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Pain Management Nursing journal homepage: www.painmanagementnursing.org Original Research Barriers to Pediatric Postoperative Pain Management--Interprofessional Focus Group Interviews Peter Forde Hougaard, Ph.D., M.S.Sc., R.N. +,?,1 , Anja Hetland Smeland, Ph.D., M.Sc., R.N. +,?Inductive coding was done descriptively and in in vivo style to preserve and explore the clinicians' experiences (Braun & Clarke, 2021; Saldana, 2016).

Pain Management Nursing
journal homepage: www.painmanagementnursing.org
Original Research
Barriers to Pediatric Postoperative Pain Management—Interprofessional
Focus Group Interviews
Peter Forde Hougaard, Ph.D., M.S.Sc., R.N. †,‡,1
, Anja Hetland Smeland, Ph.D., M.Sc., R.N. †,§
† Children’s Surgical Department, Division of Head, Neck and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway ‡ Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway § Institute of Health and Society, University of Oslo, Oslo, Norway
a r t i c l e i n f o
Article history:
Received 21 March 2024
Received in revised form 24 September
2024
Accepted 5 November 2024
Keywords:
Pediatric postoperative pain management
Pediatric surgical wards
Interprofessional focus groups
Barriers
a b s t r a c t
Background: Historically, postoperative pain management of children in hospitals has been inadequate,
despite advancements in pain physiology and management. Postoperative pain correlates with increased
complications, psychological harm, and parental stress, leading to inefficiencies in resource utilization and
prolonged hospital stays. Effective pain management relies on organizational, collaborative, and individual
efforts, with interprofessional communication and cooperation being crucial.
Aim: This study aims to explore healthcare professionals’ experiences with barriers to effective pediatric
postoperative pain management through interprofessional focus group interviews, aiming to address gaps
in understanding and improve care.
Methods: Data collection was performed using focus group interviews with twelve healthcare professionals from four surgical wards. Interviews were audio-recorded and transcribed verbatim. Transcriptions
were coded and analyzed using reflexive thematic analysis by two researchers independently.
Results: Our study aligns with prior research on barriers, revealing issues such as lack of competence
among physicians and nurses, limited availability of skilled personnel, heavy workloads, and absence
of standardized protocols. These barriers largely reflect resource limitations and resonate with existing
literature. Additionally, our findings highlight differences in perceptions between nurses and physicians
regarding opioid use and standardized pain assessment tools, underscoring potential barriers to optimal
pediatric postoperative pain management.
Conclusions: Our study underscores the importance of adhering to standardized, evidence-based pain
management protocols, revealing a link to inadequate leadership at the hospital and department levels.
Noncompliance may stem from professional inexperience and lack of trust between healthcare professionals, necessitating interprofessional dialogues facilitated by leaders to foster a culture of evidencebased pediatric care.
Clinical Implications: Establishing best practices and ensuring adherence is a leadership responsibility.
Furthermore, a lack of adherence to established routines of pain management might be a consequence
of professional inexperience and lack of competence, as well as a symptom of lack of trust between
professions and professionals. It is important that leaders of both nurses and physicians facilitate arenas
for discussing these topics. A culture of evidence-based PPPM needs to be interprofessional and inclusive
of different perspectives and facilitate open discussions.
© 2024 The Authors. Published by Elsevier Inc. on behalf of American Society for Pain Management
Nursing.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
Children with pain have historically been undertreated at hospitals. As recently as the 1980s, some newborn children underwent
major surgical treatment without analgesia (Olsson & Jylli, 2001, p.
23). This is now universally considered bad medicine and morally
unacceptable (Friedrichsdorf & Goubert, 2020; Hunter, 2000). Even
1 Address correspondence to: Peter Forde Hougaard, PhD, M.SSc, RN
E-mail address: [email protected] (P.F. Hougaard).
though there have been substantial developments concerning
knowledge of pain physiology, assessment, and management (pharmacological and nonpharmacological), children are still consistently reported to have unnecessarily high levels of pain after
surgery (Smeland et al., 2019; Sng et al., 2017; Twycross et al.,
2015).
