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Aims and objectives. To explore childrens and parents perceptions about the quality of postoperative pain management.
Background. Children continue to experience moderate to severe pain postoperatively. Unrelieved pain has short- and longterm undesirable consequences. Thus, it is important to ensure pain is managed effectively. Little research has explored
childrens and parents perceptions of pain management.
Design. Exploratory study.
Methods. Children (n = 8) were interviewed about their perceptions of pain care using the draw-and-write technique or a
semi-structured format and asked to rate the worst pain experienced postoperatively on a numerical scale. Parents (n = 10)
were asked to complete the Information About Pain questionnaire. Data were collected in 2011.
Results. Most children experienced moderate to severe pain postoperatively. Children reported being asked about their pain,
receiving pain medication and using nonpharmacological methods of pain relief. A lack of preoperative preparation was evident for some children. Most parents indicated they had received information on their childs pain management. Generally,
participants were satisfied with care.
Conclusion. Participants appeared satisfied with the care provided despite experiencing moderate to severe pain. This may
be attributable to beliefs that nurses would do everything they could to relieve pain and that some pain is to be expected
postsurgery.
Relevance to clinical practice. Children are still experiencing moderate to severe pain postoperatively. Given the possible
short- and long-term consequences of unrelieved pain, this is of concern. Knowledge translation models may support the use
of evidence in practice, and setting a pain goal with parents and children may help improve care.
Key words: children, paediatric pain, parents, postoperative pain
Accepted for publication: 24 October 2012
Introduction
Why managing pain effectively is important
Despite the evidence to guide practice being readily available, paediatric pain management practices continue to
fall short of the ideal (Shrestha-Ranjit & Manias 2010,
Authors: Alison Twycross, MSc, PhD, RGN, RMN, RSCN, DMS,
CertEd, Reader in Childrens Nursing, Faculty of Health, Social
Care and Education, Kingston University and St Georges University of London, London, UK; G Allen Finley, MD, FRCPC, FAAP,
Professor of Anesthesia & Psychology, Dalhousie University, Halifax, NS and Dr Stewart Wenning Chair in Pediatric Pain Management, IWK Health Centre, Halifax, NS, Canada
Twycross & Collis 2012), with children experiencing moderate to severe unrelieved pain while in hospital (ShresthaRanjit & Manias 2010, Kozlowski et al. 2012, Twycross
& Collis 2012). This situation is not unique to children,
with adults experiencing similar amounts of pain (Joelsson
et al. 2010, Wadensten et al. 2011). Unrelieved pain has a
number of undesirable physiological and psychological
Correspondence: Alison Twycross, Reader in Childrens Nursing,
Faculty of Health, Social Care and Education, Kingston University
and St Georges University of London, London, UK. Telephone:
+44 (0)778 552 5986.
E-mail: a.twycross@sgul.kingston.ac.uk
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consequences that can affect the child at the time and later
in life (Saxe et al. 2001, Taddio et al. 2002, Fortier et al.
2011). It is, therefore, important to ensure pain is managed
effectively.
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ate to severe pain during the postoperative period, suggesting they believe pain is to be expected after surgery
(Twycross & Collis 2012, Vincent et al. 2012). Children
also appear to believe this to be the case (Twycross &
Collis 2012). Childrens and parents perceptions in this
context need exploring further.
The study
Aim
The aim of this study was to explore childrens and parents
perceptions of the quality of their postoperative pain
management on one unit in a tertiary childrens hospital in
Canada.
Clinical issues
Design
Exploratory research sets out to explore the dimensions of
a phenomenon (Polit & Beck 2012). As little is known
about childrens and parents views on the quality of postoperative pain management, adopting this stance was felt
appropriate.
Childrens views
Sample
Ten children undergoing surgery requiring them to remain
an inpatient for at least 48 hours postoperatively were
asked to take part in the study. The following groups were
excluded:
Children in the intensive care unit, who were below
five years of age or who were unable to communicate
verbally.
Children or parents who the nurses felt were too
distressed to take part.
This age range was chosen as children aged five to six years
have a 2000- to 2500-word vocabulary, can use complex sentences, can recall and describe events and as such can be
interviewed using simple, nonleading questions (Morison
et al. 2000). Children of this age are also normally able to
self-report their pain intensity (Stinson et al. 2006).
Asked to:
Draw a picture of
how you felt when
you were in pain?
Asked:
Are there any words
you would like to
write about how you
felt when you were in
pain? (I can help you
with the writing).
Opening question:
Tell me what
happened when you
were in pain.
Prompts used as
necessary.
Children writing
answers to
interview questions
Final question:
What was the worst
pain you had while
you were in hospital?
Asked:
Tell me about the
picture and the words
you have written.
Asked:
What was the worst
pain you had while
you were in hospital?
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Parents views
Sample
The sample consisted of the parents of children participating
in the study. Ten parents (one for each child participant)
completed the questionnaire.
