Table 1 Summary of studies findings

1

Pharmacological management of invasive procedural pain in children: Facilitators and barriers

Anim-Boamah et al(2024)/ Ghana

Quali ative exploratory, descriptive study

Explore the factors that enhance or mitigate pharmacological management of invasive procedural pain in pediatric

16 nurses from the pediatric units

Semi-structured interviews by using conventional content analysis

Perceived facilitators: 1. Nurses’ initiative

2. Advocacy by nurses,

3. Desire to use pain medication

expectations from team members

Perceived barriers:

1. lack of knowledge,

2. shortage of staff,

3. time constraints,

4. doctor’s prescription patterns

5. lack of policies and facilities

6. cost implications of medications

A.Nurses’ limited knowledge, B.staffing

C.Time limitations, D.Doctors’ prescription habits

E. Lack of supportive policies and facilities

F.Medication costs

A.Nurses’ initiative, B.Advocacy, C.Desire for effective pain medication use, D.expectations from other team members to manage pain.

2

Thai Nurses’ and Midwives’ Perceptions Regarding Barriers, Facilitators, and Competence in Neonatal Pain Management

Mala et al(2024)/Thailand

Qualitative

Investigate nurses’ and midwives’ perceptions of barriers, facilitators, and competence regarding effective neonatal pain management in Thai NICUs

Neonatal nurses and midwives in three units of two tertiary hospitals

Virtual one-to-one, semi-structured interviews

Pain management relies on the expert care of nurses and midwives and understanding the contextual nuances of pain management.

Various organizational, structural, and cultural factors could impede effective pain management.

Not specified

3

Improving ambulance care for children suffering acute pain: a qualitative interview study

Whit (22)ley et al(2022)/UK

Qualitative

Identify clinicians’ perceptions of barriers, facilitators, and potential improvements for the management of pre-hospital acute pain in children

12 ambulance clinicians participated, including nine registered paramedics and three emergency medical technicians

Face-to-face semi-structured recorded interviews & Thematic analysis was used to generate themes

Several themes relating to barriers and facilitators were identified, including physical, emotional, social, organizational, environmental, management, knowledge, and experience. Improvement themes relating to management, organization, and education were identified.

Physical, emotional, social, organizational, environmental, management, knowledge, and experience aspects of pre-hospital care.

A.Exploring methods to increase rates of analgesic administration, including utilizing intranasal or inhaled routes

B.Reducing fear and anxiety in children by using child-friendly uniform

C. Additional non-pharmacological techniques

D.More public interaction

E. Reducing fear and anxiety in clinicians by enhancing training and optimizing crew mix

4

An exploration of the facilitators and barriers to paramedics’ assessment and treatment of pain in pediatric patients following Trauma (EX-PAT)

Handyside et al(2021)/UK

Qualitative

Understanding the facilitators and barriers experienced by paramedics in their assessment and management of pain in children who have sustained traumatic injuries

Paramedics employed by the South Central Ambulance Service NHS Foundation Trust

Face-to-face, audio-recorded semi-structured interviews using a piloted topic guide& analysed by using thematic analysis.

Facilitators:

1. Facilitators to pain assessment: previous positive experiences with pain scoring tools and patients’ understanding of and compliance with these tools.

2. Management facilitators: colleagues’ support, exposure, being a parent, technology, severity of the injury, and subjective pain scoring.

3. Organizational facilitators: medicines, routes, and alternative methods.

4. Situational facilitators: patient-specific solutions and parents.

Barriers:

1. Barriers to pain assessment: lack of confidence in pain scoring tools.

2. Barriers to management: issues with medicines, skills, consequences to self or patient, negative interactions, limited exposure, equipment issues, and training and culture.

