Abstract
I clearly remember one nurse’s response to my expressed frustration at the lack of pain assessment on children’s wards in the UK. Her explanation that ‘nurses do assess pain, they just don’t write it down’ did not reassure me that all was well with children’s pain assessment or the leadership of children’s pain management. I am not alone in my sense of unease, von Baeyer (2009), an eminent American pain researcher, expresses similar concerns when he states:
“Most children’s pain in hospital settings is not managed at all, and when it is managed it is on the basis of clinicians’ hunches and assumptions rather than on data obtained from self report and observational measures” (Von Baeyer 2009)
This occurs despite the plethora of guides available on how to deliver effective, evidence based pain management. In summary these guides recommend that we should: anticipate pain at all times; systematically evaluate pain using validated tools and for verbal children use self report of pain; nurses should be educated in the management of children’s pain and pain management should be led by the child’s needs.
So why are children being left in pain? Nurses have been found to delay giving analgesics to a child until they recognise that the child is in pain, Perhaps nurses feel the need for concrete evidence of pain before taking responsibility for the decision to administer analgesics for pain. Franck and Bruce (2009) suggest that poor compliance to pain assessment guidelines may indicate unspoken resistance to methods that are over simplistic, and perhaps even disrespectful of clinical experience. They suggest that organisational culture can act as a major barrier to change.
Managing pain is complex, and managing children’s pain is very complex. Nurses need some direction or incentive to move forward. The dilemma is whether this should be by the carrot or the stick. Morally the notion of using a ‘stick’ feels uncomfortable. However, effective leadership could act as a ‘carrot’ which could harness the energies of nurses to deliver effective pain management to children. Three styles of leadership will be explored here in relation to how they could fit with enhancing how nurses deal with children in pain.
The concept of authentic leadership fits well with pain management as it is considered as an ethical approach to leadership and nurses have an ethical obligation to relieve children’s pain (Simons 2011). Although there are various definitions of authentic leadership, all emphasise the importance of consistency between values, words and actions. Authentic leaders hold positive core values, such as honesty, altruism, fairness, accountability and optimism, and are motivated to do what is right for their followers (Yukl, 2009).
An alternative, though complementary, form of leadership that also resonates well with pain management is servant leadership. First developed by Greenleaf (1977), servant leadership is based on the idea that attending to followers’ needs is key to leadership. What distinguishes servant leaders from other types of leaders is their deliberate choice to serve others. Servant leaders put other people’s needs, aspirations and interests above their own. Trust is the foundation of servant leadership and mutual respect and open feedback are central to the relationship between leader and follower. The defining qualities of servant leaders are: “The ability to listen on a deep level and to truly understand The ability to keep an open mind and hear without judgment The ability to deal with ambiguity, paradoxes and complex issues Seeing things whole and sensing relationships and connections” (Marquis and Huston 2009 p.53).
A first step in improving care is to get nurses to not only assess children’s pain but also to record their pain assessments. Leadership is an essential element in enhancing care and it is my belief that the ultimate goal is to achieve effective distributed pain management leadership.