Journal of Pediatric Nursing (2014) xx, xxx–xxx

Experienced Nurses' Use of Non-Pharmacological Approaches Comprise More Than Relief From Pain1,2 Edel Jannecke Svendsen RN,MNSc,PCNS a,b,⁎, Ida Torunn Bjørk RN,MNSc,PhD a a

Department of Nursing, Faculty of Medicine, Institute of Health and Society, University of Oslo, Norway Department of Women and Children, Oslo University Hospital, Norway

b

Received 24 October 2013; revised 22 January 2014; accepted 22 January 2014

Key words: Non-pharmacological approaches; Pain; Nurses; Children

This study investigated the use of, and reasoning by, experienced nurses regarding non-pharmacological pain approaches to care for children in hospitals, with the aim of increasing our understanding, and hence optimizing, these approaches. Three focus-group interviews with 14 experienced nurses, were conducted in 2009. Our findings emphasized the role of non-pharmacological methods in building and maintaining cooperation with the child and in caring for the child by individualizing the use of nonpharmacological methods. © 2014 Elsevier Inc. All rights reserved.

SUCCESSFUL MANAGEMENT OF pain in children is important because children's perception of pain is influenced by their early pain experiences, and this can impact their future responses to painful events (Blount, Piira, & Cohen, 2003; Taddio, Ilersich, Ipp, Kikuta, & Shah, 2009; Walco, 2008). Nurses use different non-pharmacological methods in caring for children during invasive procedures (Polkki, Vehvilainen-Julkunen, & Pietila, 2001), which represent an important aspect of care for children in hospitals (Blount et al., 2003). In addition, pharmacological medicines such as morphine are insufficient in reducing fear, distress or pain during needle procedures in children (Heden, von Essen, & Ljungman, 2011). A combination of both pharmacological medicines and non pharmacological methods are often recommended (Caprilli, Vagnoli, Bastiani, & Messeri, 2012). There is some evidence concerning types of nonpharmacological methods in use by nurses in general (He, Pölkki, Vehviläinen-Julkunen, & Pietilä, 2005; Polkki et al., 2001), but the existing body of research in this field tends to 1

Conflict of interest statement: No conflict of interest has been declared by the authors. 2 Funding statement: This research received no commercial financial support from any funding agency. This material has not been presented previously. ⁎ Corresponding author: Edel Jannecke Svendsen, RN,MNSc,PCNS. E-mail address: [email protected]. 0882-5963/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2014.01.015

focus on the effect of non-pharmacological methods themselves rather than how they are applied (Pillai Riddell, Gerwitz, Uman, & Stevens, 2006; Pillai Riddell et al., 2011). Earlier studies have indicated that the management of pain in children is often inadequate due to lack of experience and knowledge (Hamers, van den Hout, Halfens, Abu-Saad, & Heijltjes, 1997; Karling, Renstrom, & Ljungman, 2002). Although knowledge about the effects of non-pharmacological methods is very important, excellent practice also requires expertise in the appropriate application of this knowledge to specific care situations (DiCenso, Cullum, & Ciliska, 1998; Sackett, Rosenberg, Gray, Haynes, & Richardson, 2007). In order to achieve such expertise, we need a better understanding of how nurses individualize care in children's pain relief. Little is known about how and what types of non-pharmacological methods are used and are considered most helpful in practice by experienced nurses. The purpose of this study was to explore and describe experienced nurses' use of non-pharmacological management in hospitalized children with the aim of increasing our understanding, and hence optimizing, such approaches.

