International Emergency Nursing xxx (xxxx) xxx–xxx

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International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

Specialist nurses’ experiences when caring for preverbal children in pain in

the prehospital context in Sweden
⁎
Karin Gunnvalla, David Augustssona, Veronica Lindströmb,d, Veronica Vicentea,b,c,
a
The Ambulance Medical Service in Stockholm (AISAB), Sweden
b
Academic EMS in Stockholm, Sweden
c
Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset in Stockholm, Sweden
d
Karolinska Institutet, Department of Neurobiology, Care Sciences and Society: Division of Nursing in Stockholm, Sweden

1. Introduction Healthcare providers’ biggest challenge according to children is for

The United Nations Convention on the Rights of the Child (UNCRC)
[33] defines a child as any person below 18 years of age. All children
are equal and have the same rights including the right to good health.
Prehospital services encounter people in need of all ages and with all
kinds of health problems. Pain is a common reason for seeking pre-
hospital care. Crucial to patients in pain is how prehospital emergency
nurses (PENs) most effectively alleviate their pain.
nurses to create good care relationships by participating in play. This is
a challenge since treatment time is limited, the environment is usually
unfamiliar and children’s medical conditions may be critical. Playful-
ness cannot always be a priority.
2. The study
2.1. Aim

1.1. Background
Pain is the body’s warning system, a subjective, unpleasant sensory
experience associated with tissue damage or impending tissue damage.
Mattsson et al. [17] and Pelander et al. [26] define pain as an un-
pleasant emotional experience associated with threatening tissue da-
mage. Ljusegren et al. [16] and Mattsson et al. [17] describe situation,
culture and environment as being other important factors in addition to
the physiological cause of the pain. Past experiences, memories, context
and ability to understand their pain also affect patients’ ongoing ex-
perience of pain.
Pain assessment and treatment constitute challenges for PENs since
pain is a complex problem. Especially demanding is how to treat pre-
verbal children since the children are unable to say what is wrong. This
makes it difficult for PENs to provide pain management and treatment
that is as personalised as possible. For this reason, relatives have a
central role in the care of all preverbal children. Relatives’ commitment,
cooperation and communication with caregivers affect these children’s
health situations [16,26]. The treatment of children’s pain requires
PENs to understand, interpret and integrate each child’s experience
with their own nurturing knowledge in nursing, assisted by both the
child and relative/s.
Samuel et al. [27] highlight what is important for healthcare pro-
fessionals to consider from children’s perspective. Children want nurses
to be supportive, patient, considerate, and positive, and to commu-
nicate openly to reduce the stress entailed by the care situation.
Pain assessment and treatment for children are generally difficult,
and particularly so with preverbal children. The aim of this study has
been to examine PENs’ experiences of pain management during pre-
hospital care of preverbal children, based on PENs’ given mission to
alleviate patients’ suffering.
2.2. Methodology
2.2.1. Study design
This study is based on qualitative care science principles. These
principles and approach involve PENs focusing on their patients with
the general aim of providing care that strengthens and supports health
[5]. They must recognise patients’ suffering as the motivation for care
[20]. The caring science approach prescribes that care must be based on
a comprehensive understanding of human life. Consequently, patients
are the foremost experts on themselves, their suffering and wellbeing
and their lives [7] and therefore healthcare professionals must have an
open and flexible response to patients’ experiences, in this case the
preverbal children’s need for help and care. Data was collected using
semi-structured interviews that were then analysed inductively using
content analysis as described by Elo and Kyngas [8].
2.2.2. Setting and sample
Informants included were PENs with at least three years’ working
experience in prehospital care. These criteria ensured that they were
sufficiently experienced and had met an adequate sample of children in

⁎
Corresponding author at: Ambulanssjukvården i Storstockholm, AISAB, Lindetorpsvägen 11, SE-121 18 Johanneshov, Stockholm, Sweden.
E-mail address: veronica.vicente@ki.se (V. Vicente).

http://dx.doi.org/10.1016/j.ienj.2017.09.006
Received 19 May 2017; Received in revised form 14 August 2017; Accepted 23 September 2017
1755-599X/ © 2017 Published by Elsevier Ltd.

