The characteristics of the participants have been presented in Table 1.
Children’s pain expression and response of caregivers
One of the recurring themes of the current study was “children’s pain expression and response of caregivers”. Pain was a common complaint among hospitalized children who could verbally communicate. Different levels of pain (mild, moderate and severe) were exhibited by the children at the time of their admission and intermittently during hospitalization. The pain experienced was caused by their medical conditions (such as fractures, sickle cell disease) and or skin breaking procedures (such as intramuscular injections, intravenous cannulation and medication, lumbar puncture, surgical operation, wound dressing among others). Children’s incomplete bodily capital thus served as a source of discomfort and subsequently subjected them to such discomforting procedures.
As a result of the pain experienced during skin breaking procedures, the children cried loudly and clung unto their family caregivers for relief. Family caregivers thus, served as a form of social capital for the children in distressing times. Nevertheless, there was no escape from pain as healthcare providers regarded the procedures to be of important value and went ahead with them even if it meant applying physical restraints to these children. The high level of respect (symbolic capital to these procedures influenced healthcare providers’ habitus of restraining these helpless children. Some family caregivers also felt helpless and even cried as they witnessed their children go through the pain associated with skin breaking procedures and some clinical conditions. In some cases, family members could not withstand the traumatic experience their children were going through and excused themselves during such procedures, leaving the children solely in the care of the healthcare providers. A mother of a 6-month old baby expressed it this way “Madam I cannot watch, it makes me sad to watch my child in pain like that”. The children were also observed to exhibit the non-cooperative behaviours that were demonstrated during the skin breaking procedures in subsequent non-painful procedures such as checking of their body temperature, auscultation of their heart and breath sounds among others. According to the children, they kept memories of these painful events which sometimes prevented them from co-operating with healthcare providers during subsequent procedures. The recollection of their previous personal experiences thus influences their noncooperative habitus.
Healthcare providers admitted to difficulties in assessing pain among children who could not verbally communicate as a result of their developmental stage or medical condition. According to the healthcare providers, this could be attributed to their lack of cultural capital in this area of pain care. They believed crying was the language of infants and toddlers and did not regard this as a cause for concern among these vulnerable population. Their habitus of not doing much in such situations on the field resulted from the low symbolic capital attributed to children’s cry. They further intimated their lack of access to cultural capital as they experienced difficulties in distinguishing crying due to pain from other causes. On the other hand, some healthcare providers believed children were more likely to be in pain if the assessment findings of the four traditional vital signs (temperature, pulse, respiration and blood pressure) were higher than the normal range of values. Healthcare providers heavily relied on family caregivers as a source of social capital in determining pain and its causes among the children. Whilst some family caregivers reported of using changes in their children’s activity, behaviour and verbalizations to detect pain, others admitted to being clueless in obtaining a definite sign or symptom of their children’s pain. A father of an 18-month child had this to say, “Hmmm Madam he’s been moaning and turning aaarrrhhh... but I can’t tell if he’s feeling any pain though he cries intermittently too”. Hence, social capital had a dualistic role in the field: serving as a catalyst for pediatric pain assessment on one hand or not favourable on the other hand. Family caregivers and healthcare providers believed children’s expression of the extent of their pain was dependent on the child’s age which served as a source of cultural capital and their lack of access to bodily capital due to their medical conditions. A nurse puts it in this way:
“Oh the pain, it usually depends on the condition of the child, what the child will bring in… so maybe if a child has trauma, maybe a child is involved in an accident, compared to a child who has a mild fever or malaria, the pain would be different. So it depends on the condition that, the child would bring.”