Background Non-pharmacological pain management includes many different methods, from massage and guided imagery to

2 thoroughly researched methods such as distraction and breathing exercises (Maclaren & Cohen, 2007). “Nonpharmacological methods” is a collective term and include a variety of methods (Anderzen-Carlsson, Kihlgren, Skeppner, & Sorlie, 2007; He et al., 2011; Nilsson, Enskär, Hallqvist, & Kokinsky, 2013). Such methods are used by parents to help the child (Cavender, Goff, Hollon, & Guzzetta, 2004; Gorodzinsky, Bernacki, Davies, Drendel, & Weisman, 2012), by the children themselves (Idvall, Holm, & Runeson, 2005), and by children's nurses. Nurses use these methods in addition to analgesics, for example to help the child during procedures or to manage the child's postoperative pain (Cohen, Bernard, Greco, & McClellan, 2002; Ellis, Sharp, Newhook, & Cohen, 2004; Sahler, Hunter, & Liesveld, 2003; Sparks, 2001). The effect of some cognitive–behavioral methods, such as distraction, have been well researched and analyzed in systematic reviews, which represent the bulk of research within this area (Carlson, Broome, & Vessey, 2000; Cohen, Blount, Cohen, & Johnson, 2004; Pillai Riddell et al., 2006; Pillai Riddell et al., 2011; Sander Wint, Eshelman, Steele, & Guzzetta, 2002; Tak & van Bon, 2006; Uman et al., 2013). These studies have investigated the effect of distraction on children's experience related to pain, distress or anxiety (Carlson et al., 2000; Cohen et al., 2004; Pillai Riddell et al., 2006; Pillai Riddell et al., 2011; Tak & van Bon, 2006; Windich-Biermeier, Sjoberg, Dale, Eshelman, & Guzzetta, 2007). The theoretical separation between anxiety and distress on the one hand, and pain on the other, is interesting. One theory is that pain has a mutual and inseparable interaction with anxiety (Montes-Sandoval, 1999). In contrast, the research reported in several reviews (Pillai Riddell et al., 2006; Tak & van Bon, 2006) invites us to consider anxiety and pain separately. This may, however, be less fruitful in some actual patient situations because such an approach risks taking a less holistic view on pain management in children (Kitson, 2002). Several studies have investigated the extent of nurses' use of different non-pharmacological methods (Jacob & Puntillo, 1999b; Polkki et al., 2001; Saccenti, 2010). To varying degrees, nurses mostly used distraction, relaxation, preparatory information and positioning (Hatava, Olsson, & Lagerkranser, 2000; He et al., 2005; Jacob & Puntillo, 1999b; Polkki et al., 2001; Saccenti, 2010; Salantera, Lauri, Salmi, & Helenius, 1999). Methods such as the presence of parents, or comforting and helping with daily activities are important methods, but were only measured in two of these studies investigating nurses' use of different non-pharmacological methods (He et al., 2005; Polkki et al., 2001). The reported differences in the types and frequencies of methods used might be explained by different definitions of nonpharmacological approaches. The overall impression from several self-report surveys is that nurses use non-pharmacological management quite extensively with children (Broome, Richtsmeier, Maikler, & Alexander, 1996; He et al., 2005; Jacob & Puntillo, 1999a; Saccenti, 2010).

E.J. Svendsen, I.T. Bjørk Observational studies have, however, showed minimal or no use of non-pharmacological management (Byrne, Morton, & Salmon, 2001; Twycross, 2007; Woodgate & Kristjanson, 1996). Nurses' experience and education can affect the use of non-pharmacological methods. Polkki, Laukkala, Vehvilainen-Julkunen, and Pietila (2003) argued that factors related to the nurse had a more substantial effect on the use of nonpharmacological methods in pediatric patients than workrelated factors and factors related to the parent or child. They claimed that a nurse's expertise was clearly beneficial, and they felt that a lack of knowledge and uncertainty could prevent the use of non-pharmacological methods. In studies that mapped the level of knowledge on pain management, non-pharmacological approaches were one of the areas where nurses had the least accurate knowledge (Clarke, French, Bilodeau, Capasso, Edwards, & Empoliti, 1996; Van Hulle Vincent & Denyes, 2004). Saccenti (2010) reported that nurses with a clinical specialization in pediatric nursing used a greater number of non-pharmacological strategies than others. Versatile use of non-pharmacological strategies was in itself conducive to high use (Polkki et al., 2003; Saccenti, 2010). Earlier research tends to explain the low use of nonpharmacological methods as being due to the nurses' limited knowledge and experience (Polkki et al., 2003). This overlooks other possible perspectives and understanding that could provide a broader explanation for the rationale of the use or non-use of non-pharmacological methods. Studies are lacking which document a comprehensive understanding of nurses' use of non-pharmacological methods; similarly, knowledge is lacking regarding application of non-pharmacological methods to specific care situations.

