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The role of the nurse consultant in managing paediatric pain

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Susan M. Aitkenhead, RSCN.

Nurse Consultant in Paediatric Pain Management, Royal Hospital for Sick Children, Yorkhill NHS Trust, Glasgow

Twenty years ago pain prevention in children was considered inadequate (Mather and Mackie, 1983). The reasons for this were:
Twenty years ago pain prevention in children was considered inadequate (Mather and Mackie, 1983). The reasons for this were:

- A lack of education addressing paediatric pain control for both medical and nursing staff

- A lack of accountability for paediatric pain management within centres

- Popular myths such as that babies do not feel pain and that, if a child was playing, he or she was not in pain

- A lack of pain assessment tools - particularly for children with complex needs, pre-verbal children and babies.

Over the years research and dissemination has changed perceptions and practice in this area (Royal College of Paediatrics and Child Health, 1997; Schechter, 1989; Wong and Baker, 1988).

Things started to improve when two reports, Pain after Surgery (Royal College of Surgeons and the College of Anaesthetists, 1990) and Children First: A study of hospital services (Audit Commission, 1993), identified pain prevention as one of 10 indicators for quality of care.

However, Services for Patients with Pain (Clinical Standards Advisory Group, 1999) found that 50% of trusts still did not provide an acute pain service for children and that staff awareness of national guidelines seemed poor. It said that children with chronic pain needed expert pain control, highlighting a requirement for specific palliative care sessions.

Nurse roles in paediatric pain management
The nurse role has been identified as 'pivotal to the success of an acute pain service. The nursing model (in which a nurse-led service educates and advises about pain management) will motivate ward nurses, develop nursing protocols for specific analgesic techniques, institute ward nurse education, and supervise the development of patient observation' (Lloyd-Thomas and Howard, 1994). The influence of a dedicated acute pain nurse can positively address 'deficiencies in knowledge of pain management among ward staff and patients' (Coleman and Booker-Milburn, 1996).

'If we are to prevent acute pain persisting and becoming chronic, then a radical revision of the structure of pain services is necessary' argued Notcutt (1997), recommending 'education at all levels of the medical and nursing profession'.

A multidisciplinary approach is vital to achieving effective pain control but 'it is invariably nurses who will co-ordinate and implement the pain control protocols and identify the need for changes in care' (Royal College of Paediatrics and Child Health, 1997).

Introduction of a nurse consultant post
Much work has been done on the changing roles in nursing in recent years (Young et al, 2003; Pearson and Peels, 2002; Caplin-Davies, 1999; Castledine, 1998; Sutton and Smith, 1995).

In 2000, the Scottish Executive approved funding for the first nurse consultant posts in Scotland. The executive based its decision on advice given by a panel that included professional nurses and midwives from the NHS in Scotland, professional organisations and trade unions. The chief nursing officer for Scotland, Anne Jarvie, stressed on behalf of the panel that these roles should meet certain criteria (Box 1).

In June 2000, the Royal Hospital for Sick Children in Glasgow applied to the Scottish Executive directorate of nursing for funding for a nurse consultant in paediatric pain management.

The role would incorporate acute, chronic and palliative pain and symptom control. The hospital had already set up the first paediatric acute pain management service for Scotland in 1994.

It was felt that incorporating the management of acute, chronic and palliative pain within a single role was vital because the children targeted could potentially experience all these aspects (Aitkenhead, 2002).

Scottish Executive criteria, described in an unpublished memo to trusts, spelt out four core functions of the role of nurse consultant (Box 2). The proposal required that these were met. The Scottish Executive also required certain other information (Box 3).

The health needs assessment
Acute pain
Local data on the paediatric pain management service relating to all aspects of service delivery were gathered. These included database records of all patient numbers, pain management techniques used and length of time in use, plus outcome measures, pain scores and any critical incidents. This showed that the need for acute pain management had increased since its inception, with the number of new patients rising from an initial 60 a month to 120 a month from 1994 to 2000.

Overall, patient safety and comfort was found to have improved. But the increasing complexity of pain prevention techniques indicated that a role for co-ordination, research and education was needed.

Chronic pain The pain management service had identified other types of pain problems with children. Some had been referred with a history of chronic pain, often having been treated by several specialists, but with no significant improvement. Admissions to hospital were common, frequently with investigations and procedures performed (Aitkenhead, 2001).

Palliative pain Children with palliative pain require optimal care in pain management and symptom control at the end stages of their lives (Abu-Saad, 2001). This is the most traumatic time for a family, and pain control is usually one of the biggest concerns. Health professionals working with these children and families also need support and advice, as they, too, can find it difficult.

Oncology and other medical areas frequently requested advice on palliative pain management. Children can require complicated methods of analgesia during the end stage of their lives. Community staff in primary care teams also sought advice regarding analgesia and symptom control for children being cared for at home in their final stage of life.

Educational and clinical support
Following the health needs assessment it was necessary to provide educational and clinical support on managing paediatric pain. Other health professionals wanted to be made aware of the choices of pain treatments.

The nurse consultant would aim to educate nurses to provide an accurate and thorough assessment of children suffering from chronic and palliative pain, thus avoiding unnecessary admissions to hospital and needless procedures and investigations.