Healthcare providers’ individual habitus of not prioritizing pain was influenced by the collective habitus operating in the field as pain was not actively assessed compared with the other four traditional vital signs (temperature, pulse, respiration rate and blood pressure). Additionally, there were no specially designed documentation sheets for pain, nor was pain assessment pages or sections integrated into the patient’s folders, unlike the four traditional vital signs. This could be attributed to the symbolic capital given to this aspect of pain care and the institution’s lack of access to economic capital in providing these resources. Thus, pain documentations if any only occurred in the physicians’ and nurses’ notes. An example of such report was:
“Patient complained of severe headache, 375mg of intravenous Paracetamol administered. Vital signs checked and recorded. Patient tepid sponged to reduce the recorded temperature of 39.6oC to 37.8oC after 40 minutes. Child is made comfortable in bed and mother reassured”
Observational data from the field work also revealed the presence of two pain assessment tools (Faces Pain Scale and FLACC-Faces, Leg, Activity, Crying, Consolability Scale) in only one of the four hospitals. The few pain assessment tools were also not used by the healthcare providers in assessing children’s pain. The hospitals’ lack of access to economic capital in purchasing these assessment tools influenced healthcare providers’ habitus of not systematically assessing children’s pain and its subsequent lack of communication during ward rounds and handing over activities. Some healthcare providers were not familiar with pain assessment tools due to their own deficiency of cultural capital and the institutions’ lack of economic capital; both of which underpinned their habitus of assessing children’s pain in a suboptimal manner on the field. Some of the healthcare providers also attributed their habitus of not using standardized tools in guiding their pain assessment of children to heavy workload and shortage of staff in the demanding pediatric care field due to deficiencies in both cultural capital and the institutions’deficiency in accessing economic capital.
Pharmacological pain management practices and attitudes
Another recurring theme from the coded field data was “pharmacological pain management practices and attitudes”. Pharmacological interventions served as the mainstay habitus in children’s pain management due to high symbolic capital given to such interventions. The common pharmacological agents used in managing children with mild to moderate pain were Paracetamol, Diclofenac and Ibuprofen (Non-Steroidal Anti-Inflammatory Drugs – NSAIDs) which were administered via enteral, parenteral and anal routes. These drugs were alternated in some circumstances due to their mechanism of action and to reduce their side effects. According to the healthcare providers, children who were admitted on account of burns were given Ibuprofen syrup or Paracetamol suppository thirty minutes before wound dressing to reduce pain. This habitus of healthcare providers on the field was influenced by their desire to reduce children’s pain and discomfort during such procedures.
Physicians’ habitus of seldomly prescribing opioids for children in pain even when it was the best medication in a particular situation was influenced by different forms of capital operating on the field. Some of these include: the symbolic capital associated with these class of analgesics, limited access to cultural capital on opioids, influence of other healthcare providers who served as a source of social capital, the institutions’ lack of economic capital in providing these medications and some families inability to afford these relatively expensive pain medications due to their deficiency in economic capital. Nurses’ habitus of infrequent administration of prescribed opioids for children were also underpinned by the above-mentioned forms of capital on the pediatric care field. Thus, opioid medications (Morphine, Pethidine and Tramadol) which were to be administered when necessary ended up not being given at all even if the child’s condition demanded it. According to the nurses, they deliberately gave other analgesics even when physicians had prescribed opioids. Some nurses further confessed that they have never administered an opioid in their practice even when it was prescribed.
“I know we are to give Pethidine or morphine, but I have never administered some for any child. After surgery, they come with Pethidine to be given where necessary, but they even do well with ibuprofen and Paracetamol administered intermittently so most times we don’t give. You know, it comes with its own issues.” (Nurse 2, hospital A)
The habitus of not prescribing and providing opioids (such as Morphine) to children and their families to be taken at home was underpinned by healthcare providers’ prejudiced symbolic capital associated with these analgesics and their insufficient cultural capital on these drugs. In spite of misconceptions associated with opioids, many healthcare workers admitted that they have not witnessed children experiencing side effects of opioids in their practice during the interview sessions. A physician expressed it this way “I am not sure I have encountered any side effects from the opioids”. A review through the hospital records (doctor’s notes, nurses’ notes and report books) also confirmed this as there were no documented evidence of pain medication side effects.
