Judy Rashotte

BACKGROUND: Although documentation of children’s pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children.OBJECTIVES: To describe health care professionals’ use of written language related to the quality and quantity of pain experienced by hospitalized children.METHODS: Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used.RESULTS: Pain narratives were documented a total of 5390 times in 1518 of the 3822 children’s medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (eg, vocal, motor, facial and activities cues), affective and physiological cues, and children’s descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers.CONCLUSIONS: The richness and complexity of vocabulary used by clinicians to document children’s pain lend support to the concept that the word ‘pain’ is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children’s pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.

BACKGROUND: Although clinical narratives – described as free-text notations – have been noted to be a source of patient information, no studies have examined the composition of pain narratives in hospitalized children’s medical records.OBJECTIVES: To describe the structure and content of health care professionals’ narratives related to hospitalized children’s acute pain.METHODS: All pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized in 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was performed.RESULTS: Three major structural elements with their respective categories and subcategories were identified: information sources, including clinician, patient, parent, dual and unknown; compositional archetypes, including baseline pain status, intermittent pain updates, single events, pain summation and pain management plan; and content, including pain declaration, pain assessment, pain intervention and multidimensional elements of care.CONCLUSIONS: The present qualitative analysis revealed the multidimensionality of structure and content that was used to document hospitalized children’s acute pain. The findings have the potential to inform debate on whether the multidimensionality of pain narratives’ composition is a desirable feature of documentation and how narratives can be refined and improved. There is potential for further investigation into how health care professionals’ pain narratives could have a role in generating guidelines for best pain documentation practice beyond numerical representations of pain intensity.

This article explores nurses' decision-making related to the administration of PRN anti-seizure medications to children with long-term seizure disorders in palliative care. Hermeneutic phenomenological inquiry guided by van Manen's approach was the method used. Six nurses participated in interviews. Data analysis revealed that not on my watch was the overarching theme in which nurses engaged in bearing witness, being attentive, creating connectedness, and finding the right thing to do. Four themes emerged: being in the know--what to know and ways of knowing; marking time--waiting and timekeeping; seeking a sense of personal comfort--developing a sense of comfort, experiencing distress, and responding to distress; and making the decision--recognizing a seizure, identifying options, weighing the options, and rethinking the decision. This study reveals the moral dilemmas and resulting moral distress that may be experienced in making this type of decision and advances our thinking about the corresponding tensions and rewards.

This study examined the impact of a 2-part unit-based multiple intervention on the use by pediatric critical care nurses of best practice guidelines for pressureulcer prevention. A total of 23 nurses participated in a repeated-measures design pre- and post-intervention to address 2 questions: Is there a difference in nurses' evidence-based practices following implementation of an educational intervention only versus implementation of both an educational and an innovative intervention? Are the changes sustained 6 months after completion of the intervention? A significant change occurred in the implementation of 2 of 11 recommended practices following both interventions: assessment of risk of pressure ulcers using an age-appropriate tool (p <= 0.001), and the documentation of same (p <= 0.001). These changes may have been sustained. The findings bring to light the real challenges encountered when attempting to implement and evaluate multiple knowledge translation strategies associated with complex best practice guidelines in clinical practice.