The Study Aim The aim of this study was to explore experienced nurses' use of non-pharmacological pain management approaches with children and thus to provide new insights into lesser known aspects of non-pharmacological pain-management in children. The following research questions were formulated: 1. How do experienced nurses use non-pharmacological approaches when caring for children in hospitals? 2. How do nurses reason about the benefits and detriments of using non-pharmacological approaches?

Design A qualitative exploratory design was used. Such a design was considered the most appropriate, since little is known about the situation at hand as scant information is available

Non-pharmacological approaches in children's nursing on how similar problems or research issues have previously been solved (Patton, 2011). Although many studies have been performed on non-pharmacological pain management in children, no research has been conducted on the use of, and reasoning by, experienced nurses with regard to such non-pharmacological approaches.

Sample and Setting Fourteen experienced nurses from three different wards participated in the study. All but one of the participants were female, and between 25 and 62 years old. Two of the nurses were Swedish, and twelve were Norwegian, and they worked in both surgical and medical wards. All but two had more than 4 years' experience working with children in hospital. The two with less than 4 years of pediatric practice had either extensive experience in using non-pharmacological methods in adult nursing or held a special interest in the methods. Approximately half of the nurses had pediatric certification; although, in Norway, a pediatric certification is not necessary to work with children in hospitals. We did not want to limit the sample to only nurses with certification, because we anticipated that also nurses without pediatric certification, but with a special interest in non-pharmacological methods could add valuable views and contribute positively in the group discussions during the interviews. To identify information-rich cases, purposive snowball sampling was used in selecting both wards and nurses. The logic and strength behind purposive sampling lies in selecting information-rich cases for in-depth study (Patton, 2011). The rationale for snowball sampling is that those individuals, recommended as valuable by experienced and knowable people, take on special importance (Patton, 2011). We used both formal and informal networks to identify wards where non-pharmacological pain management was used extensively. The chosen wards served patients with surgical and medical diagnoses. The study's inclusion criteria were focused on the recruitment of nurses, either by the nurses themselves or by other nurses, to be experts in nonpharmacological pain management. This turned out to be somewhat problematic because very few nurses considered themselves to be experts, possibly because “expert” is a characteristic that one may be reluctant to call oneself; it is a designation that others ascribe to an individual (Gherardi, 2006). We therefore asked the ward's educational nurse with responsibility for education and development to select one or several nurses from the ward, and then we asked these nurses to name other nurses in the unit, making snowball sampling appropriate for selection of the participants. Due to the different backgrounds and experience of the nurses we choose to call them experienced nurses, and not experts.

Data Collection Data gathered were collected through focus-group interviews, which are particularly useful to explore

3 knowledge and experience, and to find out how and why individuals think the way they do (Krueger & Casey, 2009; Rice & Ezzy, 1999). The presence of others enhances the intensity of interaction, and ultimately the richness of the data (Rice & Ezzy, 1999). Three focus-group interviews, one on each ward, were carried out in 2009. The interviews, which were recorded, lasted between 1 and 1.5 hours each. The themes discussed were related to the different aspects of non-pharmacological methods. For example, as an introductory theme, the nurses were asked to discuss how often they used different approaches followed by discussions on what situations these approaches were used, when these approaches were not helpful, in what patient age groups they were used, and which issues were important when rejecting non-pharmacological approaches.

Ethical Considerations The National Social Science Services approved the study. Written informed consent was obtained from all participants, confidentiality was guaranteed, and the voluntary nature of participation was emphasized. The local ethics committees of all three hospitals approved the study.