Managing pain without drugs
Another recurring theme from the field data was “managing pain without drugs” which largely interconnects with the previous theme of “pharmacological pain management practices and attitudes”. Some of the pain experienced by the children were managed without drugs on the field. Both healthcare providers and family caregivers served as a source of social capital for the children and were observed to be working together to manage the pain of the children in this regard. Healthcare providers and family caregivers were observed to be engaged in the habitus of using nonpharmacological methods such as cuddling, stroking, coaxing, consoling, positioning and breastfeeding in distracting children’s attention from pain during skin breaking procedures or upon self-report of pain from the children. A typical example of this was the observation of a mother who was softly singing and talking to her baby to stop crying after a venipuncture. Some healthcare providers were also observed to be consoling, cuddling and stroking the back of babies who were crying during and after skin-breaking procedures. A classic instance is when a nurse explained to a seven-year old after a wound dressing to stop crying as he will be leaving the hospital soon. She stated: “Oww don’t cry my darling… I will take you home today”
The pediatric care field of the hospitals were equipped with television sets, toys, play areas, and colourful wall paintings with child-friendly designs (such as rainbow, cartoons, etc); reflecting the institutions’ ability to access economic capital in the provision of these resources. According to healthcare providers, these facilities were meant to distract children’s attention from painful circumstances during hospitalization. Healthcare providers also said that the environmental layout of the ward as a non-pharmacological pain management strategy had the greatest impact on newly admitted children as they tend to engage with them in the earlier stages of admission. They however, felt its effect diminished over time as children stayed in the ward for longer periods.
Conversely, the children and family caregivers expressed happiness and contentment with the availability of these therapeutic nonpharmacological facilities which diverted children’s attention during painful procedures and served as a form of pain relief. Some children were observed playing on wooden and plastic animal toys in the play area of the hospitals. Other children were also handed teddy bears and toys by healthcare providers before skin breaking procedures to distract their minds and subsequently manage the pain associated with such procedures. Notwithstanding these, we observed shortfalls in these resources based on the number of admitted children on the field which posed as a challenge and influenced children’s habitus of using these distraction methods in managing pain. The children further appealed for the provision of additional toys on the field due to the insufficient numbers and the bad state of some playing materials; indicating the hospital’s deficiency in accessing economic capital in meeting this demand.
Communication and interaction between pain actors
The final recurring theme was “communication and interaction between pain actors”. Observation of the interactions that occurred among the participating physicians, nurses, children and their families revealed a cordial and respectful engagement with each other. Physicians and nurses had separate ward rounds but there were periods where both groups came together and reviewed the hospitalized children and their families. The physicians and nurses engaged the children and their families by addressing them by their names and asking how they were doing including any pain they were experiencing. Family caregivers whose children were not capable of communicating effectively gave reports on their well-being and asked for clarifications on issues which were unclear to them. Most of the time, family caregivers and nurses informed physicians about children’s pain complaints after which pain medications were prescribed for the children. The nurses also informed their colleagues to reaffirm their pain assessment findings prior to informing the physicians. All of these interactions reflect how children’s access to social capital can serve as a powerful tool in influencing pediatric pain assessment and management habitus.
Informal conversations with some hospitalized children and their family caregivers unearthed that they were satisfied and happy with how the healthcare providers engaged with them concerning their wellbeing including that of pain. Nevertheless, some children and their family caregivers were unhappy about their short duration of communication with healthcare providers and wished to be engaged more than what they received. In addition, the dissatisfied family caregivers felt that healthcare providers did not inform them about the treatment being prescribed and administered for their children. Resultantly, some healthcare providers were perceived as good whilst others were perceived by the children and their family caregivers as unkind. This further supports the dualistic potential of social capital in either facilitating or impeding pediatric pain care communication. An interaction with a mother of a six-year old boy who was unhappy about communication with healthcare providers expressed it this way:
“Hmmmm, since I came around at 4am, no nurse has personally come to me to interact with me… Madam it’s their work and since other patients equally need their care, I don’t want to be seen as disturbing them, but I wish one of them could come and talk with me.”
On the other hand, healthcare providers (physicians and nurses) were generally satisfied with the relationship that existed between them and the hospitalized children as well as their families.
The children clung unto their family caregivers in the hospital environment and perceived them as advocates, who made decisions in their best interest. In situations where children were asked questions by the healthcare providers, they turned toward their family caregivers even before giving responses. Thus, family caregivers mainly served as a source of social capital and the mouthpiece in identifying pain and its causes among children who could not talk. On the other hand, some family caregivers felt reluctant in constantly reporting their children’s pain for fear of being tagged as “troublesome” or “medical attention seekers”. They therefore preferred to wait for routine ward rounds before relaying any changes in their children’s condition. Again, this reaffirms the dualistic role of social capital in working for or against improved pediatric pain care. Family caregivers also assisted with the activities of daily living of the children including bathing, grooming, feeding and playing. They were constantly beside the children and offered support in care giving whenever it was required; reflecting the power of social capital on the field.