Commentary

Creating and delivering pain education for clinicians in a developing country

Shemila Abbasi

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Pakistan is a country with an estimated population of 191.7 million in 2015 (Pakistan Economic Survey, 2014-15). More than half of the total population is less than 19 years of age (Mehnaz, 2011). The majority of hospitals in the country do not have a dedicated postoperative pain service and the reliance on pain management rests on general ward staff (nurses and technicians). Clinical pain assessment in children is a complex issue and a prerequisite for effective pain management. Appropriate management improves outcomes in the forms of reduced morbidity, mortality and improved patient and parental satisfaction. This commentary describes the successes and challenges of our efforts in teaching pain assessment principles in a country where this education is not a standard part of medical training.

It was the fall of 2015 when my mentor and I had a discussion on lack of pediatric pain management practices in our hospital and came up with an idea to contribute in that area by providing pain assessment education. There are numerous tools available for pain assessment (Maunuksela et al., 1987) and measurement in different pediatric populations. However, none are formally taught in academic programs and hence not applied by the majority in our region. Therefore, we decided to apply for a grant for a pain assessment and management course. The target population was nurses and physicians involved in management of postoperative pediatric patient assessment. The idea was to familiarize the target population in at least two practical tools (e.g. CHEOPS and FLACC scale) of pain assessment for each of the different age groups. Moving on to the formation of an education team, people who were pediatric anesthetists and were involved in pediatrics cases, along with colleagues who were dealing in chronic and acute pain management were approached to be a part of this initiative. The final team members included pain physicians, anesthesiologists, a pediatric anesthesiologist, a pediatric surgeon and a pain nurse (Dr. Shemila Abbasi, Dr. Fauzia Anis Khan, Dr. M. Asghar Ali, Dr. Khalid M. Siddiqui, Dr. Saima Rashid, Dr. Bushra Salim, Dr. Saqib Qazi and Ms. Rozina Kerai). After formulating the team, a number of meetings were held in which the topic, teaching pedagogies and overall content of the course were designed and finalized. Afterward a debate continued on whether to focus on the content on pain assessment or management, the team consensus was to impart teachings of both pain assessment and management to a feasible extent. The objective was to motivate the participants to learn about pain assessment, use pain assessment scales and apply this knowledge to appropriately manage it in a way such that pain is optimally managed for all children receiving care in our region.

Being the chief person in this course, I along with my team designed the budget. During the process of finalizing the budget, we came up with more ideas related to the participants. The course was aimed to impart knowledge in such way that the participants would be able to transmit it further in their circle. For that reason we planned to provide them extra pain scales and booklets to share with their colleagues. Simulation-based workshops were incorporated in the program so the participants could practice the pain scales in the presence of facilitators and be able to demonstrate them in their respective institutions.

The next essential step was to decide where to apply for grant support. The International Association for the Study of Pain (IASP) was chosen to receive our grant application, since the previous experiences with the agency were pleasing and rewarding. All the prerequisites and requirements of the agency were thoroughly followed and fulfilled. Apart from the agency, there were internal institutional protocols which we followed including review process and internal approvals from concerned departments. The target audience was 20 participants in each course from Karachi, along with five from outside the city, in total 75 participants in three courses. The participants included nurse practitioners, medical officers, anesthesia residents, pediatric surgery residents and pediatric surgeons. The aim was to engage people from outside the city as well. Basically, the objective was to engage the maximum number of people practicing pediatric surgery and dealing with pain management every day. Eventually the grant recipients were announced and we were fortunately awarded.

As planned there were items including a booklet having baseline pediatric pain assessment tool information and material related to pediatric pain doses including details of all the possible side effects. It was designed in such a way that it also works as a notebook. A numerical pain rating scale was designed along with a bag to keep all the materials in. The Wong-Baker Faces Pain Rating Scale was printed on the pouch so it stays with them throughout the course and later if needed (Hockenberry et al., 2005).

Figure 1. Course materials

Table 1
Pain assessment and management in pediatric anesthesia and surgery

Finally, the course execution date arrived and the entire team worked hard to make it a successful learning experience for both facilitators and participants. It was a two-day course executed thrice with 75 participants in which we covered the following course content.

The first course was highly successful with productive discussion. The second course was conducted with a good mixture of participants. In the third course a large number of participants showed up which was bit challenging for us to accommodate since we had limited seats, therefore, we had to limit the number allowed to participate. This was unfortunate but did underscore both the need for this education and the success of our efforts. Hence, we planned to conduct the course every year to continue our mission of providing pain education. Practicing pediatric surgeons participated in the third course, and appreciated the course. They reported that their concepts changed and updated through this course.

“It was worth attending it. Got a lot of knowledge. My concepts are cleared now. Thank you for this session.”

The course material was highly appreciated by the participants.

“Handy material and booklets were good initiative, teaching methodology were really very interesting.”

Surprisingly, a number of undergraduate students attended the course due to their keen interest in pain management, though they were not the target audience because the course was specifically designed for practicing nurses and physicians. Students were more than satisfied as they reported not to have any formal pain teachings in their undergraduate program. They requested further formal teaching related to pain management.

“It was well organized and knowledgeable workshop. Learnt a lot of new things regarding pain management in children’s.”

“Interactive evidence based session, these lectures should continue in future.”

Overall it turned out to be an amazing learning practice for both the participants and facilitators. The entire experience from applying for the grant to developing and executing the course was thoroughly enjoyed and advanced our learning. The candidates who attended this course were encouraged to share these learning points with their colleagues and utilize them in their daily practice. Since we have the course developed, we hope to offer it at least once a year. Lastly, the model of the course can be replicated in other parts of the Pakistan. Now after six months of completion of the course, we are planning to start a follow-up survey in respective hospitals to assess any change in their practice.

Cite as: Abbasi S. Creating and delivering pain education for clinicians in a developing country. Pediatric Pain Letter 2018;20(1):1-4. www.childpain.org/ppl 

Acknowledgement

Ms. Asma Faraz, Associate, Department of Anaesthesiology, Aga Khan University for assistance.

References

Hockenberry MJ, Wilson D, Winkelstein ML. Wong’s essentials of pediatric nursing (7th ed.). St. Louis, MO: Mosby, 2005. Link

Mehnaz A. State of children in Pakistan - confronting reality. J Pak Med Assoc 2011;61:518-519

Maunuksela EL, Olkkola KT, Korpela R. Measurement of pain in children with self-reporting and behavioral assessment. Clin Pharmacol Ther 1987;42:137-141. PubMed Abstract

Government of Pakistan, Ministry of Finance. Population, Labour Force and Employment Chapter 12. Pakistan Economic Survey 2014-15. Link