Data Analysis The recorded interviews were transcribed and analyzed within three contexts as suggested by Kvale and Brinkmann (2011). All three transcripts were read several times to get an overall understanding of the text. Notes were taken on first impressions, thoughts and questions. In the first context of analysis, the transcribed text was condensed into meaning units, while preserving the subjects' own understanding. In the second context of analysis, the meaning units were first merged into subcategories at a more general level of understanding and then further merged and recontextualized into two main themes that represent the present results of the study: “The role of non-pharmacological methods in building and maintaining cooperation” and “Caring for the child by individualizing the use of non-pharmacological methods”. During the analysis, the transcripts were read as a whole several times, ensuring that the final interpretation of themes and new perspectives were rooted in the data. The subcategories were used as tools when interpreting the main themes. When writing up the findings, the subcategories within each main theme were merged in order to present a better flow and abstraction of findings. In the third context of analysis, the findings were discussed in relation to existing relevant research to gain a better theoretical understanding of the themes. The 650 meaning units were organized into categories, analysed and presented using Microsoft Excel© 2008. Table 1 provides two examples of this stepwise process.

4

E.J. Svendsen, I.T. Bjørk Table 1

Examples from the analysis process.

Transcript

Descriptive meaning unit

Subcategories

Main themes

Participant: You know, to alter the experience of pain and fear is very satisfying. They can start out and think that everything is horrible and they cry…and then to alter that into a situation where they are calm and cooperate…that is something! Participant: I use soap bubbles first… or I usually try out many standard tricks to see if I get the right reaction to it. You pick that up very fast… what they respond to or not… you know…if they need more control.

Nurses felt that non-pharmacological methods could contribute to alter the situation from fear to cooperation. Non-pharmacological methods facilitated the child's calm feelings and cooperativeness.

Non-pharmacological methods could alter a situation. Non-pharmacological methods facilitated the child's cooperation.

The role of nonpharmacological methods in building and maintaining cooperation

Nurses used soap bubbles. Nurses used standard nonpharmacological methods to evaluate how the child responded to different methods. Nurses understood quickly what type of methods the child needed. The type of non-pharmacological method is chosen on the basis of the child's need for control.

Nurses used approaches that directed the child's focus from the situation. The non-pharmacological methods were chosen on the basis of a try-out phase. The nurses evaluated the child's need for control in the situation.

Caring for the child by individualizing the use of non-pharmacological methods

Trustworthiness Several measures were taken to enhance methodological rigor throughout the study, bearing in mind the importance of ensuring reflexivity in the research process (Rice & Ezzy, 1999). Thus, a pilot focus group interview was conducted before the actual interviews, which led to rewording of questions. The pilot focus group interview increased the reflexivity of the researchers, making them more aware of potentially challenging themes and areas that were difficult to assess. To maintain interpretive rigor throughout the process of analysis, we switched back and forth between the transcripts and the preliminary themes. Part of the text was coded into meaning units by both authors, to ensure that the interpretation of data and final themes were closely linked to the interviews in accordance with the precautions identified by Kvale and Brinkmann (2011). The primary author, who knows the field especially well, formulated questions and posed context-relevant follow-up questions that worked well with the participants during the interviews. The researchers both worked with the themes of the interviews and questioned the primary authors' categories and the way these were understood during the analysis, possibly increasing the reflexivity of the researchers and thereby improving rigor.

Results The Role of Non-Pharmacological Methods in Building and Maintaining Cooperation Cooperation between child and nurse was reiterated throughout the interviews as being the main goal for using non-pharmacological methods; cooperation was especially important during painful invasive procedures. Non-pharma-