Data collection tools
Parents were asked to complete the Information About Pain
questionnaire (Foster & Varni 2002). This took no more
than 10 minutes to complete and provided an indication of
parents perceptions of the quality of their childs pain management. The questionnaire includes items on the following:
How information about pain management was provided.
Parents observations of their childs response.
The length of time their child was in pain.
The amount of time their child was in pain.
Satisfaction with pain management and recommendations.
Ethical considerations
Approval was gained from the hospitals ethical review
board. Children and parents were recruited to the study in
several ways (Fig. 2). Parental consent was obtained to conduct the interviews with children. Children were then asked
to assent/consent to taking part. Once a participant agreed
to take part in the study, they were given an identifying
code known only to the researcher. Demographic details
were separated from other data to ensure participants
could not be identified. Confidentiality was maintained by
referring to participants using these codes. Only the
researcher has access to the raw data, now kept in a secure
cupboard.
Parents of children
undergoing planned
surgery who were not
admitted to the surgical
floor prior to surgery.
Parents of children
undergoing planned
surgery and/or
emergency surgery who
were admitted to the
surgical floor prior to
surgery.
Once the child had been admitted to the floor and received an initial assessment, the nurse
caring for them gave the parents a postcard. The nurse informed the researcher if the parents did
not wish to receive further information about the study.
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If the parents were happy to receive further information about the study, the researcher
approached them.
Parents were provided with written and verbal information about the study.
Once parents had had time to consider the information provided the researc her obtained
consent for those parents who are happy to take part in the study.
Assent/consent was then obtained from the child.
Clinical issues
Data analysis
Childrens perceptions
Childrens responses to the interview questions were transcribed verbatim. Content analysis was used to analyse the
transcripts using a five-step approach:
1 Creating and organising files for data.
2 Reading through the text and forming initial codes.
3 Describing the social setting, people involved and events.
4 Analysing data for identifying emerging themes.
5 Interpreting and making sense of the findings
(Creswell 1998).
Data analysis was carried out by the primary researcher
(first author). Four themes emerged from the data:
My pain while in hospital;
Who asked me about my pain and how did they do this;
What happened when I was in pain; and
Things that could have been done differently.
For some themes, data were tabulated as this was considered a clearer way of presenting the results.
10%
10%
Mild pain
Moderate pain
Parents perceptions
Severe pain
80%
Results
Demographic data relating to the children who participated
in the study are presented in Table 1. Of the children
included in the study, four had long-term health conditions
related to their admission.
Childrens perceptions
Interview data were obtained from eight children. Two of
the younger children drew pictures, but their responses to
the questions demonstrated they did not understand them
or want to take part (Cases 2 and 10). For these cases, only
Case
Pain score
1
2
3
4
5
6
7
8
9
10
78
10
8
2
7
10
10
5
78
10
No.
Gender
No.
Type of surgery
No.
Type of admission
No.
510 years
1115 years
16 years +
4
3
3
Male
Female
3
7
General
Orthopaedic
Oral
3
2
5
Planned
Emergency
7
3
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Response
Number
Parents
Nurses
Doctors
2
7
5
It is worth noting that the child who indicated his pain had
been excruciating reported that the nurses management of his
pain was pretty good and could not think of anything that
could be done better. However, some children did provide evidence of areas where they felt improvements could be made.
One child indicated she would like nurses: to check on me
more often (Case 1). However, another child (Case 3) indicated that nurses asked her about her pain too often and that
this was particularly annoying if it meant they woke her up:
Interviewer: Did the nurses ask you about your pain as much as
A further three children indicated that besides pain medications being administered, nonpharmacological interventions were used:
Child: Kind of
Interviewer: Can you tell me a bit more about that?
Child: They asked it every time that they came in. sometimes when
Things that could have been done differently. Six participants felt nothing needed to be done differently. Three children indicated they felt the nurses had done as much as
possible to manage their pain:
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Parents perceptions
How information was provided. Table 4 provides information on whether or not the nurses or doctors talked to the
Clinical issues
remembered getting information on pain management indicated that it was easy to understand.
Childrens response to pain medications. The second section of the questionnaire is related to parents observation
of their childs response to pain medications and whether
they experienced any side effects (Table 6).
Table 4 Did the nurses or doctors talk to you or your child about
the treatment of pain after surgery? (n = 10)
Response
Yes
No
Other response
parents or child about how pain would be managed postoperatively and whether this information was easy to understand. Table 5 details when this discussion took place and
how the information was provided. The nine parents who
Table 5 Information about pain (n = 10)
Amount of pain experienced by children and what happened when child was in pain. Parents perceptions relating
to the amount of pain their child was in at the time they completed the questionnaire, and the childs worst pain since surgery on a scale of 010, as well as parental expectations of
their childs postoperative pain are detailed in Table 7. Wilcoxons statistical tests were carried out to examine whether
there were any significant differences between parents expectations of how much pain their child was going to be in after
surgery and the pain experienced. No statistical differences
were found between expected pain and the worst pain experienced when lying quietly (z = 1201, p = 02299) or
between expected pain and the worst pain experienced when
moving or out of bed (z = 0110, p = 09121).