A.Lack of confidence in using pain scoring tools, B.Medication issues

C. lack of skills D.Consequences

E.Negative interactions

F. Limited exposure, G.Equipment issues

H. training

I. culture.

A.Support from colleagues, B.Exposure to different situations, C.Parenting experience, D.Tchnology, E.Injury severity, F.Subjective pain assessment, G.Medication, H. alternative treatment methods, I.Patient-specific solutions

J. Parental participation

5

784 Healthcare professionals’ experiences of the barriers and facilitators to community paediatric pain management at end-of-life

Greenfield et al(2021)/UK

Qualitative

Explore the barriers and facilitators to community-based pediatric pain management for infants, children, and young people at end-of-life

Nine healthcare professionals: 12 nurses, five GPs, five consultants and registrar doctors, two pharmacists, and five support therapists working in primary, secondary, or tertiary care

Semi-structured interviews by inductive thematic analysis

Seven themes:

1. Parents’ abilities, beliefs, and well-being

2. Working relationships between families and healthcare professionals,

3. Working relationships between healthcare teams

4. Healthcare professionals’ knowledge, education, and experience

5. Health services delivery

6. Nature of pain treatment

7. Paediatric-specific factors.

A.Challenges in parents’ abilities, beliefs, and well-being,

B.Need for improved working relationships, C.Knowledge sharing among healthcare professionals

A.Partnership working between families and healthcare professionals

B.Partnership working within healthcare teams, sharing expertise for effective pain management

6

Barriers and Facilitators to Effective Pain Management by Parents After Pediatric Outpatient Surgery

Tam et al. (2020)/Canada

Qualitative

Describe the experience of postoperative pain management from parents’ perspectives and areas for improvement.

40 parents or legal guardians of children aged 5–18 years who underwent outpatient surgery

Semi-structured interviews

Facilitators included a combination of verbal and written instructions. Barriers to effective pain management included discrepancies in the information provided by different healthcare professionals and the experience of stress during pain management communication.

A.Discrepancies in the information provided by different healthcare professionals

B. Experience of stress at the time of pain management communication

Combination of verbal and written instructions

7

Nursing-Related Barriers to Children’s Pain Management at Selected Hospitals in Ghana: A Descriptive Qualitative Study

Kusi Amponsah et al(2020)/Ghana

Descriptive qualitative study

Identify and understand the nursing-related barriers to children’s pain management in the Ghanaian context.

28 nurses working in the pediatric units of five hospitals

Over three months of interviewing by participants

1. Communication difficulties in assessing and evaluating pain management interventions with children who have nonfunctional speech

2. Insufficient training, misconceptions about the experience of pain in children

3. Lack of assessment tools 4. Insufficient number of nurses to manage the workload

5. Nurses’ inability to prescribe analgesics

Organisational, structural, and cultural factors

Education, empowerment, and support with the requisite material resources for nurses could serve as facilitators for effectively managing children’s pain.

8

Barriers and facilitators to effective procedural pain treatments for pediatric patients in the Chinese context: A qualitative descriptive study

Hu et al(2020)/China

Qualitative descriptive study

Explore nurse and physician leaders’ perceptions of barriers and facilitators to using evidence-based procedural pain treatments for hospitalised infants and children.

By purposive sampling, nurse/physician leaders engaged in the clinical management of three pediatric inpatient surgical units in one hospital.

Focus groups, individual interviews& consolidated Framework for Implementation Research guided the data analysis.

Barriers:

1. healthcare professionals’ limited knowledge and misconceptions about pediatric pain management,

2. lack of specific policies, low priority, heavy workload, staff shortage, and limited time.

3. Unique determinants in the Chinese context included parents’ concerns about new interventions, parent wrath, a hierarchical managerial system, and nurses’ lower authority.

A.Health care professionals’ limited knowledge and misconceptions about pediatric pain management

B. No specific policies

C. Low priority

D. Heavy workload

E. Staff shortage

F.Limited time

G. Unique determinants in the context

Not specified

9

Availability of researcher-led eHealth tools for pain assessment and management: barriers, facilitators, costs, and design

Higgins et al. (2018)/Canada

An online survey by authors according to systematic review results

Exploring the availability and implementation of eHealth tools for pain assessment and management

Researchers of eHealth tools

After systematic reviews about eHealth tools for pediatric pain assessment, a survey was conducted with authors about identified tools to gather information on barriers and facilitators of eHealth tools in pain management

Few pediatric pain-related eHealth tools were reported in the literature, and authors’ beliefs in tool selection were dominant

A. Outdated technology

B.System-level barriers like lack of funding and institutional infrastructure.