Pain is defined as “An unpleasant sensory and emotional experience associated with, or resembling that associated with, achttps://doi.org/10.1016/j.pmn.2024.11.001
1524-9042/© 2024 The Authors. Published by Elsevier Inc. on behalf of American Society for Pain Management Nursing. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/)
e118 P.F. Hougaard and A.H. Smeland / Pain Management Nursing 26 (2025) e117–e123
tual or potential tissue damage” (Raja et al., 2020, p. 1976). Un- or
undertreated postoperative pain in children has long been known
to correlate with increased medical complications (Eccleston et al.,
2021) both short- and long-term psychological harm (Victoria &
Murphy, 2016), and parental stress (Yayan et al., 2020). It also leads
to inefficient use of hospital resources and prolonged hospital stays
(IASP, 2017).
Pain management in hospitals is an interprofessional endeavor,
relying on health care professionals’ (HCPs’) knowledge and attitudes toward pain (Manworren, 2021), their ability to evaluate patients’ pain (Smeland et al., 2018), and their interpretations of pain
scores (Johannessen, 2017), as well as their willingness and skill
to communicate and build trusting relationships with patients and
their relatives (Twycross et al., 2015). Furthermore, the willingness to cooperate and the ability to coordinate across professional
boundaries are important (Mäki-Asiala et al., 2022).
Acknowledging the problems of nonoptimal pediatric postoperative pain management (PPPM), in recent decades, several studies have explored why suboptimal pain management has been
and continues to be a challenge in hospitals. The results show
that nurses often lack knowledge about pediatric pain management, and there is suboptimal clinical practice (Smeland et al.,
2018). Issues with pain medication prescriptions are common, either due to insufficient prescriptions, nurses’ inability to prescribe,
or discomfort in calling physicians for medication (Bouri et al.,
2018; Czarnecki et al., 2019; Tomaszek & D ˛ebska, 2018). Various
workplace-related barriers, including a shortage of nurses, complex clinical environments, heavy workloads, lack of resources, and
insufficient training, have been identified (Kusi Amponsah et al.,
2020; Bouri et al., 2018; Mahon et al., 2022), as well as absent pain
assessment tools and pain protocols (Smeland et al., 2018).
However, none of these studies have explored HCPs’ experiences of barriers to effective PPPM by conducting interprofessional focus group interviews with surgeons, anesthesiologists, and
nurses together. Some of the barriers to PPPM might therefore not
have been addressed, and interprofessional discussions might open
up for other perspectives than those present in homogenous focus
group interviews.
The aim of this study is to explore HCPs’ experiences with barriers to effective PPPM as expressed in interprofessional discussions in focus groups.
Methods
Design
This was a qualitative, explorative study, conducted in 2019,
using focus group (FG) interviews with healthcare professionals
working with PPPM. This study represents the first step in the development of an inter-professional educational intervention study
(Pediatric Postoperative Pain Management in Surgical Wards—An
Intervention Study) (ClinicalTrials.gov Identifier: NCT03987399).
While this article is focused on HCPs’ experiences of barriers
in PPPM, subsequent studies focus on children’s reported experiences of pain treatment (forthcoming), HCP’s competencies
and effects of educational interventions, measured through PNKAS
(Seipajærvi et al., 2024), and an observational study of how PPPM
is executed in pediatric postoperative wards (forthcomming). The
Consolidated Criteria for Reporting Qualitative Research (COREQ)
were used as a reporting guide (Supplementary A) for this study.
Participants and Setting
Participants were recruited from a university hospital in Norway, with local, regional and national function, treating both
Table 1
Description of the Sample.