Details on parents perceptions about whether their child
was in moderate to severe pain postoperatively as well as
whether they or their child told a nurse when they were in
pain are presented in Table 8. The length of time the child
was felt to be in moderate to severe pain and how long parents felt it took for their child to receive pain medications
when they needed them are presented in Table 9.
Satisfaction and recommendations. The final section of
the questionnaire explored parents satisfaction with their
childs pain management and any recommendations they
had for improving pain care. Table 10 provides details of
the level of satisfaction among parents. Only one parent
indicated she was dissatisfied with the pain care provided
and sought out the researcher to discuss this and gave her
consent for the comments to be used. The extract below
indicates there may be issues with nurseparent communication about pain:
Number
Before surgery
After surgery
1
0
Both times
Couldnt remember
8
1
Number
8
4
0
1 (informed by
doctors and nurses)
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Response
Yes
No
Other
response
10
0
1
9
1
9
5
5
Case
Pain
right
now
Worst pain
since surgery
when lying
quietly
1
2
3
4
5
6
7
8
9
10
3
4
3
1
5
3
2
2
2
1
8
5
9
8
9
10
5
8
8
8
6
9
8
3
8
9
5
8
8
9
6
5
9
3
8
9
6
6
8
10
Response
Children in moderate to
severe pain at any
time after surgery
Yes
No
7
3
10
0
Mum was particularly concerned that one nurse (she said she
wasnt going to tell me who) had told the child that it was her
body and that it was up to her whether she had painkillers or not
and that she shouldnt let anyone else make the decision for her.
Mum felt that as she had told the child and nurse that she only
wanted strong painkillers (morphine) if the child had severe pain
(e.g. pain that meant she couldnt get to sleep) that the nurse was
ignoring her wishes and wasnt working in partnership with her.
The mum felt that the nurse did not understand the life style
choices the family had made and that it made her feel stupid sitting
there. The mum also said that perhaps the nurse was having a bad
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day and that some patients would need them to protect her from
their parents. (Case 5)
Clinical issues
Table 9 Time children were in severe pain
and time taken to get pain medications
(n = 10)
Number
Very dissatisfied
Dissatisfied
Satisfied
Very satisfied
1
0
1
8
Response
Number
(%)
1
1
1
1
1
8
Overall was pleased with the results. Just wish it had worked a bit
quicker. (Case 2)
Number
Number
0
1
6
3
<5 minutes
530 minutes
3060 minutes
More than one hour
7
1
2
0
Discussion
Most children experienced moderate to severe pain postoperatively although there were some individual discrepancies.
Generally, participants (children and parents) were satisfied
with the care provided, believing that nurses had done everything they could to manage their pain. Children reported
being asked about their pain, receiving pain medication and
using nonpharmacological methods of pain relief. A lack of
preoperative preparation was evident for some children.
Most parents indicated that they had received information
on their childs pain management and that this was easily
understandable. Only one parent was concerned that their
child would become addicted to analgesic drugs. This differs
from the results of other studies (Zisk et al. 2007, Zisk-Rony
et al. 2010). The reported incidence of other side effects was
in line with the results of other studies (Kozlowski et al.
2012). Key findings will now be discussed in more depth.
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this context. They have been used to improve pain management practices in one Canadian childrens hospital
(Zhu et al. 2012) and have also been shown to have some
impact on the management of cancer pain in adults (Cummings et al. 2011). Further research is needed to identify
ways of promoting sustained change in practice.
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Clinical issues
Conclusion
Children are still experiencing moderate to severe pain postoperatively despite the evidence to guide practice being readily available. Given the possible short- and long-term
consequences of unrelieved pain, this is of concern. Strategies
need to be identified that promote the use of evidence in
practice. Knowledge translation models may be useful in this
context. Individual preferences need taking into account. Setting a pain goal with children and parents may be one way of
ensuring this happens. The impact of unit culture on pain
management practices needs further exploration. Strategies
to ensure that children are prepared adequately for surgery
need developing. This may include web-based resources. On
the whole, children and parents are satisfied with the pain
care provided. This may be attributable to beliefs that nurses
would do everything they could to manage pain and that
some pain is an inevitable consequence of surgery. Further
research is needed to explore this in more depth.
Acknowledgements
The authors would like to thank the children and parents
who participated in the study.
Limitations
This is a small study carried out in one paediatric setting.
Children participating in the study underwent different
types of surgery, and four of them had long-term health
conditions that may have impacted on their perceptions
of the care provided. Data were collected while the child
was still in hospital, and this might mean participants
were reluctant to discuss negative perceptions in case this
had an adverse effect on their care. However, the results
provide an insight into childrens and parents views on
the quality of their postoperative pain care, as well as
identify areas for future research.
Contributions
Study design: AT, GAF; data collection and analysis: AT
and manuscript preparation: AT.
Funding
The first author undertook this research while on an international research sabbatical funded by the Faculty of
Health and Social Care Sciences at Kingston University and
St Georges, University of London.
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