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International Journal of Nursing Practice 2012; 18: 221225

RESEARCH PAPER

Identification of perceived barriers of

pain management in Iranian children:
A qualitative study
ijn_1981

221..225

Mahboobeh Namnabati RN MScN PhD

Pediatric Instructor, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Parvaneh Abazari RN MSN PhD

Nursing Instructor, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Sedigheh Talakoub RN MSN

Pediatric Instructor, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Accepted for publication May 2011

Namnabati M, Abazari P, Talakoub S. International Journal of Nursing Practice 2012; 18: 221225
Identification of perceived barriers of pain management in Iranian children: A qualitative study
Hospitalized children are often inadequately treated for their pain. Paediatric nurses experience these inadequacies more
than other health-care team members. This research was an attempt in the form of a phenomenological study to reveal
some major barriers in children pain management as the nurses had perceived. Sixteen nurses were interviewed in the
medical, surgical and infectious paediatric wards of a hospital in Iran. Data analysis were based on Colaizzi method that
surfaced three main themes in different areas namely: organizational barriers, limitations relating to childs characteristics
and barriers relating to the nature of disease and its treatments. The study results have shown organizational limitations
added to the lack of authority for administering some medical intervention, inadequate equipment and utilities and
unavailability of opioids as the main pain controlling and restricting factors. Additional factors that relate to the child
specifications like age, temperament, behaviour, expression and gender affect the assessment and treatment of pain. The
results revealed identified barriers in real context. It seems that some guidelines are needed to achieve optimal pain
management.
Key words: barriers, children, experience, pain management.

INTRODUCTION
Children have been remained to experience unrelieved
pain after procedures and surgery. There are some evidence that reveal pain management has been inadequate
Correspondence: Mahboobeh Namnabati, Pediatric Instructor, Department of Pediatrics and Neonatal Nursing, School of Nursing and
Midwifery, Isfahan University of Medical Sciences, Hezar-Jerib Boulevard, Isfahan 81746-73461, Iran. Email: namnabat@nm.mui.ac.ir
doi:10.1111/j.1440-172X.2011.01981.x

such as insufficient basic training programme for healthcare providers, nurse deficit or inaccurate knowledge
regarding pain management, difficulty in clinical decisionmaking, nurses fear or misconceptions that might influence decision-making specifically in the use of opioid
analgesics.1
All professionals of health team believe that a nurse has
a vital role in patients pain assessment and management,
but this golden role is effective when he or she has
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an appropriate relationship with physicians.2 The role of

physician is to assess and provide pharmacologic interventions, whereas, among the members of the health-care
team, the nurse is to play the role of patients status
assessment and serve as an advocate for the patient by
promoting understanding of existing problems. Therefore, optimal pain management of the patients pain is
dependent on adequate and accurate communication
between the two parties regarding their respective assessments. In addition, nurses are responsible to prevent or
alleviate the pain.3,4 Acquired experiences through
working years in paediatric units are valuable resources
that are worthy to assessment. These experiences can
locate some real limitations and barriers regarding the
situations, place and time that have not been described in
any book or article. It is believed that qualitative studies
are needed to assess these experiences in depth so that
optimal pain management can be revealed.
In the review of literature, barriers for optimal pain
management have been documented in many studies
throughout the world. Most researches have mentioned
lack of knowledge as well as negative attitude interfere
with patients pain management. Alavi et al.5 studied a
majority of nurses (73.1%) who had moderate knowledge
and a 69.1% of nurses with neutral attitude to pain management in hospitalized children at paediatric wards in
Shahrekord hospitals in Iran.5 Van Niekerk and Martin6
examined the knowledge of Tasmanian registered nurses
in relation to pain management issues such as addiction,
use of analgesics and the assessment of pain. In general,
the surveyed nurses display the least amount of knowledge about the pharmacological management of pain but
showed a more comprehensive understanding of the need
to modify the pain management practice to suit the needs
of each individual patient.6 Some studies have also revealed
that insufficient pain management is mainly because of
knowledge deficits and inconsistent responses.5,711 When
the respondents of this study were asked to rate eight
potential barriers to optimal cancer pain management,
two of barriers were rated by 50% of the samples
as being of major importance in their setting named as:
(i) inadequate assessment of pain and its relief and (ii) the
patients reluctance to the administration of opioids.12
The impact of the nursephysician relationship was
surveyed as a barrier. A percentage of 63.64 of the nurses
declared insufficient physicians notice to nurses suggestions. Physician knowledge about pain management, inadequate medication order and physician cooperation with
2012 Blackwell Publishing Asia Pty Ltd

M Namnabati et al.

nurse were ranked as the most important barriers. According to some of the doctors, the issue of nursephysician
relationship was not so important because of the negligibility of the subject and believing that the children generally felt less pain than adults.13 Prescription of opioid and
a regular schedule of administration are necessary to
fulfil pain management successfully by nurses. A webbased survey collected 116 studies, the result of which
support the idea that lack of knowledge, education and
experience are barriers to pain management practice that
influence decision-making to prescribe pain medication.4
Ely1 performed a qualitative and descriptive study to
examine factors that influence paediatric pain management
practices. Sixteen staff nurses from a paediatric unit in
Northern New England participated in one to six group
discussions. Barriers and solutions to clinical practice
change were identified by nurses in these group discussions. Then they were categorized into subthemes like time
constraints, lack of consistency in practice, insufficient or
no pain medications order by physicians, parental barriers
and child characteristics.1 Thus, as few studies are carried
out based on qualitative approach to examine reasons and
barriers, the purpose of this study was to gain an understanding about the barriers experienced by nurses.

