How nurses use reassurance to support the management of acute and chronic pain in children and young people: An exploratory, interpretative qualitative study

Abstract Reassurance in the context of pediatric pain is regarded to promote distress. Typically, spoken reassurance is reported as short, generic statements (“it's ok,” “don't worry”); little research has considered wider reassuring behaviors and actions undertaken by nurses. Most studies focus on unidirectional, dyadic relationships between reassurance and pain (parent‐to‐child, professional‐to‐child) failing to capture the inherent complexities. Adopting an exploratory, interpretative, and qualitative approach, this paper reports on findings from the qualitative interview component of a mixed‐methods study, concerning how nurses actively use reassurance when talking to children and their parents about pain. Eighteen nurses with experience of managing children's pain were recruited on completion of an international online survey (distributed by pain and children's nursing networks and via newsletter, email, and social media). All 18 nurses completed a semi‐structured interview concerning their experiences of managing children's pain working in the UK (n = 14), Canada (n = 3), and Australia (n = 1) in primary, secondary, and tertiary settings with nursing experience ranging from pre‐qualification to >20 years. Thematic analysis generated three themes which reflect the main ways in which nurses focus their reassurance within encounters with children and their parent(s): (a) on child and parent(s), (b) on the child, and (c) on the parent. Nurses generated reassurance using language, gesture, relationship building, individualizing approaches, education, and preparation. The study highlights the diversity of reassurance provided by nurses in relation to children's pain. Our study finds that when nurses reassure children about pain, they focus their reassurance in three distinct directions (child, parents, and children and parents in partnership); this has not been specifically acknowledged by previous research. We highlight the wide range of implicit and explicit reassurance actions undertaken by nurses and propose that reassurance that extends beyond limited vocalizations is part of a complex package of care that can support children's current and future pain experiences.


| INTRODUC TI ON
Reassurance in the context of pediatric pain was precisely defined as a core code in the Child-Adult Medical Procedure Interaction Scale (CAMPIS) handbook as "procedure-related comments that are directed toward the child with the intent of reassuring the child about his/her conditions, or the course of the procedure". 1,2, p7 A more recent definition is "a procedure-related comment to child with the intent of neutralizing the situation or suggesting that the environment is nonthreatening". 3, p1123 Reassurance is widely regarded to promote child distress during experiences of pain. 1,3,4 In painful procedures, reassuring comments by adults have been shown to precede child distress 1 and heighten child ratings of fear. 5 In work addressing postoperative distress, reassurance has been positively correlated with distress, and it is proposed it may maintain ongoing child distress. 3 This counterintuitive relationship between reassurance and children's pain has been explained through three mechanisms: (a) reassurance may warn a child that an adult is anxious or that something bad is about to happen, (b) reassurance may reinforce children's apprehension and thus their distress, and (c) reassurance gives a child permission to openly express their distress. 4,6,7 Reassurance accounts for more than one quarter of spontaneous adult vocalizations (parent, medical staff) made to children during medical procedures. 4,8 Additionally, experimental studies identified that parental reassurance accounted for 34%-53% of the variance in child distress during children's painful procedures. [9][10][11] However, gaps remain in the existing evidence regarding reassurance for children's pain. The majority of studies focus on parental reassurance [11][12][13][14] with fewer studies focusing on how nurses may use reassuring talk. 15,16 A small number of studies have examined reassurance in terms of specialisms such as oncology 8 and physical therapy 17 or setting such as the postanesthesia care unit. 3 Additionally, the focus has typically involved the study of acute pain in the context of painful procedures, such as that associated with lumbar puncture, 1 venipuncture 5 with few studies addressing the study of reassurance in the context of chronic pain. 4 The most common examples of spoken reassurance in the pediatric pain literature include short, generic statements such as "it's ok" and "don't worry". 3,11,18 Importantly, the different qualities of the construct of reassurance have not yet been sufficiently explored in the pediatric literature. 11 In particular, little research has considered the range of behaviors and actions beyond these generic statements which are undertaken by nurses with the intention of reassuring children experiencing pain. Finally, the literature tends to focus on unidirectional, dyadic relationships between reassurance and pain; either reassurance of a child by their parent or by a healthcare professional.
As other authors have noted, many studies fail to capture the complexities of what aspects of reassurance prompts child distress. 3 This paper reports on findings concerning how nurses use reassurance when talking to children and their families about pain. These findings were generated from a subsidiary analysis of qualitative semi-structured interviews that were originally undertaken as part of a mixed-methods study which explored nurses' "pain talk" in the context of managing children's pain.