cological methods were also used, albeit less frequently, in relation to other pain situations, such as postoperative pain. The nurses claimed that the different methods helped them establish a relationship with the child, making the child more willing to cooperate during a procedure. A typical example was to blow on small windmills to get the child's attention, and initiate interaction, at the beginning of the encounter. The nurse continued by letting the child blow on the windmill before going ahead with the procedure. This could make a child more accepting of a painful procedure and represent the start of a relationship. If the nurses knew the child from earlier encounters, and a relationship had already been established, then nurses were able to use methods that had been previously effective. One way of doing this was to remind the child about their earlier encounters and to talk about and use the methods they remembered the child was interested in. Cooperation was maintained by using non-pharmacological methods for less painful procedures as well, such as measuring blood pressure or removing sutures. Cooperation was vital to ensure that such procedures were done properly. Most nurses reported that the child's expectancy of pain and their level of distress affected their ability to cooperate, regardless of the level of pain during the procedure. This influenced the choice of non-pharmacological methods. One nurse said that she “tuned herself” to the child's needs and views; if she failed, the situation could turn into a frightening experience for the child, such that the child's experience of the level of pain escalated and cooperation became impossible. The following statement shows how important the nurses considered non-pharmacological methods in establishing cooperation: Focus group 3, nurse A: “If we can't get the job done…. the child will not get through the things he or she must get through in order to get well. We might have to nurse these children through many years. If we do not use these methods,

Non-pharmacological approaches in children's nursing we are unable to give them the treatment they need, without spoiling everything for them and us.” “Spoiling” in this sense referred to the use of restraint, which represented a failed attempt to establish cooperation with the child. The nurses also reported situations where they could not manage to establish a relationship and sadly had to restrain the child. This could be a difficult, chaotic and stressful event for the child, the parents and the nurses themselves: Focus group 2, nurse B: “Once we had a child here who experienced the changing of the dressing on his central line as very traumatic. It was terrible. To be able to change the dressing, they needed two or three nurses to hold him still to get it done. I would never have done that! The child cried and ran out of the ward, and the mother cried…the situation became unsolvable. I think such situations are so difficult because we are not able to handle them as we would wish.” The risk of restraint was greater when the child was very young or there was little time to use non-pharmacological methods. Selecting the right method and putting in a little extra time could reduce the strain on both the nurse and the family. As one nurse said: Focus group 1, nurse D: “If you spend an extra five minutes preparing a child for a peripheral venous cannulation, the result is that you get the procedure done without a fight and you save time. In addition, you save the child from the experience of pain and the chaotic situation that follows when you must hold a child still. Therefore, I think you can manage a lot without too much effort.” To avoid resorting to restraint, the nurses used several different non-pharmacological methods that increased the possibility of cooperation. A typical strategy was to employ more than one method at the same time. To sing a nursery rhyme while a coaching parent blew soap bubbles could be very helpful for the child. When elaborating on the use of restraint, most of the nurses emphasized that restraining the child could sometimes be the necessary and responsible thing

Table 2

5 to do, although it brought with it the risk of ruining further cooperation with the child. However, many of the nurses stated that in some cases, the use of restraint was neither unavoidable nor irresponsible. To be able to limit the use of restraint during procedures as much as possible, the nurses relied on time and space to use different non-pharmacological approaches.

Caring for the Child by Individualizing the Use of Non-Pharmacological Methods Three approaches to non-pharmacological methods were used frequently across all three wards participating in this study. Examples of these different approaches are shown in Table 2. The most comprehensive approach was to take an encouraging, connecting and positive attitude towards the child, both during and between procedures. This approach involved displaying energy, being playful and using positive language with the children and their families when meeting them in the hallway. The nurses claimed that this positive and playful atmosphere among the nurses, and with the nurses, the child and the parents made the context surrounding the procedures less negative and less frightening and therefore easier for the child to cope with. The nurses emphasized the use of humor: Focus group 2, nurse C: “You do not need to be so serious. There is enough seriousness here, so that is not the problem … Of course, you must monitor the situation so that you do not make light of things that should be taken seriously. But if you manage to use a bit of humor you might be able to keep up the spirit in a room. Humor has a positive impact on the children, so that not everything about being in hospital just becomes horrible.” The nurses wanted the children to experience a warm atmosphere and to feel calm and safe also in between

Three different non-pharmacological approaches in use.

