children's and parents’ perceptions of postoperative pain management: a mixed methods study

CLINICAL ISSUES

Children’s and parents’ perceptions of postoperative pain

management: a mixed methods study

Alison Twycross and G Allen Finley

Aims and objectives. To explore children’s 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 long-

term undesirable consequences. Thus, it is important to ensure pain is managed effectively. Little research has explored

children’s 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 evi-

dent for some children. Most parents indicated they had received information on their child’s 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 avail-

able, paediatric pain management practices continue to

fall short of the ideal (Shrestha-Ranjit & Manias 2010,

Twycross & Collis 2012), with children experiencing mod-

erate to severe unrelieved pain while in hospital (Shrestha-

Ranjit & 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

Authors: Alison Twycross, MSc, PhD, RGN, RMN, RSCN, DMS,

CertEd, Reader in Children’s Nursing, Faculty of Health, Social

Care and Education, Kingston University and St George’s Univer-

sity of London, London, UK; G Allen Finley, MD, FRCPC, FAAP,

Professor of Anesthesia & Psychology, Dalhousie University, Hali-

fax, NS and Dr Stewart Wenning Chair in Pediatric Pain Manage-

ment, IWK Health Centre, Halifax, NS, Canada

Correspondence: Alison Twycross, Reader in Children’s Nursing,

Faculty of Health, Social Care and Education, Kingston University

and St George’s University of London, London, UK. Telephone:

+44 (0)778 552 5986.

E-mail: [email protected]

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 22, 3095–3108, doi: 10.1111/jocn.12152 3095

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.

Reasons children’s pain is not managed effectively

The complexity of assessing pain explains, at least in part,

why management remains suboptimal. Nurses struggle to

reconcile children’s behaviour with reported pain scores if

they are not behaving in a way that makes it obvious they

are in moderate to severe pain (Vincent & Gaddy 2009,

Twycross & Collis 2011, Ljusegren et al. 2012). Nurses

have indicated they believe children often over-report their

pain (Vincent & Denyes 2004, Ljusegren et al. 2012,

Twycross & Collis 2012). Further, the primary factor con-

sidered by nurses when assessing children’s pain seems to

be their behavioural indicators (Vincent & Denyes 2004,

Vincent & Gaddy 2009, Vincent et al. 2010). This is

despite the, often-cited, definition of pain suggesting that

‘pain is whatever the experiencing person says it is, existing

wherever they say it is’ (McCaffery 1972). Indeed, recent

reviews of the literature on pain assessment in adults

(Schiavenato & Craig 2010) and children (Voepel-Lewis

et al. 2012) concluded that patients’ self-report of pain was

only one of several factors taken into account when making

treatment decisions.

Nurses’ beliefs about pain may contribute to suboptimal

practices. Nurses may believe that pain management is syn-

onymous with administering analgesic drugs alone and may

not see the need to evaluate the effectiveness of interven-

tions or to use other pain-relieving strategies (A. Twycross,

University of Central Lancashire, Lancashire, unpublished

PhD thesis, Twycross et al. 2013). There is also evidence

that nurses believe some pain is to be expected (and

accepted) during hospitalisation (Woodgate & Kristjanson

1996, Twycross et al. 2013). When nurses were asked

about their aims when managing paediatric postoperative

pain, more than half of them aimed for patients to be com-

fortable (Twycross & Finley 2013). Being comfortable

appeared to mean that the child was able to mobilise and

undertake their activities of daily living and did not com-

plain. Nurses’ aims may adversely impact on care.

Parents’ beliefs may also affect their child’s pain manage-

ment. Parents fear the side effects of analgesic drugs; they

think that they are addictive and that children should

receive as little pain medication as possible (Zisk et al.

2007, Zisk-Rony et al. 2010). Parents are satisfied with

their child’s pain care even if the child experiences moder-

ate to severe pain during the postoperative period, suggest-

ing 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). Children’s and parents’ perceptions in this

context need exploring further.

Children’s and parents’ views about the quality of pain

management

Children’s views on how well their pain was managed have

been explored in only a few studies. Children reported hav-

ing difficulty convincing healthcare professionals they were

in pain (Carter 2004, Kortesluoma et al. 2008) and sug-

gested nurses needed to take a more active role in pain

management. Nurses should, for example, discuss chil-

dren’s pain management with them more often (He et al.

2007, Twycross & Collis 2012) and administer more anal-

gesic drugs as soon as they ask for them (Polkki et al.

2003, He et al. 2007, Kortesluoma et al. 2008). Children

would also have liked nurses to provide them with mean-

ingful things to do to distract them from their pain (Polkki

et al. 2003).

Parents have indicated their involvement in their child’s

pain management is superficial and limited (Simons et al.

2001, Lim et al. 2011, Twycross & Collis 2012). They also

felt they needed more information on their child’s pain man-

agement (Polkki et al. 2002, Simons & Roberson 2002, Lim

et al. 2011, Twycross & Collis 2012) and that nurses were

dismissive of their concerns (Simons et al. 2001) or did not

take their views into account (Polkki et al. 2002).

Several factors have been proposed to explain why pain

management practices remain suboptimal. Some of these

relate to children and parents. Several studies have pro-

vided an indication of areas where children and parents

consider practices could be improved. However, many of

these studies are more than a decade old, and few studies

have collected data from both children and parents. It is

timely, therefore, to explore both children’s and parents’

perceptions of postoperative pain management.

The study

Aim

The aim of this study was to explore children’s and parents’

perceptions of the quality of their postoperative pain

management on one unit in a tertiary children’s hospital in

Canada.