Participant # Professional Background
#1 Pediatric nurse, pediatric surgical ward
#2 Intensive care nurse, postanesthesia care unit
#3 Intensive care nurse, postanesthesia care unit
#4 Anesthesiologist, anesthesiology department
#5 Pediatric nurse, pediatric surgical ward
#6 Pediatric anesthesiologist, pediatric intensive care unit
#7 Anesthesiologist, anesthesiology department
#8 Pediatric anesthesiologist, anesthesiology department
#9 Pediatric surgeon, surgical department
#10 Nurse, postanesthesia care unit/pediatric surgical ward
#11 Nurse, postanesthesia care unit/pediatric surgical ward
#12 Pediatric orthopedic surgeon, surgical department
children and adult patients. We purposively sampled (Polit &
Beck, 2021) individuals from different medical and nursing backgrounds and with extensive experience with postoperative pain
management for children. On this basis, we hypothesized that the
participants would be information rich (Polit & Beck, 2021) regarding the issues we planned to raise.
Fourteen HCPs agreed to participate in this study, eight in FG
1 and six in FG 2. However, two surgeons had to perform surgery,
and therefore they withdrew. The participants were from one hospital with four pediatric surgical wards treating children 0-18 years
in two locations. The hospital has acute pain management team for
children and adults. Each FG represents one location. The participants include nurses, pediatric nurses, intensive care nurses, anesthesiologists, pediatric anesthesiologists, pediatric surgeons, and
pediatric orthopedic surgeons (Table 1).
Participants within each FG mostly knew each other professionally and interacted frequently in their capacities as health professionals treating and caring for children postoperatively. The participants represent the whole pre- and postoperative patient trajectory: establishing diagnosis and recommending surgery, providing
preoperative information, and delivering postoperative observation,
treatment, and care.
Data Collection
The FGs were audio recorded and held undisturbed in conference rooms at the participants’ workplace, each lasting roughly
1 hour and 15 minutes. During the focus group interviews, the
participants, seated at a round table, were served coffee and tea
to ease the conversations. Only the interviewers and participants
were present.
Two experienced pediatric nurses, skilled in conducting FGs,
moderated the sessions. One nurse led the discussions, while the
other assisted by noting nonverbal cues and asking clarifying questions. Neither of the interviewers had prior relationships with the
participants.
The discussion was guided by an interview framework focusing on participants’ experiences with pediatric postoperative
pain management, potential improvements in pain assessment, and
pharmaceutical and nonpharmaceutical pain treatments. Most of
the questions were open and descriptive in nature, i.e. “What kind
of pain measurement tools do you use” and “How do you judge
the postoperative treatment given to children and adolescents?”
The participants’ responses were followed up through prompts by
the moderator i.e. “What do you think [of the statements], do you
have an input on this, or other thoughts about it?” “You mentioned
that premedication isn’t popular right now—can you tell us more
about that?” Some of the questions addressed the HCP ideas for
P.F. Hougaard and A.H. Smeland / Pain Management Nursing 26 (2025) e117–e123 e119
solutions, i.e. “Do you have any suggestions how this could be organized better?”
Ethical Considerations
Ethical approval was obtained from the Norwegian Regional
Committee for Medical Research Ethics (ID: 2019/388), as well as
the university hospital’s data protection officer. All participants
gave voluntary informed, written consent to participate and to
have their data used for publication. Oral information about study
participation was also given at the time of the FGs.
Data Analysis
The first author, PFH, an experienced pediatric nurse and sociologist of the professions, together with the second author, AHS,
conducted the analysis. AHS, a pediatric nurse, expert in PPPM,
and experienced pediatric pain researcher, developed the interview
guide, transcribed the interviews, and participated in the analysis. The analysis and results were presented and discussed with
fellow researchers within the larger research project and two research groups. The quotes used in the paper were translated into
English by PFH and validated by AHS,
Our analytical approach was abductive (Thompson, 2022) and
iterative (Braun & Clarke, 2021). Analysis and coding were done
thematically, broadly in line with Braun and Clarke’s six phases of
reflexive thematic analysis (Braun & Clarke, 2021). Initially, the authors individually read through and coded the transcripts. The initial analysis and findings were then discussed together. After these
discussions, the analysis was repeated. Deductive analysis using a
provisional coding style (Saldaña, 2016) ordered the data into thematic clusters after the initial inductive analysis. Inductive coding
was done descriptively and in in vivo style to preserve and explore
the clinicians’ experiences (Braun & Clarke, 2021; Saldaña, 2016).