Non-pharmacological approaches

The different methods

Encouraging, connecting and positive attitude on ward - be playful - use positive language with the children and their families - humor

Giving control over the situation - display energy - let the child take the lead - child decides when to take breaks during a procedure - child decides between different alternatives” - prepare and provide information ahead of small steps during the procedure - create predictability - explain painful aspects of the procedure - remove dressing themselves

Moving focus away from the situation - get the child's attention - help children move the focus away from looking at procedure - blow soap bubbles - blow on small windmills - guided imagery - breathing exercises - offer new and interesting toys - video games - singing

6 invasive procedures as it encouraged cooperation and well being. The nurses used two other non-pharmacological approaches, but with divergent purposes, namely, “giving control over the situation” and “moving focus away from the situation”. The purpose of “giving control over the situation” was to reinforce the child's feeling of control and understanding over the painful situation. Some nurses enabled the child control by letting the child “take the lead”, “decide when to take breaks during a procedure” or “decide between different alternatives”. The nurses prepared and provided the children with control by giving them information ahead of small steps during the procedure, and they tried to create predictability in a number of different ways. Not all nurses explicitly articulated their use of giving control over the situation, but spoke about it in an implicit way when describing how to say things, and ways of introducing painful aspects of the procedure to come. This non-pharmacological approach was used across all three wards, and many nurses also used it to empower the child: Focus group 1, nurse A: “If I have to remove stitches or change the dressing on a painful wound, I often give them control. It means that they can decide to stop me when they need a break. When they feel that they have regained control, they can decide to let me start again.” Nurse B in the same group continued: “The child may spend five minutes removing the dressing himself, where we would have used ten seconds. But if we let them do things themselves, then it's so much easier the next time; they are less afraid and everything goes more smoothly.” The purpose of “moving focus away from the situation” was to get the children's attention and help them move the focus away from the painful situation. Distraction was the most frequently used approach. Different types of distraction were commonly used by nurses. In one of the wards, all the nurses carried soap bubbles in their pockets, while in another ward small windmills were stored everywhere. The third ward did not have a main method of distraction. Other methods used to shift a child's focus away from the situation included guided imagery, breathing exercises, different types of blowing, offering new, interesting toys, video games, and singing. The nurses explained that these methods must only be used when the child's needs were well understood. The nurses stressed that the children had to feel safe and in control. If not, the children could feel deceived when the nurses tried to get their attention and shift it away from what was actually going on during the procedure. The nurses found it challenging to keep the child's focus away from the situation while simultaneously providing a satisfactory level of predictability and control. When deciding on the type of approach, the nurses evaluated the individual child's needs rather than taking a pre-determined approach. For example, a very scared child did not benefit from being distracted or having his or her focus directed from the situation. One nurse explained how she decided on the type of non-pharmacological method “after a quick try-out phase”, first using standard methods

E.J. Svendsen, I.T. Bjørk such as soap bubbles. Other nurses said they just "knew" when distraction would make the situation less predictable for the children and thus make them less cooperative. The nurses collected a wide range of single and clustered cues to help them decide on which non-pharmacological approach to use, and how to adjust it to the child's interests, age and abilities. An Example of a cluster of cues is eye-contact, reactions to distraction and body position. One of the most important cues the nurses looked for was related to the child's level of control and hence his or her capability to cooperate. “Giving control over the situation” was considered safer than “moving focus away from the situation” because the child's feeling of control and power was the basis for the successful use of different types of distraction and guided imagery. “Giving control over the situation” was considered a more all-round and sound approach because of the lower the risk of the child becoming less cooperative.

