Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Ellie Longest

Dr. Karen Mellott

NUR 4122 Nursing Research

Bon Secours Memorial College of Nursing

April 2nd, 2019

“I Pledge…”
INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to identify barriers pediatric nurses face

during the acute care of patients experiencing intense pain.

Background: Children hospitalized are under-treated for pain due to lack of physician’s orders

as well as inadequate pain management and assessments by nurses. Nurses are front line in pain

management and it is important to identify barriers to produce positive patient outcomes.

Method: This integrative review collected data from research articles found on online databases.

The articles discussed are qualitative and quantitative that were chosen based on specific criteria.

The information was used to determine barriers pediatric nurses face during the patient’s acute

hospitalization.

Limitations: A limitation of this paper is the author’s inexperience in conducting an integrative

review. Other limitations include the criteria to select five articles along with four of the five

articles being conducted outside of the United States.

Results and Findings: The evidence compiled supports the PICO question addressed in this

integrative review. Common barriers included inadequate nursing competency when it comes to

assessing their patient’s pain as well as a lack of autonomy. These barriers provide poor patient

outcomes during their acute care.

Implications: Nurses need to be empowered as well as having continuous education regarding

providing optimal pain management to their pediatric patients.

Recommendations: Recommendations for future research include providing further insight into

other medical professionals, male nurses, and the child’s parents. Also research on nursing

knowledge deficits and organizational cultures must also be further looked into.
INTEGRATIVE LITERATURE REVIEW 3

Integrative Literature Review

The purpose of this integrative review is to identify barriers pediatric nurses face during

acute care of patients experiencing intense pain. Children who are hospitalized are under-treated

for pain due to many different reasons including lack of physician’s prescribing proper

prescriptions, inadequate pain assessments by nurses and lack of adequate pain management

(Mediani, Duggan, Chapman, Hutton, & Shields, 2017). Pediatric pain management is the third

issue in pediatric medical hospitalizations. Pain that continues to go untreated can lead to an

increase of disability and puts pediatric patients at an increased risk of death (Aziznejadroshan,

Alhani, Mohammadi, 2017). The aim of this review is to examine and discuss published data

related to the researcher’s PICO question: How do pediatric nurses caring for patients with

intense pain identify barriers of pain management during their acute care?

Nurses are front line in controlling patient’s reported pain levels. Nurses believe multiple

barriers contribute to the inadequate control of optimal pain management (Czarnecki, Salamon,

Thompson, & Hainsworth, 2014). These barriers nurses endure in practice fall into different

categories in relation to health care professionals, patients (including children and their parents),

and the organization they work for (Twycross & Collins, 2013). In order for nurses to

effectively manage their patient’s pain, it is important to address these barriers and implement

change, leading to optimal pain control and increased improvement of patient outcomes.

Design and Search Methods

This integrative review is focused on five research articles. The method utilized by the

researcher began with an initial search using Academic Search Complete, EBSCO Discovery,

and EBSCO CINAHL Complete. The search yielded 200 articles found using words such as pain

management, barriers, and pediatric. The articles were then filtered by year, language,
INTEGRATIVE LITERATURE REVIEW 4

publication status, and if the research article was peer reviewed. In regards to the date, articles

were limited from the years 2013-2019 and only included articles published as well as peer

reviewed. Due to the inclusion criteria needed to select articles, many were eliminated from the

search. Limiting factors included that many of the articles did not have full text availability and

publishing language. Any articles that did not meet the requirements for the search process were

excluded.

The articles were then narrowed down and chosen based on their relevance to the PICO

question, “How do pediatric nurses caring for patients with intense pain identify barriers of pain

management during their acute care?” The researcher focused on qualitative and quantitative

articles to analyze the findings. The total number of articles chosen after these limitations were

applied was five, resulting in four qualitative studies and one quantitative study.