As pointed out by Braun and Clarke, the six phases of reflexive
thematic analysis tend to “blend together somewhat, and the analytic process necessarily becomes increasingly recursive” (Braun &
Clarke, 2021, p. 331). Such was the case in our analysis.
In the analysis, we were less interested in whether the participants agreed on the existence of the barriers. It was not frequency,
agreement, or consensus that we looked for. If only one participant
perceived something as a potential or actual barrier, we treated
it as such. In the presentation of the findings, we highlight the
clearly expressed barriers to pain management as experienced by
the participants. Although not the principal aim of the paper, patterned differences along professional lines were also identified in
the analysis and are commented on in conjunction with the findings.
Findings
The findings are organized into thematic clusters: barriers at
the organizational, collaborative, and individual levels. These clusters draw on both theoretical and empirical insights from interprofessional collaboration and hospital work (Freidson, 1988;
Strauss et al., 1997), along with our deep understanding of interprofessional pain management as academics and clinicians. While
analytically distinct, these levels are often empirically intertwined
and challenging to separate.
In general, the participants found their workplace’s PPPM quality to be good, particularly for children undergoing major elective
surgery. They acknowledged that collaborating with children and
parents on pain management could be challenging, but these challenges were seen as professional, not collaborative, issues. The responsibilities were understood to lie with the nurses and physicians, not the patients or parents. Barriers connected to cooperation with pediatric patients and their parents are not further elaborated on in this article. Still, difficulties with interpreting and
treating the patients’ pain were identified as a critical issue that
was dependent on several organizational, collaborative, and individual factors to be solved.
Although the participants stated that the overall quality of pain
management was good, all the participants agreed that there were
room for improvements. However, there were differences in what
they perceived as actual barriers, areas for potential improvements,
and solutions for improving PPPM.
Barriers at the Organizational Level
All the participants agreed that preoperative, age-adapted information about what to expect regarding postoperative pain is vital
for preparing children for the aftermath of surgery. Still, one of the
barriers that was highlighted was that children often would be less
than optimally informed. The participants identified several logistical barriers to preoperative preparations. These included surgeons
and anesthesiologists not reading nurses’ notes documenting previous successful PPPM, nurses not completing necessary preoperative pain assessment tools, and a lack of systematic preoperative
pain evaluations. Other issues included paper-based notes not following patients throughout their hospital stays and across different departments. Scheduling preoperative conversations between
patients and anesthesiologists was often difficult, sometimes even
impossible, and was highlighted as a general problem:
We don’t have time to do all these previsits in a way that allows
for a conversation with everyone, including relatives, and tell
them what to expect in the days to come. [#8 Pediatric anesthesiologist]
Furthermore, as scheduling of these conversations were difficult
to organize, arranging previsits with both nurses and anesthesiologists and the patients, to ensure feasible postoperative pain management regimes, was also impossible to implement:
We have considered having an admission interview with anesthesia and the nurses, but it is not feasible in relation to when
[the anesthesiologist] comes [and has] the admission interview.
[…] It is not possible to implement. [#2 Intensive care nurse]
Pain management was described at times as suboptimal because of a combination of nonexisting national and local pediatric
pain management guidelines and a lack of managerial decisions
about such regimens. One example that was discussed in the FGs
where the different ways that nurses were instructed to reduce
the doses of femoral nerve blocks postoperative, here the response
from one of the nurses:
We often find it difficult to know what to do when we are tapering off. We get so many different instructions. Some say we
should wait several hours between doses, while others say we
should reduce the volume of what we give. [#11 Nurse]
The following statement from an anesthesiologist also addresses
the lack of guidelines, where the anesthesiologist contrasts a lack
of managerial decisions with his one-off experience in a meeting
in which a medical leader decided a pain management policy:
I thought about what you said about random surgeons
having their own opinions about NSAID [nonsteroidal antiinflammatory drug] use. […]. You need to look at the evidence.
