What works well for children and young people suffering acute pain attended by ambulance? A realist evaluation

Abstract Introduction Access to adequate pain treatment is considered a fundamental human right, yet around 60% of children and young people (CYP) who need an ambulance for a painful condition experience poor pain management. We aimed to update our existing programme theory by exploring what works well for CYP, their parents/carers and ambulance clinicians. Methods We performed a realist evaluation using a multiple case study approach following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards II guidance. We recruited CYP aged 4–17 years who had recently suffered acute pain requiring an ambulance, their parents/carers and ambulance clinicians. Study leaflets were handed out across three ambulance services and two children’s emergency departments in England from August 2024 to July 2025, alongside social media advertising. Participants shared their experience via face-to-face, online or telephone interviews, diaries, or through artwork. We also collected three years of routine clinical record data (January 2021 to December 2023) from two ambulance services in England. A realist logic of analysis was used to refine our previously developed programme theory. Results Twenty-one ambulance clinicians, fourteen parents/carers and nine CYP were recruited, producing forty-one interview transcripts, two pieces of artwork, and one diary. We also analysed 34,068 clinical records. Our refined programme theory identified the importance of ambulance clinician preparedness, particularly around education, training, exposure, and experience. The need for compassionate person-centred care was clear, particularly establishing privacy and providing reassurance, appearing calm, empowering CYP, allaying negative assumptions, using appropriate humour, building trust, and being aware of the consequences of unmanaged pain. The involvement of parents and carers was viewed as essential, with emphasis on alleviating their fear and anxiety. The programme theory also focused on the importance of pain assessment and treatment, particularly around covering visible signs of injury or illness, providing non-pharmacological distractions such as stickers, meeting expectations, and the impact of catastrophisation on pain assessment. Conclusion Insights from CYP, parents/carers, ambulance clinicians and clinical record data have enabled us to test and refine a programme theory for improving prehospital pain management in CYP. This theory can be tested empirically and used to inform future intervention development.