| Design
An exploratory, interpretative, and qualitative approach using indepth semi-structured interviews.

| Sample and recruitment
Nurses with experience of managing children's pain were recruited from an international online survey (via children's pain and nursing networks and newsletter, email, social media) that examined how nurses talk to children and their families about pain. All 141 eligible participants who completed the survey were asked whether they would be willing to participate in a follow-up interview. Interested participants who provided their email address through the online survey received a participant information sheet from a researcher (AJ, BC) prior to providing fully informed written consent. Eligible participants were registered (or equivalent) nurses or undertaking training to obtain a formal qualification in children's nursing and aged 18 years or older.
Sixty participants expressed an interest in the study, and a matrix was purposively generated to reflect the range of grades, roles, and geographic locations. The matrix was systematically worked through to follow-up eligible participants; all who could be contacted and consented (convenience sample) within the timeframe were interviewed.
No relationships existed between participants and researchers (eg, line management, close friendship). Ethics approval for the study was provided by the University of Bath and Edge Hill University.

| Data collection
Data were collected (May 2018-July 2018) using single, in-depth, semi-structured telephone, FaceTime, or Skype interviews by AJ (female, PhD, senior lecturer psychology) or BC (female, PhD, professor children's nursing). Interviews were conducted in a private room within the researcher's/participant's work or home setting, as appropriate; no other people were present during the interviews.
A topic guide was developed from the literature and from the authors' expertise in the fields of pediatric pain and nursing and informed by discussions with nurses working with children who experience pain. The guide was minimally refined after the first interviews had been conducted to include questions about which aspects of "pain talk" they thought were important and why. The topic guide included open-ended questions that covered roles and pain-related training and experience of talking to children/parents about child pain (eg, type of language, where conversations take place, types of talk). Prompts were used as appropriate (see Figure 1 for full interview guide). Although we did not share our topic guide with the participants prior to their interview, the information sheets gave a broad indication of the topic areas such as choice of language when talking about pain and challenges faced when talking to children and/or parents about pain.
Participants were not involved in the design, recruitment, or conduct of the study. Participants will be informed via email about the publication of results.
Field notes were made during/after interviews. Interviews were audio recorded and alongside informed written consent, consent was confirmed verbally at the beginning and end of each interview.
Although data saturation is often considered a regulatory ideal, the most recent guidance for thematic analysis suggests that it is not a useful concept as judgements are situated and subjective. 19

| Data analysis
Interviews (mean 31 minutes, range 22-55 minutes) were transcribed verbatim and analyzed in NVivo version 12 using inductive reflexive thematic analysis. Braun and Clarke's stages of familiarization, coding, producing, reviewing, and labeling themes, were followed iteratively from descriptive to interpretative analysis. 20,21 Analyses were conducted by JH (female, PhD, research fellow public health) and themes reviewed by AJ and BC. Authors actively discussed the analyses and feedback at all stages of theme development, and subsequently all authors participated in such discussions throughout theme finalization and manuscript write up. Such processes were considered critical with regard to establishing analytical quality and in particular, to ensure that author interpretations and inputs into theme development were credible and grounded in the data.

| RE SULTS
Eighteen nurses with experience of managing children's pain participated. Participants were working in the UK (n = 14), Canada (n = 3), and Australia (n = 1) in a range of primary, secondary, and tertiary settings with nursing experience ranging from pre-qualification to over 20 years ( Three main themes were generated reflecting the key ways in which nurses focus their reassurance within encounters with children and their parent: (a) focus on both the child and parent(s), (b) focus on the child, and (c) focus on the parent. Each of these themes has sub-themes. Nurses generated reassurance in different ways including language, gesture, relationship building, individualizing approaches, education, and preparation. Our findings are presented as a framework ( Figure 2); each aspect is described below with illustrative quotations from the participants. Labels are applied to quotations as follows; P (participant number), and caseload is represented as A = Acute, C = Chronic, A/C = Acute and Chronic.

