Paediatric pain education: A call for innovation and change

Abstract

Over the past two decades, there has been exponential growth in the quantity and quality of paediatric pain research evidence. This evidence has advanced our current understanding of the physiology and treatment of pain in children. At the same time, there has been a growing international agenda to promote the integration of evidence-based practices into health care. This agenda has been extended to improving the quality of pain management through legislation (1), international awareness initiatives (2), and the synthesis of pain management research into clinical standards and guidelines by accreditation and health professional organizations (3,4). Moreover, inadequate pain relief, including undermedication, is now recognized as a safety issue in Canada and elsewhere (5). However, inadequate practitioner knowledge about pain management continues to be documented, despite available pain curricula (6) and the identification of pain education as a means to change ineffective pain management practices (7). The present commentary suggests that prelicensure pain education is needed, because students have lacked important pain knowledge at graduation (8–12), including minimal collaborative experience (13). It is noteworthy that published evidence of required interprofessional pain curricula models for these students has been minimal (14). Despite the substantial evidence base for paediatric pain management and a health care climate attentive to the use of this evidence in practice, gaps in health professionals’ pain knowledge and problematic beliefs persist. Consequently, clinical practice across professions often lacks an evidence base. Reports and clinical audits of health professionals’ pain management practices over the past decade indicate that children frequently receive no pain medication after surgery, or are given analgesics at subtherapeutic doses and/or inappropriately long intervals (6). Furthermore, pain is not routinely assessed in paediatric practice, and developmentally appropriate tools are not consistently used for pain assessments (15,16). Well-established evidence attests to the adverse consequences of ineffective pain relief in children, including slower recoveries, increased complications and greater use of health care resources (17,18). Pain education that involves health professionals at all levels has been identified as a critical element to changing ineffective pain management practices (7). It is imperative that current pain research evidence be made accessible to health professionals, who operate in the fast-paced health care environment and may have neither the time nor the necessary resources to access the most up-to-date information. However, the solution to sustained improvements in health professionals’ pain management knowledge and resultant practices is likely far more complex than the simple presentation of research evidence to clinicians; research indicates that even if health professionals have information about pain management, they do not necessarily use it in practice (16). Pain management educational initiatives in health care have traditionally been consistent with ‘supplier push’ models of knowledge transfer and passive methods of dissemination (19–21). That is, pain management evidence has been merely presented to health professionals, with little regard for the complexity of translating such evidence for use in the clinical setting. These initiatives have generally been met with limited success in their capacity to effect and sustain change in health professionals’ pain management practices (22,23). Future educational initiatives should transition from the didactic, uniprofessional presentation of research evidence to individuals to strategies that address the organizational context and social dimension of translating evidence into practice. Interprofessional education is a method of knowledge building that is attentive to context and the social aspect of translating evidence into practice. A constant in the health care context is that clinicians from different health professions interact on a daily basis to provide high-quality care to patients. Interprofessional education also capitalizes on health professionals’ preference for interactive, rather than didactic (eg, publications), sources of knowledge (24). Collaboration among health professionals is especially critical in the area of pain management because effective pain management can be complex and requires approaches that exceed the expertise of one profession. Moreover, recent research attests to the importance of interprofessional collaboration to the successful implementation of evidence into practice (25). Educational initiatives that encourage clinicians to examine both their unique uniprofessional and common interprofessional strengths in providing high-quality pain management to children may facilitate such collaboration. Importantly, however, research indicates that educational initiatives may be most successful when integrated early in the socialization and educational experience of diverse professionals; negative attitudes reinforced in the undergraduate years are more challenging to change later (26). Despite this assertion, both pain management and interprofessional educational efforts have been mainly targeted at health professionals after graduation. Future educational initiatives need to extend their reach to include prelicensure health professional students as well. Watt-Watson et al (14) were the first to provide data on the development, implementation and evaluation of an integrated, interprofessional, prelicensure undergraduate pain curriculum. This seminal initiative was spearheaded by the University of Toronto Centre for the Study of Pain (Toronto, Ontario) and organized by 16 members who represented the six faculties or departments of Dentistry, Medicine, Nursing, Pharmacy, Physical Therapy and Occupational Therapy. The curriculum was delivered to 540 students from the six Health Science faculties or departments during a one-week period. Based on the International Association for the Study of Pain curricula (27) and the Position Statement on Pain Relief from the Canadian Pain Society (28), the aim of the curriculum was to ensure a common, basic understanding of pain assessment and management principles upon which to build profession-specific pain knowledge within an interprofessional context. Teaching strategies included having large, multiprofessional presentations, small interprofessional group sessions to work on patient case-based pain assessment and management plans, Standardized Patients and 63 clinician-facilitators representing all of the participating professions. Overall, student evaluations of the curriculum were positive, and statistically significant changes were demonstrated in their pain knowledge and beliefs. This curriculum uses an iterative design based on extensive evaluation and will be implemented for the sixth time in 2007. The template provided by Watt-Watson et al may be useful for those wishing to develop an interactive educational initiative based on current pain research evidence that is applicable in undergraduate or clinical settings. However, it also highlights the need for organized and cooperative interprofessional efforts to design and deliver pain education to both developing health professionals and those already working in the clinical setting. Regulatory bodies and academic institutions have an important role to play in making pain education a required element of pre-licensure education requirements. Health care organizations and policy-makers can also support accountability for improved pain practices through institutional supports for education and accreditation requirements. Ultimately, interactive, contextually relevant strategies at all levels, which focus on building health professionals’ knowledge and translating this knowledge into practice, will contribute to improving both child and health care outcomes.