Please cite this article as: Gunnvall, K., International Emergency Nursing (2017), http://dx.doi.org/10.1016/j.ienj.2017.09.006
K. Gunnvall et al.
Fig. 1. Subcategories and categories describing the main category based on PEN interviews.
pain that they could later describe.
Regulations require ambulances in Stockholm to be manned by at
least one PEN and one Emergency Medical Technician (EMT) [29].
PENs have a specialist ambulance nurse education, involving courses
totalling 60 credits including at least 30 credits for in-depth studies in
Care Sciences. The criterion for entering this programme is a Bachelor
of Science Degree in Care Sciences/Nursing [24]. EMTs have undergone
40 weeks of supplementary education in prehospital emergency care,
after having qualified as Assistant Nurses [3,31].
All EMS personnel follow national medical guidelines [9] containing
protocols for procedures and treatments for specific symptoms and
groups of diagnoses. The symptoms and diagnoses are categorised into
a specific list of predetermined conditions. Today the current medical
guidelines show little understanding for the differences between the
assessment and management of pain in children compared to adults.
Pain scales specifically adapted to children of different ages are also
missing. Additionally, there is no specific training and education on
children’s prehospital care.
2.2.3. Data collection
Data collection, from year 2016, began with written consent from
the head of one of the three ambulance contractors active in the
Stockholm area. Information about the study and a repeated request for
participation were sent out via E-mail to all 130 PENs. Signed consent
was obtained from eight participants.
The interviews took place in peaceful environments chosen by each
participant. They were all tape-recorded. They started with a short
presentation of the study’s aim then the researcher first asked the main
question: “Can you tell me about your experiences when taking care of
preverbal children in pain in the prehospital setting?” This was supple-
mented by follow-up questions such as “What did you think about that?”,
and “Can you explain that a bit more?” These follow-up questions led the
dialogue more deeply into the PENs’ experiences and were dependent
upon the informants’ answers, with the intention of penetrating to the
essence of the phenomena discussed. Finally, the answers were summed
up and the participants were asked if they wanted to contribute any
additional information or comments [13].
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International Emergency Nursing xxx (xxxx) xxx–xxx
2.2.4. Data analysis
The tape-recorded interviews were anonymised and transcribed in
their entirety. Data analysis was carried out in three phases according
to the content analysis method described by Elo and Kyngas [8]. This is
a process of understanding moving between different abstract levels of
meaning. The first, preparation phase of the analysis started with a
reading of the entire transcript, to acquire an initial understanding. All
the transcribed data was carefully read several times until the re-
searchers knew the material well. After the initial reading, the tran-
script was slowly re-read and divided into meaningful units. The
second, organisation phase, involved clustering the meaningful units
into codes to uncover similarities and discrepancies in the data. By
relating the codes to each other, a pattern of meanings emerged that
generated a meaningful structure – the essence of the phenomenon and
its constituents. When describing these constituents, the aim was to be
truthful to the complexity of data. Consequently the meanings may
overlap slightly. In the final, reporting phase, the essence of the phe-
nomenon was categorised into subcategories, categories and a main
category, all described here under “Findings”. Descriptions of the
meaningful constituents follow, to clarify the meaning further by de-
monstrating variations on the essence. Quotations from the informants
are included as explicit examples. A certified English translator has
edited the quotations to ensure that nothing of importance has been
omitted or misinterpreted.
2.2.5. Ethical considerations
The study’s design fulfilled the ethical principles for research pre-
scribed by the International Council of Nurses [14]. Ethical approval
was obtained from the Regional Ethics Committee at Karolinska In-
stitutet, Stockholm [10], (No. 2016/727-31/5). All participants re-
ceived written and oral information before the interviews about the
purpose of the study and the confidentiality of information given in the
interviews. They had the right to withdraw at any time without pre-
judicing their cases.
2.3. Findings
The main category “Prehospital competence alleviates the child’s
K. Gunnvall et al.
suffering by paying attention to its life-world” is presented in Fig. 1. The
essence of the findings is that PENs must enter children’s lifeworlds on
children’s own terms to be able to alleviate children’s pain. PENs must
see each child as a unique human being with its own perspective. PENs
can thus create trusting relationships in a comforting, calm, even
playful environment. A PEN’s voice, touch, playfulness and perhaps
even singing can help a stressed child to be calmer and less stressed.