| Being a calm and knowledgeable presence: nurses providing reassurance to the child and their parents
Reassurance directed contemporaneously to both the child and parents was achieved in four main ways: acknowledging pain is real/believed; tailoring their approach to the individual child; presenting solutions and options; and using education or information.

| Acknowledging pain is real/believed
Several participants discussed both acute and chronic pain situations, highlighting the importance of communicating belief in a child's pain for the purpose of reassuring children and parents. Participants described how some parents and children talked about previous experiences of being disbelieved and had been seen by multiple healthcare professionals when seeking assistance for the child's pain, for example, "they've seen up to nine healthcare providers about their pain… they've been disbelieved" (P5-C health literacy" (P6-A/C). This individualized approach appeared to link with a sense of containment, aiming to reduce the shock of pain. Toys such as "a teddy with…an IV line" (P10-C) were key to preparing children for procedures and also aimed to help desensitize children.

| Presenting solutions and options
An important way that nurses provided reassurance involved them presenting children and parents with an array of options to manage their pain. This aimed to demonstrate their commitment and motivation to work with the child and family and to reassure the child by presenting a solution for example, "okay, this has to be done, but you are going to do something about it to help." (P8-C (P8-C)

| Creating a sense of comfort: nurses providing reassurance to the child
Reassurance directed primarily to the child was achieved in two main ways: through language and gesture, and through relationship building.

| Using language and gesture
Language was seen as powerful and as a potential ally, providing it was used carefully. Participants described the importance of using neutral and realistic language to help explain "this is what you'd feel" (P13-A) when preparing children for the experience of anticipated pain. Although a few participants did use phrases intended to be generically reassuring such as "don't worry," most were aware that "don't worry actually conveys worry" (P5-C) which in turn could increase the child's experience of pain.
Being selective about language, being honest, acknowledging they would experience some pain were deemed to be important "as opposed to giving false reassurance and saying it won't hurt" (P1-A).
Explicit reassurance aimed to inform children about key elements such as: …saying what's going to be happening in the day…, they can find that quite reassuring like if they're having physio or any other input. They know when they're having medications and timing it around…so that their painkillers are maximized before that happens, just to reassure them in that way. (P13-Acute)

| Engendering confidence: nurses providing reassurance to the parents
Reassurance directed primarily to the parent was achieved in two main ways; by encouraging parents to prepare their child and reducing the impact of parental anxiety.

| Encouraging the parent to prepare their child
Participants perceived reassurance being inherent in parents effectively preparing children for a painful procedure. Typically participants noted "we really like parents to tell the kids before they come into the clinic, we don't like it to be a surprise" (P1-A). Participants working in the community and/or chronic pain practice talked of each procedure being part of a potentially lifelong relationship with the child noting, for example, "I actually won't do the vaccines if it's a surprise to them, cos it, we're building a relationship with these kids and it's lifelong" (P1-A).
In addition, participants felt that giving parents a defined role to play in preparing their child was also reassuring for parents who could otherwise feel uncertain and powerless to help.
…because they'd [child] seen teddy or doll or whatever beforehand they seemed to respond quite positively, and I think the parents found it quite helpful as well to prepare their child. They [parents]…said they found it quite helpful and a good way of communicating as well. (P10-C)

| Reducing the impact of parental anxiety on children
Creating a reassuring emotional climate was deemed important as they knew that parental anxiety could be transferred to their child, typically commenting that "the child picks it all up from the parents" (P12-A/C). Participants highlighted how parents focusing too much on their child's pain could serve to worsen their child's experience as: you can sometimes have a child that is absolutely fine and has told you their pain score…their pain and they're having a drink or having something to eat and a chat with you and the parent will come in and say 'ooo is it hurting? It must be hurting. It's definitely hurting'. (P11-A) Causes of parental anxiety included guilt that they were to blame for their child's pain and when reassurance was provided the participants 'absolved' parents: these kids would come in with broken arms…I would say to Mum 'Isn't it terrible, you just turned around for a second and they fell off that shelf' or whatever… and you could just see the relief on the parent's face.
Managing other causes of parental anxiety such as feeling solely responsible for their child's pain management could be achieved by working with parents and picking up that responsibility. One participant noted that when "nurses will lead giving the meds…it just helps take the pressure away from the parents" (P12-A/C). Reassurance also was engendered through generating confidence and supporting the parent to support their child as: they need to know what's going on…have confidence in you, so they know what's happening; they can make sure their child is kept calm. (P8-C) Steps taken by participants to reassure and alleviate the impact of parental anxiety on children's pain included keeping the parent as involved as possible; this included "walk[ing] people through that experience and hopefully make them feel as comfortable as possible" (P15-A/C). Reassurance and relationship building with parents, meant parents were better equipped to ensure their child is kept calm and consequently reduce the child's experience of pain.

