Background: The majority of patients requiring medical attention experience some degree of pain. The nurses´ assessment of pain is crucial in reducing the patients suffering in a proper and timely manner. Previous studies have shown that the treatment of pain in a emergency situation is poorly managed. The patients´ pain experience is often under assessed and undertreated which leads to increased suffering for the patient. This results in higher costs for the health care system due to prolonged hospitalization. Aim: The purpose of this study is to define the ambulance nurse´s pain assessment of patient in the field and the affecting factors their evaluation. Method: A qualitative interview study with a descriptive design was conducted including seven emergency services nurses. Both male and female participants were involved with varying degrees of education as well as durations of employment. Result: Pain assessment by emergency personnel in the field was broken down into four categories for analysis as follow: communication (both verbal and nonverbal), measurable components, environment and evaluation of diversities. Verbal communication with appraisal of patients´ body language and facial expression was the most frequent factors in assessing pain. Measurable components such as vital signs and generalized symptoms were also accounted. VAS and NRS scales where most frequently used by nurses in rating pain among patients. The result suggested differences in pain assessment with respect to gender, age and cultural background. Conclusion: The participating nurses in this study describe verbal and nonverbal communication as the most influential factors in pain assessment of patients. In rating pain, the most frequently used tool was the NRS scale providing the nurses with what they consider to give the best understanding of patients´ pain experience. A risk has been identified in the analysis of patients´ vital signs which could lead to an under assessment and restrictive treatment of pain. The authors of this study believe that lack of knowledge in pain assessment and how to implement pain rating tools could contribute to this fact, and would therefore appreciate an improvement in skills assessing pain and a better understanding in the use of pain tools for emergency service nurses. This could lead to a better caliber of patient care for those suffering with pain. / Bakgrund: En stor andel av patienter som söker akutsjukvård upplever smärta. Smärtbedömning är en viktig del i sjuksköterskan arbetsuppgifter för att minska lidandet för patienten. Tidigare studier har visat på att smärtbehandlingen inom akutsjukvården varit dålig. En anledning till detta kan vara en underskattning och underbehandling av patientens smärta som i en förlängning kan leda till ett ökat lidande för patienten samt ökade samhällskostnader i form av längre vårdtider. Syfte: Syftet med uppsatsen var att beskriva hur sjuksköterskan i ambulanssjukvården bedömer smärta hos patient prehospitalt och vad som påverkar smärtbedömningen. Metod: En kvalitativ intervjustudie med deskriptiv design genomfördes med sju stycken sjuksköterskor som var verksamma inom ambulanssjukvården. Informanternas anställningsår och utbildningsnivå skilde sig åt, både män och kvinnor har deltagit i studien. Resultat: Resultatet beskrivs i fyra kategorier, kommunikation, mätbara observationer, miljö och bedömning av mångfald. Kommunikation innefattar verbal och icke-verbal kommunikation. Verbal kommunikation tillsammans med bedömning av patientens kroppsspråk och ansiktsuttryck (non- verbal kommunikation) användes mest frekvent för att bedöma patientens smärtupplevelse. Även mätbara observationer som vitalparametrar och allmän påverkan bedömdes. VAS-skala och NRS-skala var smärtbedömningsinstrumenten som sjuksköterskan använde mest frekvent. Resultatet visade även på skillnader i smärtbedömning gällande kön, ålder och kulturell bakgrund. Diskussion: Sjuksköterskorna som deltog i studien beskrev verbal och icke-verbal kommunikation som viktiga faktorer för att smärtbedöma patient. Sjuksköterskorna beskrev att numerisk skattnings skala (NRS-skala) var det smärtskattningsinstrument som används mest frekvent för att skapa en förståelse om patientens smärtupplevelse. En risk som identifierades var sjuksköterskornas bedömning av vitalparametrar, som kunde leda till att smärtupplevelsen hos patienten kunde underskattas eller överskattas. Författarna anser att kunskapsbrist i smärtbedömning och hur man använder smärtskattningsinstrument kan vara en bidragande orsak. Författarna anser att mer kunskap om smärtbedömning och användandet av smärtskattningsskalor som arbetsverktyg för sjuksköterskor inom ambulanssjukvården, skulle leda till bättre omhändertagande för patienter som lider av smärta.