Consideration of personal beliefs in making tools for users

10

An exploration of Indonesian nurses’ perceptions of barriers to pediatric pain management

Mediani et al(2017)/Indonesia

Exploratory descriptive qualitative study

Explore Indonesian nurses’ perceptions of barriers to effective pain management in pediatric patients

37 nurses from two hospitals in Indonesia, selected through purposive sampling

Semi-structured, in-depth interviews

Organizational, structural, and cultural factors that impeded nurses’ ability to deliver effective pain care to pediatric patients

Nurses’ inappropriate clinical practice due to organizational structure and culture.

Strategies to improve clinical nurses’ performance and competency in providing effective pain care

11

Experience of nurses about barriers to pain management in pediatric units: A qualitative study

Aziznejadroshan et al. (2017)/ Iran

Qualitative

Assess the perception of Iranian nurses on the barriers to pain management in pediatric units and centers

19 nurses from Amirkola Children’s Hospital in Babol and Children’s Medical Center in Tehran

Unstructured and deep interviews & analyzed by conventional content analysis method.

Five themes of barriers to pain management:

1. Inappropriate organizational structure

2. Interruption in pain relief activities

3. Inadequate competency of the nurses

4. Individual characteristics of the child and parents

5. Inefficacy of caregivers

A.Inappropriate organizational structure

B.Interruption in pain relief activities

C.Inadequate competency of the nurses

D.Individual characteristics of the child and parents

E.Inefficacy of companions

Improving organizational structure and enhancing nursing competencies

12

Experiences of Iranian Nurses on the Facilitators of Pain Management in Children: A Qualitative Study

Aziznejadroshan et al. (2016)/ Iran

Qualitative

Assess the perception of Iranian nurses on the facilitators of pain management in pediatric units and centres

19 nurses from Amirkola Children’s Hospital in Babol and Children’s Medical Center in Tehran

Unstructured interviews with the participants by purposeful sampling and conventional qualitative content analysis

Four themes:

1. Mother and child participation in diagnosis and pain relief; 2.Timely presence of medical staff and parents, 3.Proper communication, 4. Training and supportive role of nurses

Not specified

A, Mother and child participation

B.Presence of medical staff C.Proper communication D. Nurse training

13

A qualitative study of the barriers to prehospital management of acute pain in children

Murphy et al(2014)/Ireland

Qualitative

Identify the barriers to achieving optimal prehospital management of acute pain in children.

Sixteen advanced paramedics

Two focus group interviews & were analyzed by Attride–Stirling’s framework for thematic network analysis

Barriers:

1.Analgesic Practioner education and training;

2. Current clinical practice guidelines for pediatric pain management

3. Realities of prehospital practice. Challenges: 1. Limited exposure to children in the prehospital setting,

2. Difficulty assessing pain intensity in small children,

3. Challenges in administering oral or inhaled analgesic agents to distressed and uncooperative children.

4. Short transfer times to the emergency department

5. Medical because of pain

A. Limited exposure to pediatric cases

B.Difficulties in pain assessment and medication administration in children

C.Situational factors like short transfer times and the nature of the pain’s cause

A.Practitioner education and training, offering alternatives to assessing pain in preverbal children

B.Exploring the intranasal route of drug delivery in managing acute severe pain

C.Robustly developed evidence-based guidelines that are practitioner-friendly and patient-focused

14

Assessment of pain management adequacy among hospitalized pediatric patients: institutional-based cross-sectional study

Kasahun et al(2023)/Ethiopia

Institutional-based cross-sectional study

To assess the adequacy of pain management among hospitalized pediatric patients at the University of Gondar Comprehensive Specialized Hospital

422 pediatric patients

Structured interview-based questionnaires and reviews of the patient’s medical records. The pain management index (PMI) score was used to determine pain management adequacy.