| D ISCUSS I ON
This study highlights the diversity in the nature of reassurance provided by nurses in relation to children's pain. The study illustrates that nurses' reassurance for children's pain is directed at the child Our findings demonstrate numerous types of reassurance undertaken which move beyond the short, generic 'empty' 22 reassurance statements (such as "it's ok" and "don't worry") described in the existing literature. 3,11,18 There are similarities between the reassurance described by participants and the Holt  Participants also discussed several forms of explicit cognitive reassurance. Participants emphasized the importance of neutral and realistic language and gesture 27 with nurses demonstrating their credibility and authenticity; both important aspects of successful reassurance. 28 This sense of credibility also provided the foundation for tailored information-sharing practices including providing hope to parents and children by vocalizing the different options/ solutions available to manage pain and creating opportunities for shared decision-making. 29 Other research advocates the importance of supporting children's literacy through providing clear information tailored to their needs and available in a timely manner before their procedure. 26 Generic reassurance was also used to increase credibility. By communicating belief in the child's pain, a factor known to be important to children and parents, 24 the nurses established a context of trust for further interactions.
Encouraging parents to prepare their child before painful procedures was another form of cognitive reassurance. Previous studies show parents are often reluctant to provide information to children about procedures due to misconceptions that this might heighten children's anxiety. 30 The nurses recognized that they had a role to play in encouraging and empowering parents to provide information to their child. Nurses in this study also recognized the cyclical relationship between parental and child anxiety about pain. Other studies also note that a parent who looks or sounds fearful or anxious can cause a child to become more distressed which can in turn increase the parent's anxiety and fear. 4,8 With the aim of limiting this cyclical relationship, nurses in this study reported using generic reassurance practices such as keeping parents involved and calm to reduce the impact of parental anxiety on children.
The strength of this study is its use of in-depth qualitative interviews to explore the types of reassurance nurses used when talking to children and their parents about pain in a way which had not been done by previous experimental 10 and survey [31][32][33] studies. The study recruited nurses from a range of specialisms, settings, years' experience, and international geographical locations. While these varied perspectives are a strength of the study, most were working in the UK which limits the international comparisons that can be made about reassurance practices. Also, while the 18 participants were purposefully selected, they were chosen from a self-selecting sample of 60 nurses recruited from existing pain-focused networks who may have different perspectives from a more generic sample of nurses.
In conclusion, our study finds that when nurses reassure children about pain, they focus their reassurance in three distinct directions, child, parents, and children and parents in partnership, which has not been specifically acknowledged by previous research.
It also highlights the wide range of implicit and explicit reassurance actions undertaken by nurses. However, by highlighting these complexities, our study also reveals some gaps in the existing evidence.
By focusing on what nurses say they do, our findings only describe reassurances given by nurses (adults) to children and does not acknowledge that children's response to pain may have a reassuring impact on parents and nurses particularly among older children.
This study highlights that the current evidence base in this area is theoretically thin. 34 Further research on parents and children's perspectives on reassurance and application of relevant social learning and behavior change theories are needed to more fully understand the relationships between reassurance and children's experiences of pain. So in the face of the current zeitgeist that reassuring children in pain promotes distress, 11 our findings suggest that reassurance that extends beyond limited 'empty' 22 vocalizations is part of a complex package of care that can support children's current and future pain experiences.

ACK N OWLED G M ENTS
The authors would like to thank all of the participants for kindly taking the time to share their experiences and thoughts about managing pain in children with us.

AUTH O R CO NTR I B UTI O N S
AJ and BC conceived, designed, and undertook data analysis. JH contributed to data analysis and literature searching. AJ, BC, and JH contributed to writing the paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request due to privacy/ethical restrictions.