Pain assessment continues to be poorly managed in the clinical arena. A review of the communication process in pain assessment is carried out and the hierarchical approach often recommended in the literature -with self-report as its "gold-standard," is criticized as limited and simplistic. A comprehensive approach to pain assessment is recommended and a model that conceptualizes pain assessment as a complex transaction with various patient and clinician dependant factors is proposed. Attention is then focused on the pediatric patient whose pain assessment is often dependent on nonverbal communicative action. The clinical approaches to pain assessment in this population -mainly the use of behavioral/observational pain scales and facial pain scales, are explored. The primal face of pain (PFP) is identified and proposed theoretically as an important link in the function of facial pain scales. Finally, the existence of the PFP is investigated in a sample of 57 neonates across differences in sex and ethnic origin while controlling for potentially confounding factors. Facial expression to a painful stimulus is measured based on the Neonatal Facial Coding System (NFCS) and applying an innovative computer-based methodology. No statistically significant differences in facial expression were found in infant display thereby supporting the existence of the PFP.

The assessment of pain in children has been an enduring theme in the research literature over many decades, with particular focus on how pain can be adequately measured and the extent of under-measurement of pain (American Academy of Pediatrics 2001; Coyne, 2006; McCaffery & Beebe 1989; Subhashini et al., 2009). Definitions of pain, and hence development of pain measurement tools, are often criticised for not addressing the influence of culture and ethnicity on pain (Bates et al., 1993; McCaffery & Beebe 1989; Zinke, 2007), in children, the perception and expression of pain is also affected by cognitive development (Hallström and Elander, 2004). Whilst there has been an increase in the number of children living in the United Kingdom (UK) who do not speak English as their first language, it has been acknowledged that the measurement and management of pain by health service professionals relies predominantly on their experience with English speaking children (RCN, 2009). This study aimed primarily to examine how primary school age children in key stage 1 who speak English as a primary or additional language experience, express, and explain pain. This aim was addressed through three research questions: (1) how do primary school age children in key stage 1 talk about pain? (2) What are the similarities and differences in the language used to talk about pain by children with English as a primary and additional language? (3) Are there differences in the perceptions of pain by children of different age, gender, language background, and country of birth? A second aim was to examine whether language would affect actions taken by final year child health students and nurses working in Minor Injuries Units to manage pain in primary school age children. Study objectives were addressed using a two phase mixed methods design. The first aim was addressed using six focus group interviews with groups of primary school children (aged 4-7) (Phase 1). Two methods were used in the interviews: use of drawings from the Pediatric Pain Inventory (Lollar et al., 1982) to capture the language used by children to describe pain and observation of the children’s placing of pain drawings on red/amber/green paper to denote perceived severity of pain. Following data collection, the vocabulary of each child was assessed using a standardised lexical test (British Picture Vocabulary Score version II - BPVS II) (Dunn et al., 1997). To address the second aim, a factorial survey was conducted (Phase 2) with nurses working in Minor Injuries Units and child health nursing students to determine whether language has an impact on decisions made about the management of children in pain following a minor injury. Phase 1 findings demonstrated that children from English as an Additional Language (EAL) backgrounds used less elaborate language when talking about pain but tended to talk about the pictures prior to deciding where they should be placed. The children’s placement of pain drawings varied according to language background, gender, and age. The calculated language age of English lexical comprehension (BPVS II score) of monolingual children (M=69.85, SD=19.27) was significantly higher than EAL children (M=47.93, SD=14.32; t (32) = 3.60, p =0.001, two-tailed). However, when these differences were explored in terms of year group, the differences remain significant with foundation and year 2 but not with year 1. For the EAL children, there were also significant relationships between BPVS II score and length of stay in the UK (spearman’s rho 0.749, p = 0.33). The Phase 1 findings were used to construct vignettes, describing hypothetical care situations, for Phase 2. Multinomial logistic regression was used to analyse the impact of a child’s age, gender, language, parent’s language, injury mechanism, and reaction to pain on the way in which the child’s pain would be assessed and whether parents or an interpreter would be invited to assist in pain assessment. Findings demonstrated that observing the child’s behaviour is the most significant assessment process that is used to assess EAL children, rather than the Visual Analogue Scale (VAS), which was used with non-EAL children. This is significant as VAS is the mostly widely used tool to assess pain in health care settings. However, VAS is only effective if it can be understood by the child. Further, MIU nurses and child health students were more likely to involve parents who speak English well than those who speak English poorly but would ask for an interpreter if their involvement was necessary. In order for the respondents to explain their decisions, they were asked an open ended question for each vignette. They reported that language and age of children are the most common difficulties they faced during assessment of pain. Therefore, they suggested some solutions, like using an age appropriate tools for assessing younger children. Respondents also identified that using an interpreter is a time consuming process, which might delay the management of pain. In light of the growing numbers of EAL children in the UK; this research has application in a number of contexts. The variation in language would apply if children were reporting their own pain. However, the findings emphasise the need for sufficient time to be allocated to pain assessment to allow an individualised approach. Study findings suggest several factors that may be important in assessing pain in EAL children; these should be explored further in the context of clinicians’ assessment of pain. The implications of the study impact on policy, practice, education, and future research.