Discussion A central finding in our study was that the nurses used non-pharmacological approaches to establish and maintain cooperation with the child with the aim of getting procedures done. The nurses emphasized how, through interaction, they tested and adjusted different non-pharmacological methods to optimize cooperation. Nursing literature emphasizes how and to what extent non-pharmacological approaches may reduce children's stress and pain in postoperative pain management (He, Vehviläinen-Julkunen, Pölkki, & Pietilä, 2007), and what types of non-pharmacological approaches are used by health-care providers to achieve this (He et al., 2011; Polkki et al., 2001). It is argued that stress and pain are problems of the child and must be relieved by the actions of health-care providers (Polkki et al., 2003; Salantera et al., 1999). However, for our nurses, the main reason for using non-pharmacological approaches was not only pain relief but also promoting interaction between child and nurse. In the literature, interaction per se as a factor affecting the child's pain is less emphasized than factors such as genetics and the child's temperament (Walco, 2008), despite the fact that pain is inflicted during an interaction. To our knowledge, establishing and maintaining cooperation as a goal for using non-pharmacological approaches has not previously been documented. Establishing cooperation also helped the nurses avoid the use of restraint when performing procedures. The use of restraint is controversial in nursing. Whereas the use of restraint during procedures has been discussed in nursing research (Maclaren & Cohen, 2007; Robinson & Collier, 1997), how to avoid restraint has not been discussed (Demir, 2007). The contribution of non-pharmacological approaches has been discussed, albeit to a lesser degree (Demir, 2007). The effect of selected non-pharmacological approaches on stress and pain has been the focus in earlier research on nonpharmacological pain-relieving approaches (Ellis et al.,

Non-pharmacological approaches in children's nursing 2004; Sahler et al., 2003). However, one recent study on preoperative anxiety in children showed that nurses' sensitivity to the child, and flexibility in altering actions, were key strategies in avoiding physical restraint (Berglund, Ericsson, Proczkowska-Björklund, & Fridlund, 2013). Our findings highlight other reasons for using non-pharmacological approaches in addition to the stress- and pain-relieving aspects. These findings may help us understand how different non-pharmacological approaches benefit interactions between nurse and child. The nurses in our study “tuned themselves into the child” and decided which non-pharmacological approach best suited the particular child during a try-out phase. In other words, they did not just select a method such as distraction and offer it to all the children. Expert practice, as defined by Manley and McCormack (1997), includes the ability to see the patients as a unique individual and thus to be sensitive and sympathetic to the individual character of the patient. This view supports our findings: during the try-out phase, while the nurses were collecting cues, they paid close attention to the child's reaction to different methods. This allowed them to determine the best approach, for example whether the child tolerated methods that aimed at “moving the focus away from the situation” or whether the child only responded well to methods that aimed at “giving control over the situation”. Hoffman, Aitken, and Duffield (2009) found that expert nurses collected a wide range of cues and clustered them more than did novice nurses when deciding on the appropriate method. This applied to our experienced nurses in their non-pharmacological approaches. Nursing research has hitherto provided limited focus as to whether some approaches may be inappropriate in helping particular children. Most intervention studies on the effect of distraction found that distraction was effective in some children (Pillai Riddell et al., 2006; Pillai Riddell et al., 2011; Tak & van Bon, 2006). Thus, the important question remains as to what approach to use with the children who do not benefit from distraction. Our study indicates that to attempt to distract children who do not tolerate distraction is deleterious for the cooperation with the child, and therefore impedes the chances of successfully completing the procedure. When research seeks only to address the issue of “effect” versus “no effect”, it is valid to question the consequences of such intervention studies on clinical practice. There is an imperative that new research evidence is translated and integrated into pediatric nursing practice in order to improve health outcomes for children (Christian, 2013), but we believe that our study shows that caution must be exercised when applying results from existing intervention studies to clinical work, as these studies do not seek to explain how to choose or adjust an approach. The most common method used for “moving the focus away from the situation” was distraction. This is in line with findings from other studies (He et al., 2005; Polkki et al., 2001). Distraction serves to redirect attention from threatening and anxiety-provoking aspects of medical

