Being safe & taking risks : how a group of nurses managed children's pain : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University
A small, grounded theory study was conducted in a children's surgical ward in a large, urban teaching hospital involving registered nurse volunteers. The purpose of the study was to investigate how nurses' deal with children's acute pain. Ten unstructured, but focused in-depth, taped interviews were conducted with five nurses. The constant comparative method as proposed by Glaser and Strauss (1967) and Glaser (1978) was used to generate substantive theoretical categories, a core category and basic social process. Analysis revealed that what nurses may want to do and what they can do when managing children's pain is not necessarily the same thing. A number of structural barriers to prompt and effective pain management were identified, such as doctors not always being available to write prescriptions, under prescribing or doctors even refusing to prescribe opioids for children at times. Lack of equipment for delivering continuous analgesic infusions meant that optimal methods could not always be used. The predominant method used was intermittent incremental intravenous doses of morphine, which appeared to provide poor pain control in many cases. The analgesic protocols the nurses were expected to follow were time consuming and impractical when they had several children needing analgesia at once. The nurses' solution to such dilemmas was to still act to relieve pain even when this involved some risk because the nurses' believed that the risk-taking was done responsibly, and that it was more important to promote the child's wellbeing. The types of risks they took included administering several doses of morphine in quick succession without always monitoring for respiratory depression, and altering prescriptions (but not in writing). Being Safe and Taking Risks emerged as a paradoxical core category, which reflected the pattern for the nurses' pain management decision-making and practice. It also emerged that a moral interest (Being Ethical) appeared to direct and connect the nurse's thinking and practice; they tended to do what they considered was in the child's best interests and believed that the benefits outweighed potential harms.