Findings and Results

The findings and results of the five reviewed studies indicate that pediatric nurses are

facing a variety of barriers when attempting to provide optimal pain management to patients in

intense pain during their acute care stay. A complete synopsis of the research is detailed in

Appendix 1-Article Summary Tables. Inadequate nursing competency as well as lack of

autonomy were two common themes identified resulting in two major barriers pediatric nurses

face while providing care. These barriers resulted in decreased pain management in pediatric

patients thus leading to poor patient outcomes. The results of the literature are presented below.

Inadequate Nursing Competency

The qualitative phenomenological study by Aziznejadroshan, et al. (2017) studied the

experiences of nurses and barriers faced when providing pain management to patients on

pediatric units. The study included nineteen nurses from two teaching hospitals in Iran who had
INTEGRATIVE LITERATURE REVIEW 5

at least three years of working experience in different pediatric units. Data was collected through

sixty to ninety minutes of deep unstructured interviews. Data collected was based off the nurses

and their personal experiences providing patient care during acute hospitalization. Data analysis

was employed through conventional content analysis as well as use of the MAXQDA10 software

to transcript and classify codes. The interview techniques were proven appropriate for the design.

Findings concluded five main themes that elicited to barriers of providing optimal pain

management including: inadequate nursing competency, inappropriate organizational structure,

interruption in pain relief activities, and individual characteristics of child and parents.

The purpose of the qualitative phenomenological study by Twycross and Collins (2013)

was to ascertain nurses’ views about the barriers they deal with when it comes to providing

effective pediatric pain management. The sample size consisted of thirty nurses from a hospital

in the south of England, which was large for the type of study. Modifications were made into

focus groups of four to six participants to help achieve further in depth views on the subject.

Data was collected based off the nurses views about several aspects of pain management

including pain assessment, pain management, child and parent involvement, and barriers. Data

was analyzed using content analysis, which was appropriate for the type of study. Data was

inserted into a Microsoft Word Document allowing researchers to take recurrent responses and

place them into different categories. Five themes then emerged from the study including: pain

assessment and management practices, child and parent involvement in pain management,

barriers to assessing and managing pain effectively, things that would help nurses assess and

manage pain more effectively, and the usefulness of the hospital’s clinical guidelines. All of the

findings related to barriers nurses face when it comes to being able to provide effective pain

management to these nurses’ pediatric patients.

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An interpretative qualitative phenomenological research study by Murphy et al., (2013)

was conducted to assess the barriers of prehospital (emergency room) in providing acute pain

relief to children. The sample size consisted of sixteen nurses who worked in emergency rooms

from two regions in Ireland (Dublin and Cork) with at least three years of experience. Data

collection consisted of interviewing two focus groups where an interview guide enabled a

structure and sequence of particular questions asked regarding the topic. Data was collected on

two main topics, including experience of pain management in children and alternatives to current

practice. Probing questions were then asked to elaborate on the topic. Thematic network analysis

was used to analyze the manuscripts from both focus group interviews, which was appropriate

for the type of study conducted. The process involved consolidating interview quotations into

codes, basic themes, and global themes. Findings suggest that obstacles towards providing

pediatric pain management include: education and training, current clinical practice guidelines

for pediatric pain management, and realities of pre-hospital practice.

Lack of Autonomy

The purpose of the exploratory descriptive qualitative study by Mediani et al., (2017) was

to explore nurses’ perceptions and experiences of barriers in providing pediatric pain

management to hospitalized children. This study used techniques associated with grounded

theory when data collection and analysis occurred. The sample size consisted of 37 nurses who

had more than three years of experience and were currently working full time in hospital

pediatric units in two hospitals in Indonesia. Data collected was qualitative in nature. Individual

semi-structured interviews that lasted between 50-90 minutes were conducted, asking broad and

open ended questions. Data was analyzed using the constant comparative analysis as well as

using thematic analysis procedures to identify themes, patterns, and essential information that
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was essential to the study. Themes were centralized around five barriers towards nurses inability

to provide good pain management skills including an imbalance in nurse to patient ratios, lack of

sufficient education training, lack of organizational support, lack of professional autonomy, and

feeling powerlessness.

