the child's fever had reached 40 degrees and the child
was showing clear signs of discomfort and pain. After receiving the report from the night nurse,
it was evident that the patient required blood work and peripheral intravenous (PIV) access for
bolus administration due to dehydration as a result of the pain crisis they were experiencing.
Additionally, upon review of the chart there was no history of pain analgesia or topical
anesthetics given within the last 10 hours that the patient was in the hospital. Unfortunately, due
to dehydration, inserting a PIV and performing blood work was extremely difficult. The night shift
nurses made a total of six attempts to start a PIV, notably the policy for inserting PIVs in PED
only allows 2 attempts per nurse. The night nurse praised the child's courage and his ability to
remain still during the first couple painful attempts. When my instructor made two more insertion
attempts, the child was screaming in pain and looking around tearfully for his father, who was
standing silently in the corner unbeknown of what to do to support his child. On the instructor's
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second attempt, which was the eighth attempt overall, we were finally able to secure the PIV
and start the bolus. The moment the IV was successfully inserted, using minimal verbal
distraction as our pain management technique, the gravity of the situation became apparent.
Analysis of sociopolitical factors
Upon analysis of this situation there are various socio-political factors involved, a primary
factor is racial bias which is when black individuals are systemically undertreated for pain due to
false beliefs about biological differences compared to their white counterparts (Hoffman et al.,
2016). Racial bias dates back to the early 19th century where false knowledge was reinforced to
strengthen existing racialized power structures and justify mistreatment of black individuals
(National Academies of Sciences et al., 2020). The bias experienced in this situation could also
be explained as unconscious bias which refers to unconscious stereotypes that affect one’s
understanding, interactions and decision with a targeted group (National Academies of Sciences
et al., 2020). Furthermore, by applauding the child's bravery and strength rather than providing
appropriate topical anesthetic, such as EMLA cream which is effective for local pain control such
as PIV, the nurses were unintentionally dismissing the child's pain (Chumpitazi et al., 2022). The
long-term repercussions of this scenario may lead to inadequate pain treatment for the patient,
potentially resulting in their suffering, frequent requests for pain medication, or multiple visits to
the ED (Shapiro et al., 1997). While this is understandable behavior to their unacknowledged
pain, a biased healthcare professional may view this as proof of symptom dramatization or early
addiction for these patients (Shapiro et al., 1997). Another factor present in this scenario is the
barrier in providing adequate pain management in the pediatric population, examples of
contributing barriers are nursing shortages resulting in increased workload (Twycross, 2013).
The complexity and subjectivity of pain assessment, specifically in the pediatric population
demands a significant amount of time however, when nurses are overwhelmed with tasks they
are unable to perform thorough pain assessments utilizing age appropriate pain measuring
scales (Kusi Amponsah et al., 2020). Pediatric pain assessment and management is intricate
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and multileveled, unlike adults, children are usually unable to accurately rate their pain from
0-10 and require different tools such as the Wong-Baker scale (O’Donnell & Rosen, 2014).
However, their use often requires specialized knowledge and training but the occurring staffing
shortages results in decreased availability to learn (Chumpitazi et al., 2022). Consequently, the
use of age-appropriate pain scales may be limited thus further exacerbating inadequate pain
management. The absence of interprofessional collaboration within the interdisciplinary team is
another factor that has been identified in the scenario. Child-life specialists are crucial and
underutilized members, they are psychosocial healthcare professionals with a focused
education on child development, family relations and supportive interventions based on
scientific evidence (Boles et al., 2020). They facilitate patient coping by preparing them and their
families for surgery or unpleasant medical procedures by utilizing open communication, play
based learning and identifying the child’s perceived fears to alleviate their anxiety and prevent
medical trauma (Boles et al., 2020). Multidisciplinary collaboration would have been vital in this
situation, if utilized appropriately then the nurses would have been able to feel confident tending
to the patient's medical needs while still ensuring that their emotional coping needs are being
addressed (Boles et al., 2020). By collaborating with the interdisciplinary team, the family and
the child to create suitable coping strategies the Child-life specialists have the ability to
transform traumatic procedures into empowering experiences for this population (Boles et al.,
2020).
Action plan
The PED serves a diverse patient population thus adequate pain assessment scales and
diversity, equity and inclusion training is crucial to facilitate quality patient care, minimize racial
bias and address unconscious bias amongst health care professionals (Young et al., 2022). One
potential solution is for the PED manager to offer paid training to nursing staff on using a more
inclusive pain scale, such as the Oucher visual analog scale, which is appropriate for children
aged three and above (O’Donnell & Rosen, 2014). The Oucher scale incorporates actual
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photographs of children's facial expressions from five different ethnicities, making it a valuable
tool for inclusive pain assessment (O’Donnell & Rosen, 2014). By equipping nursing staff with
the knowledge and skills to utilize this scale, the PED can provide more effective pain
management for a diverse patient population. Due to shortages in nursing staff, nurses
frequently report feeling overwhelmed and stressed during their shifts. While addressing this
issue is crucial, it is imperative to recognize that pain management is a shared responsibility
among parents, children, and nurses (Kusi Amponsah et al., 2020). Upon arrival, caregivers
should receive education on their vital role in assessing their child's pain and communicating it
to the nurse to alleviate the nurse's burden. The PED manager must assist the nursing staff by
providing training on how to facilitate this conversation with the parents to reduce stress and
improve the patient's quality of care. This education does not exonerate the responsibility of the
nurse to provide appropriate pain management; however, collaborating with the family can
enable the nurse to more accurately address the child's pain if the parents are capable of
detecting deviations from the child's baseline behavior and promptly reporting them (Parvin
Aziznejadroshan et al., 2017). The implementation of the proposed action plans can transform
the PED into a collaborative family-centered care unit, resulting in reduced burnout among
nurses and decreased fear and anxiety among patients and their families.