PENs generally found it difficult to identify pain and treat preverbal
children. Not only did they fear doing wrong, they also felt that more
experience, competence and guidelines could help them to treat chil-
dren on a more professional level.
Three categories that underpin the main category were identified as:
“PENs’ attitude towards children’s suffering”, “Seeking the help of others’
competence” and “Suffering changes children’s lifeworlds”. These three
categories are presented below with their associated subcategories il-
lustrated by quotations.
2.4. PENs’ attitude towards children’s suffering
Informants found it difficult to distinguish pain from anxiety in
children, but they learnt to tell these conditions apart after soothing
children. Informants used body language, facial expressions and pain
evaluation scales for pain assessment. PENs’ most important task, that
must be performed early using pharmacological and non-pharmacolo-
gical means, was alleviating children's suffering. In general, preverbal
children were considered to be undertreated in the prehospital setting.
Several informants emphasised the importance of a warm, safe, caring
environment. This category is presented with two subcategories:
“Identification of pain” and “Alleviation of suffering”.
2.4.1. Identification of pain
Several informants described difficulty in identifying pain in pre-
verbal children:
“Are you screaming because you’re in pain? Are you screaming because
you’re sad? Are you screaming because you’re afraid? Are you screaming
because … well, I don’t know.”
This child clearly could not communicate whether pain, anxiety or
fear was causing it to cry. Several informants concluded that if it was
possible to soothe a child, it was often easier to rule out pain as the
cause of crying. Nevertheless, silent children might also possibly be in
pain, since great distress drains the energy to cry. Several informants
assessed body language, facial expressions and grimaces:
“For example, with facial expressions and muscle tone, you simply have
to look for clinical signs, where you notice something that really must
hurt. It sounds terrible, but it’s like, I mean, this unmistakeably distended
abdomen, or this dislocated or swollen body part or something like that,
you have to weigh in those findings as well.”
Some PENs wanted to use a Visual Analogue Scale (VAS) adjusted
for children, but this was not possible because there are no such cus-
tomised pain scales in the ambulance ‘service today.
2.4.2. Alleviation of suffering
One frequently mentioned and most important task for PENs was to
alleviate childrens’ pain and suffering, thereby also comforting chil-
dren. Early pain management makes things easier for children:
“It’s very important to alleviate children’s pain. Especially thinking about
their future healthcare, since they’ll remember the second we get there
until the second it no longer hurts. If we can make the pain disappear
right away, then we’ve come a long way, then we’re the heroes of the
day.”
Satisfaction was gained from good use of the resources at hand.
PENs reflected on suitable pain management for children and tried to
explain what was about to happen. Informants described different
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strategies for pain management in children – pharmacological and non-
pharmacological methods. Many described the importance of a safe
environment including keeping parents as close to children as possible.
Singing, blowing on injured body parts, unloosening tight clothing and
supporting aching limbs helped some children handle their pain. Sugar
sometimes soothed small children, alleviating their pain. Most in-
formants were confident about interacting with preverbal children, but
wanted to study more about medication dosage before treating chil-
dren.
Informants regarded creating relationships as the first task with
children. Trusting relationships were essential to help children through
their pain:
“You know, I have to build up a relationship. Even if things happen
quickly sometimes, I just must get the child to feel some kind of trust
towards me, or it will be impossible for me to do anything at all. If not, I’ll
get nowhere in caring for the child, I won’t even be able to alleviate the
child's pain.”
PENs must acknowledge children’s lifeworlds to be allowed to al-
leviate their suffering. Their goal was thus to meet children in their
reality, respecting their fears. The first step was to give children enough
time and physical contact. Eye contact and a calm, pleasant voice
conveyed composure and assurance. Addressing children directly
calmed them and made them feel safe even if they did not understand
what was said. Feeling safe may lessen pain, as worry can increase pain:
“I am fully aware that a four-month-old baby will most likely not un-
derstand my reasoning, but maybe it can hear my voice and understand
when I touch it.”