62.8% of the participants were prescribed pain medication, but about 63.3% received inadequate analgesics.

The type of painkillers administered did not match the severity of the pain experienced by the patients.

Pediatric patients less than one month old and those between one month and one year were found to have inadequate pain medication compared with their counterparts.

A. Inadequacy of pain medication prescribed

B. Mismatch between the type of painkillers administered and the severity of the pain.

Using the PMI score for assessment and structured interviews could facilitate an understanding of pain management adequacy.

15

Reducing pain in children with cancer at home: a feasibility study of the KLIK pain monitor app

Simon et al(2021)/Netherland

Feasibility study

Assess adherence to, the feasibility of, and barriers and facilitators to the implementation of the KLIK Pain Monitor app, which is designed to reduce pain in children with cancer at home

Children aged 8–18 years undergoing cancer treatment and their parents (for children aged 0–7 years) participated in the study

The KLIK Pain Monitor app was used for 3 weeks, with pain assessed twice daily using an 11-point numeric rating scale (NRS-11). Healthcare professionals from the hospital’s Pediatric Pain Service were instructed to follow up with clinically significant pain scores within set timeframes

63% of families used the app daily during the three weeks, and 18.5% reported pain scores twice daily. Clinically substantial pain scores were reported by 44.4% of children at least once, with healthcare professionals following up within the set timeframe in 70% of cases

Not specified

Most app functions were evaluated positively by ≥ 70% of families and healthcare professionals, indicating feasibility.

16

Understanding the toolbox: A mixed methods study of attitudes, barriers, and facilitators in the parental intervention of children’s cancer pain at home

Parker et al(2021)/UK

Mixed methods study

Understand

How parents of children with cancer manage their child’s pain at home.

Parents of children with cancer on active treatment

Convergent, parallel mixed methods design including pain diaries, surveys, and interviews. Each data collection method was analyzed separately and then integrated

Parents frequently under-medicate their child’s pain at home. Practical barriers such as the analgesic context and children finding medications unpalatable led parents to prefer non-pharmacological interventions. Attitudinal and practical barriers resulted in parents having an “empty toolbox” of pharmacological interventions, making

non-pharmacological interventions essential to managing their child’s cancer pain at home.

A.Analgesic context B. unpalatability of medications

C. Attitudinal barriers that led to an underuse of pharmacological interventions.

The study did not explicitly mention facilitators but implied that understanding parents’ attitudes and the context in which they manage pain could lead to better support systems.

17

COVID-19 pandemic impact and response in Canadian pediatric chronic Pain care: A National Survey of Medical Directors and pain professionals

Killackey et al(2021)/Canada

National survey-based study

Evaluate the impact of the COVID-19 pandemic on Canadian pediatric chronic pain care.

Pediatric pain clinic directors and other multidisciplinary pediatric pain healthcare professionals from Canadian pediatric pain clinics and rehabilitation programs.

Two online cross-sectional surveys

All clinics provided virtual care during the pandemic. Most clinics reported no perceived change in patient pain levels (69%) or occurrence of pain flares (77%).

The study also highlighted the rapid mobilization of virtual care as a response to the pandemic.

A. Challenges of providing comprehensive care virtually

B. Potential disparities in access to technology among patients

Need for additional resources to support virtual care

A.Transition to virtual care was facilitated by the existing infrastructure

B.Willingness of healthcare professionals to adapt to new modes of care delivery

18

Barriers and facilitators to using pain treatment during newborn screening blood tests at a mother-baby unit

Venegas (2019)/Canada

Online survey

Explore the nurse’s preferences for pain treatment during newborn screening (NBS)

Nurses in a mother-baby unit

Registered nurses and registered practical nurses mainly work in the mother-baby unit.

Nursing staff preferred sucrose over family-led interventions like breastfeeding and skin-to-skin care during newborn screening procedures.