Then a leader of the orthopedics has to decide what policy
you’ll have [#6 Pediatric anesthesiologist]
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One understanding of this statement is that since medical decisions concerning standardized pain management regimens seemingly are devolved throughout the organization and specializations,
one end of the organization does not need to attune its practices
with the others. This results in nonstandardized, nonefficient, and
nonevidence-based PPPM.
PPPM is typically the responsibility of anesthesiologists, who
frequently initiate and adjust treatment. Participants in this study
highlighted various instances of inadequate access to skilled anesthesiologists, particularly during evenings and nights. A pediatric
nurse illustrated the discrepancy in the availability of expertise between nighttime and daytime:
It can be a completely different ball game at night. Not because people don’t know how, but because they are stuck with
other things. We try to get pediatric anesthesia at night, but if
they work with a critically ill child in the intensive care unit,
then we can’t expect that they should just leave things there
and help us. And then we are very dependent on the surgeons
again. And then it’s like this: who is on duty, do they have experience with that type of procedure, do they have experience
with basic pain treatment? [#5 Pediatric nurse]
As can be seen, this pediatric nurse did not refer only to a lack
of organizational workforce resources but also to a lack of competence and knowledge among surgeons.
The participants in the FGs reported a lack of resources within
the hospital. Expertise in PPPM is perceived to be related to certain segments of the anesthesiology department. Competence was
described as a scarce organizational resource, which cannot be
counted on to be readily available. The lack of organizational resources relates not only to physicians of different medical specialties, the participants pointed out, but to organizational resources
per se. Throughout the FG interviews, the lack of appropriate
rooms, equipment, educational resources and adequately competent nurses, surgeons, and anesthesiologists were also mentioned
as present obstacles to optimal pain relief. About this there was
full agreement among our participants.
Barriers at the Collaborative Level
Some nurses highlighted a lack of consensus regarding pain
medication strategies between different groups of physicians, thus
representing an intraprofessional barrier, as expressed by a nurse
working in a postanesthesia care unit:
I often wish that we consider surgical procedures as always being painful. It’s better to start with high pain relief and then
reduce it if it’s not necessary, rather than having to adjust it up
afterwards. When we are on the ward, we often have to start
assessing how much pain relief is needed. Can I give this much?
Why can’t this patient get Ibuprofen, for example, while the patient in the next bed, who has a different surgeon, gets it? [#5
Pediatric nurse]
This nurse’s frustration was echoed by others as well, and not
only toward the medical professions’ lack of consensus but also
within the nursing profession itself.
Both physicians and nurses mentioned that they often disagreed about the threshold for giving pain medication, especially
when children seem agitated. These disagreements seemed to stem
from different assessments of symptoms and the effects of medications. An anesthesiologist put it this way:
I am often summoned because it is somehow considered an extra pain problem out of the ordinary for this type of surgery.
Often my assessment is that the child has received too much
and is confused and nauseous and itchy and has side effects to
the drugs, [drugs] used correctly are good […]. So, there should
be a balance. And this is where experience comes in. I am sure
you enjoy the scoring tools, and it’s documented, so it’s fine.
But personally, I think that experience plays a big role. [#6 Pediatric anesthesiologist]
This disagreement, which ran along professional lines, seemed
to stem from different risk vs. benefit assessments. The nurses
were more explicitly concerned about the immediate benefits pain
medications would give, while stressing how pain could produce
long-term effects, e.g., hospital anxiety or other kinds of psychological harm. Because of this, the nurses seemed to have a more liberal view when discussing the use of opioids and other pain medications than the physicians. The physicians on the other hand were
more concerned about the immediate risks, e.g., overdose of opioids, respiratory depression, regurgitation, and aspiration, as well
as the long-term effects of overly liberal use. The following excerpt
is an example of the latter, more conservative attitude:
We have to prescribe postoperative pain medication after an
expected course, and I do not agree that one should have, for
example, opioid prescribed for everyone, that it should be carte
blanche for the PACU nurse to give [opioids]. [#6 Pediatric anesthesiologist]
Nurses and physicians sometimes disagreed on the use of standardized pain assessment tools, or rather what should be done
based on these tools. In the FGs, the physicians were asked
whether they used such tools actively, and the following answers
were given:
I cannot say that I do that. I know about them and have in a
way read a bit about it and stuff, but in practice, I cannot say
that I use them. [#7 Anesthesiologist]
We use other things as well, such as observing the child, see
how they move or are interested in playing compared to other
children of the same age. [#9 Pediatric surgeon]
An anesthesiologist expressed a warning about trusting standardized pain assessment tools:
If you’re always going to believe in the patient and scoring systems like that, and the conclusion is always that you should
give pain medication if they are stating having pain, you often
get in trouble for opioid overuse. [#4 Anesthesiologist]
As evidenced by these statements, disagreements regarding the
use of evidence-based tools, medications, and dosages are perceived and described as real barriers to PPPM.