Czarnecki et al. (2014) composed a cross-sectional quantitative study reassessing

previous data dated three years before to see if barriers of pediatric pain management perceived

by nurses change over time. The study consisted of a total of 442 nurses working in any type of

nursing role (staff nurse, nurse manager, clinic nurse, etc.) or working in a pediatric pain

management clinic at the Children’s Hospital of Wisconsin. An electronically formatted 39

question survey, known as the Barriers to Optimal Pain Management, was sent out to these

individuals work emails. Modifications were made to the survey based off of answers to the

previous study that had been conducted. Data was analyzed using descriptive statistics, including

frequencies, frequency distributions, means, and Pearson correlations. ANOVA analysis was also

used to determine demographical differences in the participants. Findings concluded a total of 21

different barriers, but statistically significant findings included delays in orders being processed

and delivered by pharmacy, inadequate doctor medication orders resulting in low priority and

autonomy of nurses and pain management, and insufficient time and pre-medication orders

allowed to pre-medicate children prior to procedures.

Discussion and Implications for Practice

Similarities were noted between the five selected articles in relation to the PICO question

of barriers nurses face when treating pediatric patients during their acute care and who are

experiencing intense pain. Two main occurring themes immersed from all five articles were

inadequate nursing competency and lack of autonomy. Inadequate nursing competency was a
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barrier that impacted nurses and their ability to care for their pediatric patients who were

experiencing intense pain. One of the studies noted that deficiencies such as inadequate

experience, lack of knowledge, overlooking pain assessment, and a lack of in-service training

programs provided by their workplace resulted in nurses not being able to properly assess their

patient’s pain adequately as well as not being able to relieve their patient of their intense pain

(Aziznejadroshan et al., 2017). Another study noted that when nurses are trained on pain

management skills, the focus is mainly on acute pain in adults rather than educating nurses on

the knowledge and skills need to assess and treat acute pain in children (Murphy et al., 2013).

Lack of autonomy was another barrier found within the five articles. Nurses felt that they

did not have authority to control pain management decisions and their opinions were not valued

by physicians. Nurses described feeling inferior to physicians and felt as if they were not heard,

therefore having no impact on decision making (Mediani et al., 2017). Nurses do not have the

independent ability to write their own order regarding what type of pain relief will be used as

well as different analgesics. Before any action to treating their patient’s intense pain occurs,

physician’s orders must be observed and nurses must inform them before changing or

implementing new orders (Aziznejadroshan et al., 2017).

Implications for practice came directly from nurses in the study performed by Murphy et

al., (2013) including providing eLearning to nurses as an efficient way of teaching how to assess

and provide pain management practices to children in intense pain as well as simulation training

to provide extra exposure. To achieve optimal pain management processes and practice,

improvement of nursing competence overall should be prioritized in planning (Aziznejadroshan

et al., 2017). In order to give nurses the power and autonomy they need to provide pain

management, it is important that empowerment is instilled upon them. For nurses to be able to
INTEGRATIVE LITERATURE REVIEW 9

provide effective pain management during their nursing care they must empower and stand up to

physician’s if needed (Mediani et al., 2017). These implications for practice relate back to the

original PICO question of identifying barriers pediatric nurses face when caring for their patients

experiencing acute pain in acute care settings.

Recommendations for future research included exploring physician’s perceptions and

experiences regarding pediatric pain management (Mediani et al., 2017), involving more male

nurses (Aziznejadroshan et al., 2017), researching knowledge deficits among nurses as well as

the impact of organizational cultures (Twycross & Collins, 2013), and also examining

perceptions of parents (Czarnecki et al., 2014). Overall, there are many personal and

organizational factors that are in need of future research.

Limitations

Many limitations were addressed while conducting the researched integrative review. A

large influencing factor includes the limited experience of the researcher as well as a lack of

knowledge. Lack of knowledge in conducting the integrative review limits the accuracy of the

information. Due to limited qualifications, the researcher was limited to providing reliable, in

depth discussion of the subject. In relation to the PICO question, the researcher was only able to

provide limited insight to the topic.