Informants agreed that warmth and safety are most important fac-
tors when caring for children in pain and they preferred to work as
much as possible in the safe, familiar environments of children's homes:
“… I usually prefer to do as much as possible in their home. Like we said
before, then you can involve parents, colleagues, other relatives. And you
can also involve the room, toys and such ….”
However, children hurt or taken ill out of doors mostly preferred to
get into the ambulance as a safe, calm room where parents and PEN
could help them. Familiar objects such as blankets and teddy bears
helped too. PENs’ own security in the ambulance, their familiar en-
vironment, enabled them to communicate greater security to their pa-
tients:
“I know my ambulance. I feel good, I like it there. I think I can convey
this to the child: you’ll like it here too.”
2.5. Seeking the help of others’ competence
Most informants regretted lack of experience in the pain manage-
ment of preverbal children in the prehospital setting. This led to stress
and fear of making mistakes. More experience, more education and
better guidelines are required. Furthermore, PENs described how
courage, intuition and flair are needed when treating pain in preverbal
children. They were very open to seeking the help of others’ compe-
tence: fellow team members, the doctor at the dispatch centre, hospital
paediatricians, the physician on call and the EMS helicopter. One in-
formant suggested a special paediatric ambulance. Several informants
wanted more education like classes, lectures and practising. This cate-
gory contains two subcategories: “PENs’ competence levels” and
“Collaboration between professions”.
2.5.1. PENs’ competence levels
Most informants felt stress when treating preverbal children in pain.
They feared making mistakes because of insufficient experience and
insecurity:
K. Gunnvall et al.
“I’m not that keen on treating pain in a child … because children in-
capable of communicating make me feel insecure, I don’t know what
effect my treatment is having. Is it bad, is it good, what information am I
getting?”
Preverbal children were seldom encountered in the prehospital
setting, resulting in lack of practice. More experience, more education
and better guidelines would help them to care better for children in
pain. Insecurity based on lack of experience and inadequate knowledge
of available prescriptions led to avoiding pain management and chil-
dren thus being under-treated. PENs agreed that the medical guidelines
needed developing:
“As for education and guidelines, of course we’re not allowed to give
sufficiently high doses, even according to paediatric experts. The first
thing they do at the receiving unit where we drop the child off is to
supplement our pain treatment and that doesn’t feel at all satisfactory.”
Greater experience clearly led to faster decisions and the necessary
courage to treat these children correctly. Intuition and flair sometimes
helped more than experience. Clear and honest communication was
also an important feature in PENs’ approach to children.
Informants emphasised the importance of not getting worked up
when treating children. Even if most felt they did not have enough
knowledge and experience around children in pain, one participant
expressed the opposite feeling: “So I have gained experience from a lot of
children in pain, I must say.”
Several suggestions were presented about the best ways of devel-
oping one’s own competence and securing prehospital competence in
general. One suggestion was to have a specific children’s ambulance.
Another was more education in the form of classes and lectures and
more onsite practice.
2.5.2. Collaboration between professions
All informants described seeking help from all resources at hand:
“I think I may be more inclined to call for help from specialised units and
the helicopter and such, as compared to when it’s an adult.” “Seek as-
sistance from the resources at hand. We have good resources, we have
specialised units and units with doctors in them and doctors on the
phone.”
Several informants also declared that they gladly called the doctor
at dispatch centre or phoned the paediatric emergency department (ED)
directly to seek advice when it came to preverbal children in pain and
the management of pain.
For practical reasons, collaboration with one’s colleague, like
switching seats if the colleague was better at caring for children, was a
good solution:
“Oh no, this child is reacting strongly against me somehow, you know.
My voice or whatever, they can get scared. Then it might be better for the
colleague to step in, much better.”
All the informants agreed about the importance of joint decisions
and teamwork in the ambulance, with everyone working together in the
child’s best interest.
2.6. Suffering changes children’s lifeworlds
Caring for children also involved caring for their relatives, being
central in children’s lifeworlds. Relatives’, mostly parents’, participation
increased their children’s well-being. PENs described their helping to
assess children’s pain. Two other important strategies were play and
comfort. This category is presented via two subcategories: “The presence
of relatives eases children’s suffering” and “Children’s communication”.