Barriers at the Individual Level
In the discussions in the FGs, individual knowledge deficits
were expressed as reasons for nonoptimal pain management. Lack
of competence was often ascribed to inexperience. One of the
anesthesiologists stated one reason for giving insufficient pain
medication:
If you are not used to [prescribing] opiates to children at all,
then it is very likely that you will stay a bit in the lower tiers
[of opioid prescription]. [#7 Anesthesiologist]
We observe that appendicitis, often treated by the residents
who do not specifically work with children, can result in children being underdosed with pain medication. Then we need to
review and adjust this correctly. If things have been rushed, the
anesthesiologist may not always have prescribed [pain medication into the EPJ]. Additionally, it could be a surgeon who is not
P.F. Hougaard and A.H. Smeland / Pain Management Nursing 26 (2025) e117–e123 e121
very experienced with pain management in children, who has
prescribed something that is usually too cautious, such as half a
dose or just over half of what we can use, and perhaps only using paracetamol instead of using both paracetamol and NSAIDs
from the start. [#9 Pediatric surgeon]
Several of the physicians and nurses expressed similar reasons
for suboptimal postoperative pain management of pediatric patients.
Individual lack of expertise in PPPM combined with a lack of
organizational know-how, as well as not knowing their co-workers
appeared to be a significant reason for noncompliance with pain
management regimens. As the following statement from one of
the anesthesiologists shows, not knowing the person who is calling
makes physicians cautious:
Prior to working with children myself, I always thought it was
a scary question, when [a nurse] at some ward called me, and
I had no idea who worked there, and you’re supposed to start
dosing morphine for children. I don’t think like that now, but
I understand where the underdosing [of opioids] comes from.
[#7 Anesthesiologist]
Relying on experienced HCPs was described at times as difficult as they were scarce. This was not only a concern relating to
the physicians. When the nurses were asked about inexperienced
physicians, one nurse replied that the phenomenon of inexperience
applied both to physicians and to nurses:
You can meet a nurse who has no idea. And if you have an
anesthesiologist who also has no idea, then it sucks for that patient to be in the PACU. […] Relying on experienced ones is very
difficult. [#2 Intensive care nurse]
The barrier constituted by inexperience in PPPM is not only an
individual-level obstacle but also an organizational one. Therefore,
inexperience represents one of the many barriers that participants
described and discussed relating to organizational, collaborative,
and individual levels of pain relief delivery.
Discussion
Findings Discussion
Although we cannot generalize our findings to other contexts,
the fact that these barriers are present should raise concerns about
to which extent they are to be found elsewhere, e.g., in less specialized hospital settings. Hospitals, regardless of their national
or local cultural context, are institutions that are governed by
similar structures, such as management systems, protocols, regulations, and hierarchical organizations (Kirkpatrick et al., 2013).
These structural similarities make it plausible that findings derived
from one set of hospitals may be applicable to others, particularly
where these similarities are strong.
Our findings are aligned with previous research on barriers to
PPPM: a lack of competence among both physicians and nurses
(Bouri et al., 2018; MacKenzie et al., 2022), limited availability
of competent physicians (Tomaszek & Debska, 2018), tight schedules and heavy workloads (Czarnecki et al., 2019; MacKenzie et al.,
2022; Mahon et al., 2022; Twycross, 2013), and lack of policies
and pain protocols within and across departments and professions
(Bawa et al., 2015; Smeland, 2023). Our findings are regretfully not
new. They only reconfirm that these barriers exist.