Another limitation the researcher faced was the process of choosing five articles. The

researcher had trouble finding full in-text articles between the years of 2013-2019, limiting the

amount of information for the researcher. Due to the search limitations only to the past five

years, this was not a comprehensive review and an in class assignment causing limitations to the

study.
INTEGRATIVE LITERATURE REVIEW 10

A common limitation found in the majority of articles chosen included that many results

came from self-reported, qualitative data which introduced bias feedback, therefore hindering

potential true results of the study. A quantitative study may have been ideal as it would have

allowed for a larger sample size (Murphy et al., 2013). The homogeneity of the sample may have

also limited the ability to generalize results to other organizations (Czarnecki et al., 2014). The

sample size for many of the studies using focus groups were large, not allowing participants to

fully articulate their experiences (Murphy et al., 2013). Lastly, a limitation observed by the

researcher was four of the five articles selected were conducted outside of the United States.

With each country having a different health care systems, it may differ nurses perceptions and

experiences that individuals are facing here in the United States.

Conclusions

The evidence concluded from the integrative review notes that pediatric nurses are faced

with a variety of barriers when providing pain management to children experiencing intense pain

in acute care settings. Murphy et al., (2013) found that pediatric nurses have little education and

training on children and proper pain management assessment and skills. Nurses face huge

knowledge deficits and incompetency when caring for their patient’s experiencing intense pain (

Twycross & Collins, 2013). Nurses do not feel as if they have the proper experience, pain

assessment techniques, or any in-service training programs resulting in a negligence in providing

pain relief to their patients (Aziznjadroshan et al., 2017). Even though nursing incompetency

regarding pain management in children exists, pain management is still a high priority for nurses

when caring for patients. Nurses feel as if they are a low priority when partaking in providing

and pain management practices to their patients (Czarnecki et al., 2014). This leads to nurses

feeling powerless with a lack of autonomy when engaging in pain management decisions. Nurses
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feel they lack authority and they do not have a voice in their patient’s care decisions (Mediani et

al., 2017). In relation to the PICO question, lack of autonomy and inadequate nursing

competencies were barriers identified by pediatric nurses in all five articles that did not allow

them to treat intense pain in acute care settings as they felt properly.

References
INTEGRATIVE LITERATURE REVIEW 12

Aziznejadroshan P., Alhani F., & Mohammadi E. (2017). Experience of nurses about barriers to

pain management in pediatric units: A qualitative study. Journal of Nursing and

Midwifery Sciences, 4(3), 89-96. doi:10.4103/JNMS.JNMS_2_17

Czarnecki, M., Hainsworth, K., Salamon, K., & Thompson, J. (2014). Do barriers to pediatric

pain management as perceived by nurses change over time? Pain Management Nursing,

15(1) 292-305. doi:10.1016/j.pmn.2012.12.003

Mediani, H., Duggan, R., Chapman, R., Hutton, A., & Shields, L. (2017). An exploration of

Indonesian nurses’ perceptions of barriers to pediatric pain management. Journal of Child

Health Care, 21(3), 273-282. doi:10.1177/1367493517715146

Murphy, A., Barrett, M, Cronin, J., McCoy, S., Larkin, P., Brenner, M., . . . O’Sullivan, R.

(2013). A qualitative study of the barriers to prehospital management of acute pain in

children. Emergency Medicine Journal, 0, 1-6 doi:10.1136/emermed-2012-202166

Twycross, A., Collins, S. (2013). Nurses’ views about the barriers and facilitators to effective

management of pediatric pain. Pain Management Nursing, 14(4), 164-172.

doi:10.1016/j.pmn.2011.10.007

Appendix 1-Article Summary Tables

 INTEGRATIVE LITERATURE REVIEW 13

Article Reference  Aziznejadroshan P., Alhani F., & Mohammadi E. (2017). Experience of
nurses about barriers to pain management in pediatric units: A qualitative
study. Journal of Nursing and Midwifery Sciences, 4(3), 89-96.
doi:10.4103/JNMS.JNMS_2_17