Paramount was the need to improve children's quality of life, facilitate a return to school when possible, reduce visits to accident and emergency departments and enable the child and family to become more self-reliant.

The nurse consultant would also support GPs and community staff in the effort to prevent readmission.

Defining the role
The post was implemented in April 2001. The job description incorporated the components shown in Box 4. The role aims to act as an interface between primary, secondary and tertiary services. It aspires to link all settings and provide a wider base of care for all children with pain-management problems.

Breaking down the role
The postholder and trust carried out a training needs analysis. The local clinical services manager, who had previous strategic experience, facilitated the induction period and provided direction and mentorship. Many strategic skills are not taught in 'traditional' nursing career pathways.

Recognising this, the chief nursing officer for Scotland charged the Nursing and Midwifery Practice Development Unit for Scotland (now part of NHS Quality Improvement Scotland) to provide a training and support network for nurse consultants in Scotland. This has taken the form of useful action learning sets (in which a group of people work together on problems specific to one individual for a period of time), invited speakers and organisational support.

At a local level the working week was split into 'sessions' to give the post structure and encompass clinical work with the other responsibilities and objectives of the role.

One session would take a morning or afternoon. Of 10 weekly sessions, five would be for direct clinical work and the rest would combine research, audit, education, service development, quality assurance and dissemination of information at a wider level.

Weekly clinical work includes one acute pain session, two chronic pain sessions and two palliative pain sessions, although the latter two are flexible, dependent on patient requirements.

The pain-management service has a clinical nurse specialist in acute pain management working in the trust's acute sector. The nurse consultant manages this post, with advice and clinical support provided and enhanced by the weekly acute session.

Chronic pain sessions include nurse-led clinics to assess and manage pain. A monthly evening teenage meeting/clinic is facilitated in partnership with the trust's clinical nurse specialist for young people. Teenagers from around Scotland and one young woman from Belfast attend, as do other interested health professionals. The service has two inpatient beds for a chronic pain management programme and admissions are often arranged around these monthly meetings for teenagers who live far away.

A monthly outreach chronic pain clinic, held at a local school for children with complex health needs, has been extremely successful in collaborating with the school's physiotherapy staff.

Requests to run other clinics outside the hospital are also presenting at a national level. The nurse consultant facilitates individual pain management programmes for outpatients and inpatients, working with all members of the multiprofessional team, and referrals continue to increase from around the UK.

Palliative pain sessions have shown success in partnership working. We have worked with the Scottish paediatric hospice Rachel House. The clinical nurse specialists within the trust's oncology/haematology unit have worked with the nurse consultant by visiting children at home to jointly assess and plan their analgesic and symptom control requirements when necessary.

A similar process has been facilitated with the REACT nurse (Rapid Effective Assistance for Children with potentially Terminal illness) based in the trust, and we hope to continue this valuable work.

Non-clinical sessions depend on service requirements and future strategic developments. Research is being undertaken to examine what children perceive as successful outcome indicators following their chronic pain treatments, and what exactly they would like to achieve.

Most of the literature addresses adult chronic pain and a child's voice identifying what merits a successful treatment is not only interesting, but necessary, to take this work forward.

Research is also being undertaken into the efficacy and profile of certain analgesic drugs for use in paediatric pain management.

Much of the role is about providing education. Current priorities are to identify and manage chronic pain as early as possible. This is useful for primary care teams, and guidelines are being developed. The postholder regularly lectures on courses around Scotland. Acute pain management guidelines are also being developed into competency-based teaching packages at a local level.

Strategic work is varied and has included working with the Scottish Intercollegiate Guidelines Network, the cross-party parliamentary group on chronic pain management in Scotland, and the Scottish Executive's committee regarding the safe administration of intrathecal drugs. The postholder chairs the British Pain Society's special interest group, Pain in Children, and hopes to continue to raise the profile of paediatric pain management via this group.

Audit of the role
An audit of the roles of nurse consultants in Scotland was commissioned by the Scottish Executive. The Royal Hospital for Sick Children in Glasgow agreed that such an audit would be useful, which is now ongoing. The aim of the audit, as defined by Professor Jean McIntosh of Glasgow Caledonian University, is to identify:

- The organisational and policy context in which the posts were conceptualised and developed.

- The key goals of the posts

- Any internal/external influences on the development/changes to the nature and scope of the post

- Perceived difficulties in implementing the remit for each post and the strategies to address such problems.

It is still relatively early to comment on the success of this role in paediatric pain management. Common problems associated with introducing a new post have arisen.

For example, it can be difficult to establish where a new post fits into an organisation. It can be difficult to explain the role, particularly in its early stages when the postholder is still trying to define it themselves. It is also difficult to protect non-clinical sessions, in the context of increasing clinical commitment and growing numbers of referrals of increasing complexity.

It can also often be difficult to balance the wide-ranging non-clinical activities of research, education and service development.

A training-needs analysis is a useful exercise. Peer support is invaluable, as is mentorship to guide and direct. However, the 'mix' of direct clinical input and strategic planning appears to work well.

Hopefully, practice is being positively influenced and the postholder feels that there is great benefit in being involved in, experiencing and understanding current practice issues and then having the ability to participate at a strategic level to directly improve care. The audit of the post continues.

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