Predominance of nurses’ preferences in pain management than family-centered care

The potential of family-centered care as facilitators in the context of mother-baby units

19

Nurses’ knowledge and attitudes regarding pediatric pain management in western Australia

Peirce et al. (2018)/ Australia

Cross-sectional, descriptive study

Investigate nurses’ knowledge and attitudes regarding pain management

590 nurses in an Australian pediatric hospital

Pediatric Pain Knowledge and Attitudes Questionnaire

The mean knowledge score was 77.56 out of 100; the mean attitude score was 72.46 out of 100

Senior registered nurses and. Nurses with specialist pediatric qualifications had significantly more positive attitude scores than others.

51% of respondents believed that children tolerate pain better than adults do.

Inadequate knowledge

It does not explicitly focus on facilitators but suggests that targeted education using in-service education and workshops could serve as facilitators.

20

An Assessment of Newly Identified Barriers to and Enablers for Prehospital Pediatric Pain Management

Whitley et al. (2017)/USA

Quantitative assessment

Assess the prevalence of newly identified barriers and enablers to prehospital narcotic analgesic administration in a sample of paramedics.

Determine whether these barriers and enablers differ between new and experienced paramedics

A convenience sample of paramedics from urban, suburban, and rural practice settings in an emergency medical services system.

Descriptive statistics were calculated to describe responses, and differences between new (≤ 5 years) and experienced (> 5 years) providers were assessed.

Notable barriers to analgesic administration:

1. Causing more pain from intravenous catheter insertion

2. Parental influences

3. Difficulty assessing pain

4. Worry about allergic reactions.

Enablers:

1. Belief that analgesic administration is important

2. Education to administer analgesics

3. Support from agency leadership.

Differences between new and experienced providers:

1. Overall comfort with pediatric patients

2. Receiving negative responses from superiors about giving pediatric patients analgesics

3.Usefulness of the Broselow tape for dosing fentanyl for children

Skills and knowledge deficits

A.Support from agency leadership

B.Personal views on analgesics

21

Prehospital Pediatric Pain Management: Continued Barriers to Care

Mellion et al(2017)/USA

Not explicitly mentioned

Assess the current state of prehospital pediatric pain management in children with fractures and burns and identify ongoing barriers to care.

Examining prehospital pain management for children with fractures and burns is not detailed in the sources

Not provided specific information about the participants

Disparities exist in rates of prehospital pain management for children with fractures and burns

Lack of validated pain scales for prehospital use

A.Leadership support in EMS

B.Single guidelines for pain management

22

Pediatric pain management in the emergency department: the triage nurses’ perspective

Thomas(2015)/Canada

cross-sectional survey-based study

Understand triage nurses’ perspectives on pain management for children

Triage nurses at three Canadian pediatric emergency departments

A paper-based survey

Nurses reported a longer acceptable delay between triage time and administration of analgesia.

Most nurses felt more comfortable with protocols involving the administration of acetaminophen or ibuprofen than for oral morphine or oxycodone.

Three reported barriers were monitoring capability, time, and access to medications

A.Monitoring capability

B.Time constraints

C. Access to medications

Nurses were open to improving pain management protocols for children in the ED.

23

Reported practice variation in pediatric Pain Management: A Survey of Canadian Pediatric Emergency physicians

Ali et al(2014)/Canada

Prospective survey-based study

Describe pediatric emergency medicine (PEM) physicians’ reported pain management practices and explore factors that facilitate or hinder pain management.

Canadian pediatric emergency physicians

Through the Pediatric Emergency Research Canada physician database

Almost all pain screening in emergency departments (EDs) occurred at triage (97%).

24% of physicians noted institutionally mandated pain score documentation.

Ibuprofen and acetaminophen were commonly prescribed in the ED for mild to moderate pain.

The most common nonpharmacologic interventions used for infants and children were pacifiers and distraction, respectively.

The training background and gender of physicians affected the likelihood of using nonpharmacologic interventions.

Physicians noted time restraints to be the most significant barrier to optimal pain management.

Request for improved access to pain medication, better policies and procedures, and further education

A.Time constraints

B.Lack of institutionally mandated pain score documentation

C.Variability in the use of nonpharmacologic interventions

A.Improved access to pain medications

Better policies and procedures

C.Further education