Problem Statement /  Children’s pain in the hospital continues to not be managed well with nurses
playing a critical role in their pain management.
Background /  Previous literature shows that nurses lack pain management knowledge in
pediatrics as well as there are many barriers that do not allow them to
Research Question- Specific provide pain management properly.
Aim or Purpose /  The study was conducted to explore the experience of nurses’ barriers to
pain management in pediatric units.
Significance statement  Pain relief is an important quality in medical care for pediatric patients and
if pain is not taken care of properly it can lead to ineffective care and a
prolonged hospitalization.
Conceptual or  This article does not specify a certain conceptual or theoretical framework
Theoretical Framework being used due to limited relevant theories that are aligned with this
research.
Method Design /  This study is a qualitative study using the phenomenology approach.
Philosophical
Underpinnings
Sample /  The sample size consisted of 19 nurses. Purposive sampling was used with
maximum variation. The sample size was adequate for the method being
Setting / used. There was no attrition rate that occurred during the study.
 The setting was conducted at two teaching pediatric hospitals (Amirkola
Ethical Considerations Children’s Hospital in Babol and Children’s Medical Centers in Tehran,
Iran).
 The study does not state if there was IRB approval. Participants were
ensured of their confidentiality and voluntarily nature of the study. Written
informed consent of the nurses were also obtained.

Major Variables Studied (and  Nursing Barriers

their definition)
 Pediatric Pain management

Measurement Tool /  Interviews were used to assess variables.