2.6.1. The presence of relatives eases children’s suffering
Relatives play an important role for all patients, but even more so
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when treating children, especially preverbal children. Relatives must
thus also be given care and consideration:
“Well, I think that when we have children as patients, we often have
several patients; even if we don’t treat the adults, they play a big part in
our handling of this instance of care.”
Respecting relatives and allowing them to participate in care as
much as possible promoted children’s well-being. Several informants
had dealt with relatives’ feelings of guilt when their children had hurt
themselves. It was important to take time with relatives to calm them
and explain what was going on, since they were the key to children
being calm and safe. Worried relatives stressed children just as com-
posed relatives relaxed them:
“Talk to the parent first, take that detour, and try to keep the parent calm
because how the parents are is reflected so much in the children, it’s
reflected a whole lot in the child.”
Relatives were best able to comfort children in pain, while PENs
were administering additional pain treatment. Relatives helped to de-
cide whether children were in pain since they knew their children best.
They were a great resource in assessing preverbal children. Without
relatives, the situation was different:
“You know, you don’t get a background on a child like this if they’re not
verbal, you don’t get a background on a child if they don’t have a relative
around.”
2.6.2. Children’s communication
Administering care to preverbal children in pain involved keeping
them in focus since it was vital to try to take in all their reactions:
“And I view this taking care of a child’s pain, that it’s not only a matter of
taking care of the child but the whole situation around it, because it’s the
child’s lifeworld I’m taking care of.”
Children must be understood as human beings and helped on their
own terms. Even if the children treated were preverbal, PENs told them
what they were going to do and allowed them to participate on their
own terms:
“But everything I’m going to do I explain first, and then, well, see the
reaction. I want the child to participate, at least to have the sense of being
in on it and making decisions.”
PENs took time with children if possible and did not stress them.
They gladly played with their toys as a way of approaching them. They
described children’s play and curiosity as being healthy signs to look
out for:
”Well, their play, in so far as … or, rather, kids’ curiosity. All kids are
curious. And that’s also very important when, like, you see these tired,
drooping, pain … if you see the slightest sign of curiosity in their eyes,
then you know, well, it’s not like … OK, the kid is sick, but not taking it
so super seriously … A lot of times you get that feeling.”
It was hard to communicate with preverbal children. Participants
often asked relatives for help to interpret children’s signals. They also
tried to create the good relationship needed when using touch to care
for children. Informants often reported experiencing difficulties when
caring for preverbal children:
“How are you going to assess pain in children who cannot communicate,
who are too small // Yeah, well, these preverbal children, it’s very, very
hard to communicate.”
K. Gunnvall et al.
3. Discussion
3.1. Discussion of the findings
Giving children professional care required experience and practical
knowledge [30,35]. In order to help children to greater well-being
while in the ambulance, PENs had to take into account not only pa-
tients’ suffering but also their lifeworlds. This study’s care approach,
following Dahlberg [4] scientific definition, is that people are seen as
unique human beings in their natural and existential contexts. Wireklint
Sundström and Dahlberg [35] highlight the importance of including
patients’ lifeworlds in the care given, pointing out that without this
holistic perspective the risk exists that patients’ medical problems will
be missed. Nursing ontology states that a human being is a whole.
Suffering is a central human experience with both external, observable
symptoms and also an internal process [2,35]. PENs must find a balance
between nursing care and medical treatment.
According to PENs, nurses are programmed to relieve suffering. This
study confirms that of Wireklint Sundström and Ekeberg [34], showing
that one of PENs’ most important tasks is to alleviate suffering. PENs in
this study aimed to focus fully on their child patients and take in all
their reactions. The current study deals mainly with physiological pain
caused by illness or injury. Besides the physiological cause of pain,
several other factors may affect children’s experiences of pain, e.g. the
current situation, their culture, the environment, fear and anxiety of the
unknown and separation from their parents [16,17,23,25]. Children’s
previous experiences, memories, contexts and ability to understand
their pain also affect their ongoing experience. This links up with
Dahlberg [4] concept of the lifeworld in which children are situated i.e.
a greater context than just the experience they are currently under-
going.
This study also confirmed that play was a comforting method of
approaching children and examining them. Play and distraction con-
stituted analgesic interventions as emphasized by UNICEF [32]. Fur-
thermore, safe and peaceful environments alleviated children’s suf-
fering practically as well as existentially. Nilsson et al. [22] describe
calm and careful nurses as creating trust and confidence in children and
making them more tolerant of pain.
