Clinical Judgment of Pain in the Non-Verbal Child at the PICU- A Phenomenographic Study

Abstract

Background: The thesis has a standpoint in a synthesis of caring science and education science from a clinical perspective. Children in a Pediatric Intensive Care Unit (PICU) are in an exposed position, dependent on nurses to acknowledge their needs. The alleviation of children's pain has been investigated from various perspectives, but undertreated pain remains a problem in the PICU. There is a preponderance of empirical evidence pointing toward the role of nurses in uncovering children's pain and suffering. How nurses interpret the child's expressions and judge the clinical situation influences their actions in the clinical care. In a PICU, the basis for nurses' concerns and interpretation of what is meaningful in the nursing care situation are formed by professional concern, workplace culture, traditions, habits, and workplace structures. This influences how parents interpret the meaning of care as well. Patricia Benner's theory on clinical judgment forms a reference framework for this thesis. The assumption is that children need to be approached from a holistic perspective in the caring situation in order to acknowledge their caring needs. A nurse's clinical education and insights allow for the possibility to enhance the quality of care for children and parents in the PICU. Aim: To uncover clinical concerns, from caring and learning perspectives, in caring for children in the Pediatric Intensive Care Unit (PICU) from nurses and parents perspective. Methods: Qualitative methods were used in all studies to unfold and explore the phenomena in the nurses' and parents' everyday clinical life world. In Papers I and II, a phenomenographic method was adopted. In Papers III and IV, an interpretive phenomenological approach was adopted. Findings: Nurses that have a holistic view of the child and approach the child from a multidimensional perspective, with a focus on the individual child and his/hers caring needs, develop a clinical "connoisseurship" and meet the parents' expectations of the meaning of care. The nurses express that it is only when they focus on the child that subtle signs of pain are revealed. The meaning of nursing care, in the ideal case, is a holistic care where all aspects are integrated and the child as a person has first priority. Conclusion: The meaning of caring and children's needs must become elucidated to improve the cultural influence of what can be seen as good nursing care within the PICU.