 To ensure accuracy and reliability of the data credibility, confirmability,
dependability, and transferability were all used using Lincoln and Guba’s
criteria. To increase data credibility prolonged engagement with participants
was also used for two years with the researcher performing long term on
site observation experiences of pain management by nurses. Transcribed
interviews were also returned to participants to ensure accuracy of codes
and interpretations. Two qualitative research experts were also there to
supervise the researchers conducting the data ensuring confirmability.
 INTEGRATIVE LITERATURE REVIEW
Data Collection Method
Data Analysis
Findings / Discussion
Appraisal/Worth to practice
Article Reference
14
Dependability was assessed through three nurses who did not participate in
the study to confirm coding as well. Transferability was checking as
sampling was done with maximum variance of nurses.
 Sixty to ninety-minute-deep and unstructured interviews were used to
collect data and measure variables.
 Conventional Content Analysis was used to analyze the data. The
MAXQDA10 software was used for transcription and classification of
codes.
 Five themes of barriers to pain management were identified including
inappropriate organizational structure, inadequate nursing competency,
interruption in pain relief activities, individual characteristics of child and
parents, and inefficacy of companions. Success or failure of pediatric pain
management largely depends on these influencing factors.
 Further research is still needed since the study states that there is little
research that has been done on the topic.
 Limitations of the study include that the nurses studied were female nurses
in Iran. The involvement of male nurses is essential in future studies to
explain the barriers they may feel when caring for pediatric patient’s pain.
Another limitation is that the study is conducted outside of United States.
 The study did not give specific implications for nurses, but in order to
achieve optimal pain management it is essential to prioritize these barriers
and remove these pain-relief delaying factors.
 Czarnecki, M., Hainsworth, K., Salamon, K., & Thompson, J. (2014). Do
barriers to pediatric pain management as perceived by nurses change over
time? Pain Management Nursing, 15(1), 292-305.
doi:10.1016/j.pmn.2012.12.003
 INTEGRATIVE LITERATURE REVIEW
Problem Statement /
Background /
Research Question- Specific
Aim or Purpose /
Significance statement
Conceptual or
Theoretical Framework
Method Design /
Philosophical
Underpinnings
Sample /
Setting /
Ethical Considerations
Major Variables Studied
(and their definition)
15
 Optimal pain management has been a health care goal for pediatric RN’s but
nurses are continuing to report barriers interfering with their ability to
accomplish this goal.
 Since the initial study done three years before, three additional studies have
also been done by other researchers regarding barriers to pediatric pain
management. These studies indicate that RNs in a variety of settings have
similar barriers to adequate pain management.
 The purpose of the study was to reassess barriers that pediatric RNs perceive,
and how they describe optimal pain management after an initial assessment
was done three years before.
 Identifying changes of pain management barriers three years later will allow
researchers to see if there has been an improvement in pain management and
if not how can implications be made to change to make it more efficient.
 No conceptual or theoretical framework was identified.
 This is a cross-sectional quantitative study.
 The sample size consisted of 442 RNs representing a 38% response rate. The
sample size was adequate for the type of study, but due to the large number
of nurses in the hospital a larger sample size from the hospital could have
allowed for more sufficient data.
 The study was conducted at the Children’s Hospital of Wisconsin with 236
bed capacity providing services offering inpatient acute and critical care,
medical, surgical, and ambulatory services, Level 1 trauma/ER center, and a
NICU.
 Approval was given through the original Human Rights and Review Board.
The researchers explained that the survey was voluntary implying informed
consent and confidential. All data was kept secure and the use of password
protection.
 Nursing Barriers
 Optimal pediatric pain management
 Patient care
.
 INTEGRATIVE LITERATURE REVIEW
Measurement Tool /
Data Collection Method
Data Analysis
Findings / Discussion
Appraisal/Worth to practice
16
 The survey Modified Barriers to Optimal Pain Management was used with
small adaptions from the study previously done. Once the survey was
modified the tool reached an internal consistency of 0.87 confirming
reliability and validity.
 Data was collected through a 39 question survey (Modified Barriers to
Optimal Pain Management). The survey was sent through electronic email.
 Descriptive statistics including frequencies, frequency distributions, means,
and Pearson correlations were conducted. ANOVA analysis were used to
determine demographic variables. One-sample t tests were used to compare
findings for each barrier from a previous study done.
 Even though 21 barriers were questioned the top 5 major barriers to effective
pediatric pain management included delays in orders being processed by
pharmacy, delays in orders being delivered by pharmacy, inadequate
doctor’s orders, insufficient time allowed to pre-medicate prior to
procedures, and insufficient pre-medication orders prior to procedures.
Findings were statistically significant.
 Findings from the study were compared to the previous research done
before, with many of the findings being similar to the study done three years
before.
 Future studies are still needed with the perspective of other health care
providers and professionals as well as parents of the children.
 Limitations of the study regarding methodology, participants, time of year