PENs clearly experienced identifying pain in preverbal children as
difficult. Previous research confirms this [28]. Preverbal children could
obviously not say whether it was pain, anxiety or fear that was making
them cry. PENs used different strategies to identify the cause of chil-
dren’s crying. They tried to calm children to see if that stopped their
crying. Children who did not stop crying after repeated attempts to
calm them were assumed to be in pain. PENs also assessed children’s
presumed pain by observing their body language, facial expressions and
grimaces. PENs wanted to use customised pain scales for preverbal
children in the ambulance service’s care but unfortunately no such
pain-rating scales are available in the ambulance service today and this
was highlighted in the results. Adelgais and Brown [1] mention dif-
ferent pain scales for children. One of them requires observation of
behaviour, and another is a self-rating scale. This latter scale is directed
towards preverbal children who are unable to assess their pain and
translate that feeling into words.
In several cases reported, PENs mentioned children’s relatives
playing a central role in their lifeworlds. This is confirmed by the fa-
mily-centred care approach [12] that plays a significant part in the care
of preverbal children. According to Harrison [12], children’s and fa-
mily’s or relatives’ needs constitute the basis for the nursing care. Thus
the focus is on the child and its care. In order to create functioning,
family-centred care, it is important for PENs to see families and re-
latives as constants in children’s lives, so that the strengths of families
are reinforced and children are encouraged to learn and participate in
decisions regarding care given. Working in a family-centred way fa-
cilitated communication between PENs and children, in addition to
comforting children and providing security [18]. Relatives could often
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International Emergency Nursing xxx (xxxx) xxx–xxx
explain the difference between children’s normal behaviour and their
behaviour in the emergency situation. They could often help PENs to
identify the pain and thereby optimise pain treatment. However, PENs
found that relatives could be both a support and a stress factor in care
encounters with preverbal children. Sometimes PENs found themselves
not only having to care for the children but also for their relatives. This
created a sense of having several patients to attend to at the same time.
Some PENs underlined the importance of relatives’ participation as
much as possible in the care administered, while others emphasised
how stressful their presence could be. PENs often felt powerless when
confronted with sad and worried relatives, as earlier research has
shown Norden et al. [23]. In certain situations with critically sick
children, PENs did not want the relatives anywhere near their patients.
They wanted instead to be able to work methodically and undisturbed.
PENs’ meeting with preverbal children and their relatives requires
specific skills: feeling secure in their medical care and nursing of chil-
dren; being able to meet children’s emotional needs; and being a good
support for relatives/family. In the specialist ambulance nurse educa-
tion and in the ambulance service today, deeper understanding, edu-
cation and clinical training in family-centred care are lacking.
This study shows that PENs felt considerable dissatisfaction with the
pharmacological methods available in the ambulance. They also felt
uncertain about drug dose management for children. They were un-
accustomed to small children’s reactions to different drugs. According
to them, children generally received poor pain relief in prehospital care,
one main reason being the fear of overdosing and not being able to
handle consequences such as respiratory depression. Inadequate
knowledge about pain assessment and drug administration could lead
to deficient or absent pain relief and also to extra suffering caused by
unsatisfactory treatment or even non-treatment. The introduction of
this extra, unnecessary suffering changes children’s lifeworlds
[1,21,28].
PENs often experienced extra stress and fear of making mistakes in
their care encounters with children. They so rarely meet children in
their daily work in the ambulance that they felt relatively inexperienced
when caring for children. At present the frequency of children cared for
in the ambulance service in Stockholm is approximately 8 percent of the
ambulance assignments. PENs noted that the more experience they
gained, the faster their decision-making process became. They also
found it important to enlist the help of a multidisciplinary team in-
cluding e.g. reinforcement units in the prehospital service like the
physician on call and/or paediatricians at the ED. Collaboration be-
tween the multidisciplinary team, nurses and physicians is essential to
child healthcare and survival [19]. In summary, there is much ongoing
research on teamwork intra-hospital and between different professions
in healthcare, but a significant lack of research focused specifically on
prehospital teamwork.