METHODS
Research paradigm (Design)
The purpose of studying these experiences is to understand their nature, meaning and essential structure. Live
experiences of the world of everyday life are the central
focus of phenomenological inquiry. In other words, it is
the live experience that presents to the individual what is
true and real in his or her life. Furthermore, it is the live
experience that gives meaning to each individuals perception of a particular phenomenon and is influenced by
everything internal and external to the individual.13 Phenomenology was chosen as the research paradigm for this
study. This approach is, therefore, ideal for exploring
barriers to pain control in children as has been experienced by paediatric nurses. Generally, nurses described
their experiences about any type of pain like acute,
chronic, postoperative and procedural pain.

Setting and participants

This phenomenological study involved in-depth interviews with 16 nurses who were selected through a
purposive sampling technique. Therefore, qualitative
researcher consciously selected certain participants or rich

Identification of perceived barriers

informative cases to include in the study.14 The nurses are

employees of an educational hospital in Iran. They have
worked in the medical, surgical and infection wards. All
of the participants were female aged 2635 years old.
They were bachelor in nursing with a background in paediatric setting ranging from 4 to 10 years. The interview
lasted from 25 to 50 min. The data analysis were based on
Colaizzi method.

Data analysis
Interviews were transcribed in 190 pages. Colaizzi
method was used to analyse data.13 After collecting data,
the descriptions of the participants were carefully read to
acquire a general feeling of them and extract significant
statements. The meaning of each significant statement was
formulated and then organized into clusters of themes.
They are defined as essential aspects of the experiences
since they are double checked by two expert nurses for
further validation. The results were integrated into an
exhaustive description of the phenomenon, and a final
validation was achieved by returning to each participant.

Ethical issues
Data collection for this study was approved by research
bureau of Isfahan University of Medical Science and local
authorities of educational hospital. The interviews were
made by the researcher in accordance with the appointment schedule. She is not a member of the hospital staff.
At the beginning of the interview, an introduction to the
aim of the study and demographic data of the interviewee
were reciprocated between the interviewer and interviewee. This information could be kept confidential as
they wished. Also, the interview could be cancelled if the
interviewee would request.

RESULTS
Three major themes emerged from the analysis of the
interview transcriptions as follows:
1. organizational barriers,
2. limitations relating to children characteristic and
3. barriers relating to the nature of disease and its
treatments.

Organizational barriers
To have a routine pain assessment, an organized form like
the pain chart sheet and available pain scale should be
established. All nurses claimed that even though it has not

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been a mandatory regulation, we normally recorded the

pain claimed by the patient in the patient file.
Actually there is not a special form, preferably attachable to
the top of bed for charting the pain. However; if a child has
pain we record it in a nursing care sheet. (Participant 4)
There is no pain chart, but should a patient claim pain, we
will report the case to the physician and he prescribes medicine
as needed. Then the prescription would be recorded in medication sheet. (Participant 6)
Being available, opioids are easily administered to relief
pain. Procuring these medicines should be done under a
formal order in some institutes.
It was in the midnight, and the patient had serious pain. We
needed morphine. The hospitals pharmacy refused to deliver
the medicine. That was a terrible night. At last, in cooperation
with the supervisor, we could provide morphine. (Participant 6)
Usually, the physicians do not order analgesic based
on a standard protocol. However, should they do that
in rare occasions, the order will be an imperfect one like
inadequate analgesia dose or as needed order.
If there has been a petedin order, as needed, we have to call
the resident to confirm prescription. (Participant 2)
Sometimes they prescribe PRN petedin, but after revisiting,
the doctor blames us for the administration since he thinks the
childs pain had not been so serious to be in need of it.
(Participant 12)
Until now, using opioids is not routine as a regular schedule
for pain management in medicalsurgical and infectious
ward. We have seldom administered morphine in infectious
ward unless we have surgical cases. (Participant 10)
During a 34 years time that I have worked, we have administered morphine only 3 to 4 times for few patients like
leukaemia, who were in the end stage of disease, in our ward.
(Participant 8)
Being transferred from the operating room, patients are normally administered phenobarbital I.M. or acetaminophen
suppository to relieve their pain. Opioids are not routinely
used for the patient. (Participant 8)
The disproportion between the work forces and the
number of patient in the ward is another organizational
barrier that imposes some limitations on optimal pain
management.
There are 26 patients in this ward and we are only three
nurses in the shift. How well could we take care of all these
patients in one working shift? (Participant 5)
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M Namnabati et al.