and shift work were not controlled and may have impacted results. Since the
link was sent via email there is no way to verify licensure and ensure that
only RNs responded to the survey. Bias is also possible due to self-reporting.
 Implications were given including a PRN medication for insufficient
doctor’s orders, targeting education regarding procedural pain management,
and allowing an order set to already be made for certain procedures being
done to already have premedications included.
 INTEGRATIVE LITERATURE REVIEW
Article Reference
Problem Statement /
Background /
Research Question- Specific
Aim or Purpose /
Significance statement
Conceptual or
Theoretical Framework
Method Design /
Philosophical
Underpinnings
Sample /
Setting /
Ethical Considerations
Major Variables Studied (and
their definition)
Measurement Tool /
Data Collection Method
17
 Twycross, A., Collins, S. (2013). Nurses’ views about the barriers and
facilitators to effective management of pediatric pain. Pain Management
Nursing, 14, 164-172. doi:10.1016/j.pmn.2011.10.007
 Children continue to experience moderate to severe pain during
hospitalization.
 Unrelieved pain has a number of undesirable mental and physical
consequences that can affect the child while they are in the hospital and later
in their life.
 The aim of this study was to ascertain nurses’ views about the barriers and
facilitators to effective pain management.
 With the knowledge to guide nurses with pain management practices, it is
important that we do not continue to fall short when it comes to practicing
optimal pain management.
 No conceptual or theoretical framework was identified.
 This study is a qualitative study using the phenomenology approach.
 The sample size consisted of 30 nurses. The article did not state the type of
sampling strategy used. No attrition rate occurred during the time of the
study. The sample size was large for the type of study, but groups were
broken down to 4 to 6 nurses to capture more in depth views.
 The study was conducted at a hospital in south England during the nurses
lunch breaks.
 The Research Ethics Committee was contacted for approval. Participants
were ensured of their confidentiality and voluntarily nature of the study.
 Pain assessment
 Pain management
 Child and parent involvement
 Facilitators
 Barriers
 This research study used focus groups with in-depth open-ended group
discussions.
 The study does not state if validity and reliability were assessed.
 Four to six nurses were put into small groups and given a set of flipcharts
with key questions. Participants were asked to write down their views about
each question onto the flipchart. They were given ten minutes to complete
 INTEGRATIVE LITERATURE REVIEW
Data Analysis
Findings / Discussion
Appraisal/Worth to practice
18
each question.
 Data was analyzed using the principles of content analysis. Data was read
through several times and recurrent responses were placed into themes.
 Major findings from the research resulted under five themes including lack
of pain assessment and pain management practices, child and parent
involvement in pain management, barriers to assessing and managing pain
effectively, not adequately having the information they need to manage pain
more effectively, and hospital clinical guidelines. The findings of this study
concur of those with previous research studies that have been done.
 The research article states that there are improvements for practice needing
further research done on the topic.
 Limitations of the study included focus groups not allowing the researchers
to explore what was meant into further depth.
 This study provided a table of ways nurses personally felt would help them
to assess and manage pain better. This makes this a great research study as it
gives us the nurses personal views of what can implications can be made for
better pain management practices.
 INTEGRATIVE LITERATURE REVIEW
Article Reference
Problem Statement /
Background /
Research Question- Specific
Aim or Purpose /
Significance statement
Conceptual or
Theoretical Framework
Method Design /
Philosophical
Underpinnings
Sample /
Setting /
Ethical Considerations
Major Variables Studied (and
their definition)
Measurement Tool /
Data Collection Method
19
 Mediani, H., Duggan, R., Chapman, R., Hutton, A., & Shields, L. (2017).
An exploration of Indonesian nurses’ perceptions of barriers to pediatric
pain management. Journal of Child Health Care, 21(3), 273-282.
doi:10.1177/1367493517715146
 Despite a variety of research and clinical studies on pain management in
pediatric patients, children continue to experience moderate to severe pain
during their hospitalization.
 Since this study was done in Indonesia, the lack of pain management in
pediatric patients may be geared more towards the fact that there is a deficit
in qualified nurses.
 The aim of this study is to explore Indonesian nurses’ perceptions of and
experiences with pain management of hospitalized children, while focusing
on Indonesian nurses’ perceptions of barriers to pain management.
 Even though pain management practices are readily available, optimal pain
management practices still continue to fall short of the ideal and factors
affecting pain management.
 No theoretical or conceptual framework was identified.
 This is an exploratory descriptive qualitative study. Ground theory
techniques were employed around the data collection and analysis.
 The sample size of this study consisted of 37 nurses using purposive
sampling. The sample size was adequate for this type of research. No
attrition rate was noted in the research.
 The study was conducted in Indonesia in two states in West Java
Providence in two different hospitals.
 Permission for this study was obtained through Curtin University’s Human
Research Ethics Committee and the research ethics committee at the
Indonesian hospitals. Participants signed a consent form agreeing to