Our findings show a concerning lack of consensus regarding the
use of standardized pain assessment tools. Even though the use of
standardized pain assessment tools has been shown to contribute
to significantly better outcomes (Friedrichsdorf & Goubert, 2020),
our findings indicate a lack of trust in, competence with, and adherence to these tools among physicians.
Bianchi et al. (2018) found in nursing, and Djulbegovic and Guyatt (2017) in medicine, that implementing evidence-based practices must be actively supported by organizational leadership. Only
then is it reasonable to expect HCPs to develop assessment and
treatment practices based on shared standards and understandings. Our findings illustrate that professionals need practice with
standardizing, for example, the use of evidence-based tools, drugs,
and dosages; to be confident and comfortable in their professional
roles; and to establish good professional working relationships.
Leaders at all levels at hospitals are important and irreplaceable
in establishing such standards of practice, as well as securing professionals’ adherence to these standards (Kueny et al., 2015).
Mirroring our findings, Mahon et al. (2022) found that pain
education varied across departments and clinical roles. Our findings show that these variations of practices are also present within
departments, constituting barriers of collaboration within and between professions that are potentially detrimental for pain management outcomes for the pediatric patients.
Establishing an interprofessional culture of evidence-based
PPPM is dependent on the continuing education of HCPs.
Mahon et al. (2022, p. 178) states that it is an institutional responsibility to “encourage inter-disciplinary approaches to education on this issue.” As an institutional responsibility, the issue of
securing HCPs’ up-to-date knowledge on best practices in pediatric
pain management is clearly within the purview of leaders at all
levels in an organization, and organizational-wide policies for pediatric pain management (Health Standards Organization, 2023).
Overall, our findings suggest that there are important obstacles
to interprofessional PPPM endeavors. Our findings are not new discoveries. Still, we would argue that our findings relate to two possibly interrelated issues, which we would characterize as dimensions of trust and professional power struggles.
First, several of the participants mentioned that they did not
use standardized pain assessment tools because they found them
to be unreliable in establishing actual levels of pain. Even though
the tools at hand were scientifically validated and have been
shown to increase patient outcomes, some were seemingly skeptical and relied on their clinical judgment. Interestingly, this skepticism seemed to be more prominent among the physicians, a
profession that in many other settings promotes the paradigm of
evidence-based medicine and practice (Djulbegovic & Guyatt, 2017;
Sullivan et al., 2017).
Although somewhat speculative, one interpretation of our findings might be that the lack of trust that physicians express is not
in the use of the tools themselves but in the users and promotors
of the tools. This would in fact be an expression of physicians’ lack
of trust in the nurses’ competence and their usage of the tools. If
that is the case, the lack of trust between physicians and nurses
is a serious barrier for evidence-based PPPM, which must be addressed both in the educational settings as well as within healthcare institutions.
The assessment of pediatric postoperative pain is of critical importance and should not be hampered by lack of trust between
professions. Grimen (2009, p. 21) states that in the context of trust
between patients and HCPs, “To trust someone in health care is to
delegate power to assess and take risks. It is to transfer (de facto)
the right to assess what is risky to professionals whose judgments
can—and often do—differ significantly from one’s own.” Pain management is treatment, and therefore it is possibly understood as
something that should be under the sole authority of physicians.
As trust is “to delegate power” (Grimen, 2009, p. 21), what we refer to as lack of trust might actually be a question of professional
power struggles (Bochatay et al., 2021). As nurses are becoming
e122 P.F. Hougaard and A.H. Smeland / Pain Management Nursing 26 (2025) e117–e123
increasingly competent and actively engaging in suggesting how to
manage pediatric pain, physicians might see this as an infringement on their professional jurisdiction and a threat to their professional power and autonomy (Abbott, 2005). On the other hand,
Schot et al. (2020), in their review of how healthcare professionals
contribute to interprofessional collaboration, found that such assumptions of interprofessional power struggles might not be well
grounded. They found on the contrary that physicians often “play a
leading role in the reconfiguring of tasks within collaborative settings” and take “a leading role in the finding of workable divisions
of labor in the face of collaborative demands” (Schot et al., 2020,
p. 336). If this perspective is more accurate, the divergent view between nurses and physicians on the use of pain assessment tools
and use of opioids might more easily be mitigated through interprofessional discussions and education.