This study shows clearly that PENs felt inadequately equipped with
regard to knowledge and skills for treating preverbal children pre-
hospital, but also that the ambulance service’s medical guidelines are
not adapted to children and their treatment needs. Pain management in
children must be taken seriously. It is not acceptable that children
should not receive adequate pain relief because of PENs’ ignorance or
inexperience [1,21,28].
The prehospital medical guidelines [9] currently approved by the
Stockholm County Council (SCC) stipulate that children should be as-
sessed according to the same pain scale as adults. These guidelines
therefore ignore children’s specific needs, a study result of ethical im-
portance. This study was motivated partly by the need to investigate
whether or not children and adults have the same rights to equal
treatment. According to the UNCRC [11] children have the right to get
their basic needs met; to receive protection against exploitation and
discrimination; to express their opinions; and to be respected.
Thanks to this study, our knowledge has increased of how PENs
experience pain management in preverbal children in the prehospital
context. This knowledge underlines the importance of improvements in
K. Gunnvall et al.
education and training to strengthen ambulance nurses in their care
responsibilities in prehospital care. This study also asserts that the
prehospital medical guidelines [9] must be revised and quality assured
to meet children’s specific needs in the ambulance service.
3.2. Methodological considerations and limitations
This research has been carried out using a qualitative care sciences
approach [5,6]. Qualitative research seeks to understand the world
from the PENs’ perspective, asking what their world as they experi-
enced it seemed before the scientific explanations were formulated
[15]. This study offers the possibility to discover new meanings in
prehospital emergency care.
The authors are clinically active in prehospital care. This constitutes
a strength since that they know a good deal about the context, but it
also constitutes a weakness since it involves a high degree of pre-un-
derstanding of the phenomena. During the data collection process the
researchers had to hold back their tendency to take things for granted.
This has been achieved by not “understanding” too hastily [5]. This
approach involves maintaining openness to what the participants say or
indicate, which means being observant and sensitive to the informants’
world of experiences. However, a qualitative researcher must recognise
that one can never completely capture another person’s experiences in
the same way as the person actually lives them.
The trustworthiness of the study was reinforced by the fact that
three authors read the interviews independently of each other. The
authors then clustered the meanings into a valid structure and the
whole research team reflected on them. This multi-professional team is
a further guarantee for the analysis that has been carried out.
One of the limitations of this study is that only eight PENs were
interviewed. When determining the sample size, the researchers judged
the quality of the data collected against the specific aim. The research
team concluded that the experiences described by the participants were
rich in content. The number of interviews was sufficient to answer the
research question [15]. Content analysis according to Elo and Kyngas
[8] can be converted into different levels of abstraction. This study
analysed preliminarily on the manifest level, but throughout the ana-
lysis process the abstraction level sometimes rose to the latent level
when the content density of the material was very rich. Qualitative
research has been neglected when it comes to PEN perspectives in the
EMS, and these perspectives underpin the value of the findings.
4. Conclusion
Children have the right to have their basic needs met; to receive
protection against exploitation and discrimination; to express their
opinions; and to be respected. This result is transferable to many other
healthcare settings and is valid not only in the ambulance service. This
study’s findings shows that a lifeworld perspective with a family-
centred approach may support PENs in alleviating pain and suffering in
preverbal children. What is required to meet children’s specific needs
and security are customised prehospital guidelines consisting of both
medical and care guidelines; collaboration within a multidisciplinary
team; clinical skills and education. Our recommendation is that atten-
tion must be drawn to the current guidelines in Stockholm, Sweden, and
their lack of understanding about the differences between the assess-
ment and management of pain in children compared to adults.
Healthcare providers must develop the medical guidelines based on best
practices so that they meet children’s basic care needs in the future.
Conflict of interest
No conflict of interest has been declared by the authors.
6
International Emergency Nursing xxx (xxxx) xxx–xxx
Funding statement
Not received any financial assistance.
Authors contributions
All authors have agreed on the final version and meet at least one of
the following criteria [recommended by the ICMJE (http://www.icmje.
org/recommendations/)]:
• Substantial contributions to the conception or design, acquisition of
data, or analysis and interpretation of data.
• Drafting the article or revising it critically for important intellectual
content.
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