participate.
 Nursing barriers
 Pediatric pain management
 Personal experiences
 Semi-structured in depth interviews were used to measure variables.
 Reliability and validity were established through member checking,
prolonged engagement with participants, and peer review methods. Once
the interviews were coded participants were given a full transcript of their
interviews with a summary of emergent themes to see if the codes and
themes were similar to what they had experienced. Four expert supervisors
did peer checking on 60% of all transcripts as well to ensure further
validity. Findings were then also confirmed with veteran nurses who did not
 INTEGRATIVE LITERATURE REVIEW
Data Analysis
Findings / Discussion
Appraisal/Worth to practice
20
participate in the study to ensure that the themes were similar to their past
experiences.
 Individual semi-structured, in-depth interviews lasting from 50-90 minutes
were conducted. Interviews used broad questions allowing for authentic
data to be collected.
 Data was analyzed using the comparative method. Data was managed using
manual thematic analysis procedures to identify themes, patterns, and
essential elements contained with the text and constant comparative analysis
using open, theoretical, and selective coding.
 Five themes were found contributing to nurses inability to provide optimal
pain management including: imbalance in nurse to patient ratios, lack of
sufficient education/training, lack of organizational support, lack of
professional autonomy, and feeling powerlessness. These findings were
consistent with previous research.
 Further research is still needed to provide optimal pain management for
pediatric patients.
 Limitations of the study include upcoming studies should look at
perceptions and experiences of physicians and pediatric pain management
as well as this is conducted in Indonesia.
 Implications include it is important to empower nurses to provide optimal
pain management.
 INTEGRATIVE LITERATURE REVIEW
Article Reference
Problem Statement /
Background /
Research Question- Specific
Aim or Purpose /
Significance statement
Conceptual or
Theoretical Framework
Method Design /
Philosophical
Underpinnings
Sample /
Setting /
Ethical Considerations
Major Variables Studied (and
their definition)
Measurement Tool /
21
 Murphy, A., Barrett, M, Cronin, J., McCoy, S., Larkin, P., Brenner, M., . . .
O’Sullivan, R. (2013). A qualitative study of the barriers to prehospital
management of acute pain in children. Emergency Medicine Journal, 0, 1-6
doi:10.1136/emermed-2012-202166
 Effective pain management in the prehospital setting is a performance
indicator, but seriously lacks in the pediatric population.
 Previous studies have shown that there is difficulty when it comes to
assessing children and their pain and inadequate treatment causes alterations
in immune function, delayed wound healing and a lower pain threshold in
subsequent painful experiences.
 This study aimed to identify barriers as perceived by a national cohort of
individuals working in ER’s to achieving prehospitalization optimal pain
management of acute pain in children.
 If barriers to optimal pediatric pain management are identified early effective
pain management in children will optimize their journey during their
hospitalization.
 Attride-Stirling’s framework was used in the research study and aims to
overcome challenges and develop strategies for effective learning.
 This is a interpretative qualitative research study using the phenomenology
approach.
 The sample size consisted of 16 nurses who worked in emergency rooms.
Sampling size was adequate for the type of study done. No attrition rate was
noted.
 The setting occurred from two regions in Ireland (Dublin and Cork) from two
different hospitals in their emergency rooms.
 Ethical approval was granted for this study through the Centre for Prehospital
Research by the Mid-Western Regional Hospital Research and Ethics
Committee in Ireland.
 Pediatric pain management
 Barriers
 Enablers
 Variables were assessed through focus group interviews.
 Validity and reliability were measured by inviting participants to review the
transcript and coding of their interview. Guba and Lincoln’s framework was
also used to ensure the way interpretation was achieved is clear and traceable
in a clear, logical, and coherent way.
 INTEGRATIVE LITERATURE REVIEW
Data Collection Method
Data Analysis
Findings / Discussion
Appraisal/Worth to practice
22
 Two focus group interviews were used, using a focus group interview guide.
The interview guide enables a structural sequence to the way questions were
asked and discussed. Interactive dialogue was allowed evolving particular
topics and themes.
 Thematic network analysis was used to analyze manuscripts transcribed
following focus group interviews. The process consolidated interview
quotations into codes, basic themes, organizing, and global themes.
 Findings focused on three emerging themes including lack of nursing
education and training in regards to pain management, current clinical
practice guideline for pediatric pain management (limitations of current
pharmacological treatments and limitations of current pain assessment tools in
young children), and lastly realities of emergency hospital practice.
 The study states that future research is still needed and particularly a
quantitative study to allow for a broader spectrum of an understanding of the
subject with a larger variety of participants.
 Limitations of the study is that due to the focus groups it may have not
allowed all participants to fully articulate their experiences. Also a limitation
is that this study was conducted outside of the United States.
 In order to limit barriers to optimal pediatric pain management is to provide
much more proper education and training, offering alternatives to assessing
pain in children, and having evidenced-based practice that is nursing friendly
and patient focused.