The findings we have presented and discussed all point to a
continued need for interprofessional collaboration and discussions,
as well as leadership.
Methodological Discussion
This study does have certain limitations that warrant discussion. With only two FGs and twelve participants, it is not feasible
to extrapolate our findings with any certainty to other hospital settings. The participants do not represent a typical cross-section of
nurses or physicians, nor is the institution they represent considered standard. The participants are employed at a university hospital, viewed as a premier institution in the realm of pediatric surgical treatment. Nevertheless, we contend that it is highly probable
that the identified barriers related to competence levels, resource
scarcity, and lack of consensus on children’s pain management are
prevalent elsewhere. Given that the participants work at a university hospital, most are specialists, and all have extensive experience
in treating pediatric surgical patients, it seems improbable that the
situation would be drastically different or improved in other contexts where children receive treatment.
Within each focus group, the majority of participants were acquainted with each other. The ensuing conversations and discussions were likely shaped by their professional and personal histories as colleagues. This could lead to the conjecture that certain
barriers were omitted from the discussions out of mutual respect
or to evade conflict. If this were the case, it would undermine the
credibility and trustworthiness of our data. We have kept this possibility in mind throughout the data collection and analysis process but have not detected any evidence of such deference. On the
contrary, participants appeared to be forthright and honest in their
discussions, expressing their disagreements and viewpoints regardless of their standing in what is often portrayed as the professional
hierarchy within hospitals (Rogers et al., 2020; Weller et al., 2011).
This suggests that the participants’ expressed views are truthful
and represent their actual opinions.
The FGs did not encompass participants beyond the realms of
nursing and medicine. While these two professions are arguably
the most crucial in managing postoperative pain, the exclusion of
other professions limits the diversity of viewpoints brought to the
table in the FGs. It is entirely possible that a hospital administrator, a hospital clown, or a psychiatrist could highlight different obstacles than those we have identified in our research. These
viewpoints warrant further exploration. However, this does not diminish the significance of the barriers we uncovered, nor does it
negate the fact that our FG participants represent the professionals
most frequently engaged in PPPM. They are the ones closest to the
patients and bear the primary responsibility for pain prevention
and treatment.
For the sake of analysis and clarity in presentation, we have divided the findings into different levels—organizational, collaborative, and individual. This is a simplified representation of the intricate nature of professional work, organizational dynamics, and
pain management. The logistical issues related to providing information to patients and their families, which we classify as an organizational barrier, undoubtedly also impedes seamless interprofessional and collaborative pain management. The inherent complexities in the organization our participants work in and discussed in
our FGs, as well as in the phenomenon of pain management itself,
cannot be neatly compartmentalized into such distinct levels. However, we believe that these analytical levels are meaningful and
make sense to both the researchers and the HCPs with whom we
have discussed these matters.
Conclusions
Our findings suggest that the identified barriers to PPPM are often linked to a lack of standardized, evidence-based PPPM routines
and adherence to these standards, issues closely linked to insufficient leadership at the hospital and department levels.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to
influence the work reported in this paper.
CRediT authorship contribution statement
Peter Forde Hougaard: Formal analysis, Visualization, Writing
– original draft, Writing – review & editing. Anja Hetland Smeland: Conceptualization, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing.
Acknowledgments
The authors would especially like to thank the participants
and hospital staff for their cooperation. They also wish to thank
The Youth Council at Oslo University Hospital for their input.
The authors wish to thank the Children’s Surgical Department
at Oslo University Hospital, Norwegian Pediatric Pain Association
and Medicines for Children Network, Norway for funding this
study. Lastly, we want to thank Hilde Silkoset and Kristian Kolstad
Kjærnes for conducting the focus group interviews.