The extent of our job description is too much. We could not

have a routine accurate pain assessment for all existing
patients during 6 hours a day. . . . You imagine 2324
patients with only two nurses especially in the evening shift.
(Participant 4)

Limitations relating to
childrens characteristic
The assessment of pain is difficult in children especially
in the young children and infants since they could not
express their pain in verbal way as well as difficulties in the
discrimination pain and fear.
Unfortunately, they cannot say about their pain due to we
dont know what do we for them? Or what part of her body is
in pain? . . . Of course, children those who are experienced
LP, virtually; they have more fear than pain. (Participant 8)
Gender differences and childs mood can affect display
signs and behaviours of the children stemming from pain.
Some children are so quiet and do not show off their suffering
and pain, but others especially girls with seeing a needle or
venset makes screaming and crying (Participant 3).
It depends on them temperament especially children who have
a long stay period at the ward. (Participant4).

Barriers relating to the nature of disease

and its treatments
Hospitalized children should undergo some painful, invasive procedures that virtually cause pain more than the
disease itself. The disease and a variety of its treatments
including diagnostic and required procedures as well as
medicine administration bother the child.
Depending on the type of disease, patients especially those
who are in the end stage of leukaemia have serious pain.
(Participant 15)
Most of meningitides cases have severe headache, and there is
no special treatment to execute but cure of disease and elapsed
of time. (Participant 12)
Interesting descriptions about side effect of medication
and some procedures were explained by nurses who can
compare the intensity of pain in arterial and vein puncture.
Arterial puncturing is very painful since we have to insert the
needle deeply. (Participant 11)
Phenytoin must be administered in a bolus way while the heart
rate is monitored. This procedure is actually so painful that
2012 Blackwell Publishing Asia Pty Ltd

makes the child screams. Ceftieraxon causes the child feel

burning at the vein so he starts shouting and screaming.
(Participant 5)

DISCUSSION
The finding of study revealed that nurses encounter with
some barriers in pain management in children. Organizational deficits and limitations have an effective role in
optimal pain management. It is suggested to include vital
sign paper and charts in the patients file to indicate the
intensity of pain and regular required assessment and
adequate treatment. Whereas Young et al.3 reported that
nurses had positive attitudes about the use of pain management tools to improve patient outcomes, and a more
positive attitude towards pain assessment is related to
more education but not necessarily to more experience,3
using pain assessment tools depends on nursing beliefs.
Some studies have pointed out the attitudes and the behaviours of health-care providers who consistently underassess and underdocument the pain, as major factors of
effective pain management.4
Insufficient knowledge and the lack of a standard protocol cause inadequate treatment. Usually, doctors do not
follow a routine plan in prescription analgesics especially
for opioids. Other studies have cited inadequate or
insufficient physician order and low priority given to pain
management by medical staff.4,6,10 Pain was not assessed
seriously in many cases, and inadequate dosages of opioids
were used that resulted in continued pain and suffering for
child and family. Most therapeutic and diagnostic procedures performed to day have been painful. Although not
all procedures are painful, some produce anxiety instead
of pain. In these cases, the procedures might be modified
by providing sedation so as to decrease the anxiety and
enhance cooperation as well as persuading the child to
remain motionless during the procedure. Administration
of analgesia during a procedure must be made on the basis
of awareness of the level of the pain that the procedure
could impose on the patient. Should the health-care team
doubt whether the procedure is associated with pain, they
must do required considerations.2 It must be routine to
make procedures as less terrifying as possible and/or
make sedation to permit a child to remain motionless.15,16
In a study, some potential barriers were rated in optimal
cancer pain management. Fifty per cent of respondents
rated inadequate assessment of pain, pain relief and
patients reluctance to take opioids as major barriers
in effective pain management practices. Van Niekerk17

Identification of perceived barriers

reported that three main types of barriers were patientrelated barriers, provider-related barriers and systemrelated barriers. More than one-third of nurses had
encountered each type of barrier at least one time.
However, the most frequently cited system-related
barrier was patient to nurse ratio.1,17 The present study
mentions that the inadequate assessment of pain in patient
is also because of insufficient personnel in a shift. Being
insufficient personnel in the shift with respect to 26
operated patients in the ward, nurses experienced that
they are not able to have a regular assessment on patients
pain.
Patients characteristic was highlighted as a barrier in the
survey. A childs responses to and understanding of pain
depends on the childs age, sex and the level of development.18,19 Girls and younger children are highly reliant on
their parents and therefore they display their suffering and
sadness more than the boys and older children. Although
Perquin et al. reported that the girls had a marked increase
in chronic pain between 12 and 14 years of age, multiple
and severe pains were more often reported by girls.20
The study suggests that institutional protocols and
standardized pain management plans can be developed for
routine management of pain; thereby, the nurses would
proceed pain management independently as well as establishing more cooperation among professional health team.
In addition, the authors concluded that nurses success
in pain management depends on a team effort involving
nurses, physicians and other disciplines. Education for
both nurses and physicians, concerning the role of the
nurse in the work place, will help to ensure that nurses
encounter fewer barriers during pain management.

ACKNOWLEDGMENT
The authors would like to thank for the cooperation and
financial supports of research bureau of Isfahan University
of Medical Science. The authors would also like to thank
the nurses who participated in this study.

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2012 Blackwell Publishing Asia Pty Ltd

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