7 treatments to non-threatening objects or situations (Blount, Piira, Cohen, & Cheng, 2006). Distraction is easy to use and might seem to work well for the child. However, according to the nurses in our study, the use of distraction is complicated and risky. Our nurses claim that distraction only benefits a child suffering from pain when the child has a satisfactory level of control. Without sufficient control throughout the procedure, the child may feel deceived by the distracter, which in turn may threaten the cooperation. We suggest that the reason that distraction has an effect on some children and not on others may be partly explained by the child's perceived level of control rather than the actual effectiveness of the method itself. This is also addressed in a study investigating differences in passive and active distraction, which explored whether a sense of control and engagement in the distraction may be important (Nilsson et al., 2013). A major finding in this study was that nurses used many different methods, the aims of which were “giving control over the situation”, and not just providing information. This differs from previously reported findings (Hughes, 2012). However, providing the child with control is recommended in guidelines for reducing distress during procedures (Duff, Gaskell, Jacobs, & Houghton, 2012a). Our findings address how this is done by experienced nurses. In our study, we found that the nurses frequently used a variety of methods to help children gain more control and a better understanding of the situation while simultaneously preparing them for the procedure by providing them with information. Although providing control through informing the child is a well known non-pharmacological method (Polkki et al., 2003; Salantera et al., 1999), methods such as “let the child take the lead”, “let the child decide when to take breaks during a procedure” or “let the child decide between different alternatives” have not been acknowledged as separate non-pharmacological approaches (He et al., 2005; He et al., 2007; Polkki et al., 2003; Salantera et al., 1999). In psychology (Blount, Bunke, & Zaff, 2000) and play therapy (Duff et al., 2012b), giving the child appropriate control is recommended during medical procedures, but how this is actually done by nurses during a procedure has not been described in the earlier literature—an example of how cross-disciplinary collaboration in research is sometimes lacking. We argue that previous nursing research on nonpharmacological approaches in pain management has neglected the use of non-pharmacological approaches using a qualitative approach. This has led to important methods being overlooked. Charlton (1995) and Kitson (2002) both expressed this concern within nursing research. We share this concern. Methods that aim at giving a child control over the situation have not been investigated in quantitative research papers or in controlled trials on non-pharmacological approaches (see for example the Cochrane review by Uman et al. (2013)). Although the relevance of enhancing a child's control in distressing situations has been a topic in

8 studies in other fields, future nursing studies need to investigate this approach within a nursing context. The limitations of the present study must be borne in mind. The initial purpose was to explore the experiences of expert nurses, whereby the definition of “expert” was partly decided by the nurse herself or himself: others might not have considered them experts. Looking at additional criteria could have ensured a wider range of specialist abilities amongst the nurses recruited into the study. The choice of method may also limit the findings, because focus groups may include both a tendency towards conformity, in which some participants withhold to perspectives that they might otherwise say in private, and a tendency towards “polarization”, in which some participants express more extreme views in a group than in private (Sussman, Burton, Dent, Stacy, & Flay, 1991). The presence of a group also affects what is said and how it is said. This may become especially relevant when openly seeking views of experienced persons, because each participant may feel another participant is the “true” expert and thus may tend to agree. Furthermore, the main focus of this study was not expert practice as such but the non-pharmacological methods and the experienced nurses' accounts of them. The study was conducted in Norway, where health care is characterized by free services and a high standard of social services, enabling parents to be admitted into the hospital together with their child and to be with them at all times. The findings from our study are therefore mainly applicable to similar health-care settings, and may only be of limited value in very different healthcare settings.

Conclusion The findings of this study indicate that the nurses are concerned with establishing and maintaining cooperation with a child. Because cooperation is essential in the painful and challenging context of a medical procedure, non-pharmacological approaches are important tools for the nurses. Cooperation represents the opposite of restraint, which the nurses wish to avoid when performing medical procedures. Our nurses felt that children cooperated better during medical procedures when they were offered the appropriate non-pharmacological approach. In their views, the use of distraction could be unsafe due to the risk of impairing future cooperation. Clinical practice should therefore value the time needed to establish and nurture a positive relationship with the child by informed application of non-pharmacological methods. Clinical practice should also be supportive and consider the use of the type of non-pharmacological approach that achieves maximum benefit for individual children rather than just using one type, for example distraction, for all children. Future research should focus on exploring different methods that are helpful to a variety of children, on

E.J. Svendsen, I.T. Bjørk investigating how different non-pharmacological approaches are interconnected, and on demonstrating which specific methods are most effective. It would also be beneficial to investigate the relationship between nonpharmacological approaches and cooperation, and the potential for reduction in the need to use restraint.

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