3096 Journal of Clinical Nursing, 22, 3095–3108

A Twycross and GA Finley

Design

Exploratory research sets out to explore the dimensions of

a phenomenon (Polit & Beck 2012). As little is known

about children’s and parents’ views on the quality of post-

operative pain management, adopting this stance was felt

appropriate.

Children’s 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 sen-

tences, 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).

Data collection tools

An adapted draw-and-write technique was used with youn-

ger children (Pridmore & Bendelow 1995). This allowed

children to draw and tell, draw and write, or write their

story about their postoperative pain experiences. Older

children were offered the option of being interviewed or

recording their views independently in a tape recorder.

Children who had undergone jaw surgery were provided

with pens and papers so that they could write their

responses. An interview schedule comprising a checklist of

areas to be covered was developed for children opting for a

semi-structured interview. All the children were asked to

rate the worst pain experienced during the first 48–

72 hours postoperatively using the numerical (0–10) pain

assessment tool.

Procedure

Interviews with children took place on the second or third

postoperative day while they were still in hospital. The

decision to interview children while still in hospital was a

pragmatic one. Participants lived across three Canadian

provinces and were usually discharged within 72 hours of

surgery. Interviewing them following discharge would have

been difficult to do and resource-intensive in relation to

time and travel expenses. As children have been inter-

Children opting fordraw and write

technique

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).

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?

Children opting forsemi-structured

interview

Opening question:Tell me what

happened when you were in pain.

Prompts used as necessary.

Final question:What was the worst pain you had while

you were in hospital?

Children writinganswers to

interview questions

Same format as for semi-structured

interviews except children where given a pen and paper to

write down their responses.

Figure 1 Procedure for different interview

strategies.


Journal of Clinical Nursing, 22, 3095–3108 3097

Clinical issues Pain management: children and parents’ perceptions

viewed while in hospital in other studies, doing so was not

considered problematic (Polkki et al. 2003, Kortesluoma

et al. 2008).

The interviews took place at the child’s bedside. Children

were given the option of whether or not their parent(s)

would be present during the interview; all children opted to

have them there. Interview data were recorded using a tape

recorder. The procedure for each interview technique is

outlined in Fig. 1.

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 child’s pain man-

agement. The questionnaire includes items on the following:

• How information about pain management was provided.

• Parents’ observations of their child’s response.

• The length of time their child was in pain.

• The amount of time their child was in pain.

• Satisfactionwith painmanagement and recommendations.

Construct validity of the tool has been demonstrated

previously through selected interitem relationships, and

the psychometric analyses support the initial measure-

ment properties of the instrument (Foster & Varni

2002).

Procedure

Parents were asked to complete the questionnaire on the sec-

ond or third postoperative day while their child was still in

hospital. Once they had completed the questionnaire, they

were asked to put it in a sealed envelope and either return it

to the researcher or leave it in a box on the unit’s reception

desk.

Ethical considerations

Approval was gained from the hospital’s ethical review

board. Children and parents were recruited to the study in

several ways (Fig. 2). Parental consent was obtained to con-

duct 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.

Posters placed in key places on surgical floor

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.

• 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 researcher obtained

consent for those parents who are happy to take part in the study.• Assent/consent was then obtained from the child.

Figure 2 Process of consent.




Data analysis

Children’s perceptions

Children’s responses to the interview questions were tran-

scribed 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 consid-

ered a clearer way of presenting the results.

Parents’ perceptions

Data collected from the questionnaire completed by parents

were analysed by examining the number of responses to

each question to provide insight into perceptions of their

child’s pain care. As only 10 parents completed the ques-

tionnaire, minimal statistical testing was carried out.

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.

Children’s 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

data pertaining to the worst pain children had experienced

postoperatively were included in the analysis. Four children

opted for the semi-structured interview, three opted to

write the answers to the interview questions, and one child

used the draw-and-write technique. Interviews took

between 15–30 minutes.

My pain while in hospital

Children were asked to indicate on a scale of 0–10 what their

worst pain had been postoperatively (Table 2; Fig. 3). In this

study, mild pain was considered to equate with a pain inten-

sity score of 1–3, moderate pain to a score of 4–6 and severe

pain to a score of 7–10. This decision was made taking into

account the findings of studies on children’s perceptions

of bearable pain postoperatively (Gauthier et al. 1998,

Demyttenaere et al. 2001, Birnie et al. 2011).

Table 1 Demographic data (n = 10)

Age No. Gender No. Type of surgery No. Type of admission No.

5–10 years 4 Male 3 General 3 Planned 7

11–15 years 3 Female 7 Orthopaedic 2 Emergency 3

16 years + 3 Oral 5

10%

10%

80%

Mild pain

Moderate pain

Severe pain

Figure 3 Children experiencing mild, moderate and severe pain

postoperatively (n = 10).

Table 2 Children’s worst pain postoperatively (n = 10)

Case Pain score

1 7–8

2 10

3 8

4 2

5 7

6 10

7 10

8 5

9 7–8

10 10




Who asked me about my pain and how did they do this

Seven of the eight children interviewed indicated they had

been asked about their pain. Responses relating to who had

asked children about their pain are summarised in Table 3.

Children also discussed how they were asked about their

pain. One child indicated nurses just talked and did not use

a special tool (Case 5). Six other children reported they were

asked about their pain using a numerical scale:

With the nurses and doctors we use a scale from 1–10. 10 being

the worst. (Case 8)

They used the 1–10 scale, 10 being really bad. (Case 1)

What happened when I was in pain. When discussing

what happened when they were in pain, one child indicated

their pain had not been taken care of:

It’s not really been taken care of it’s excruciating. (Case 3)

Four other children indicated they were given pain

medications:

The nurses asked me if I wanted tylenol [paracetamol] or morphine

and which ever, they gave to me. (Case 5)

Gave pain medicines. (Case 6)

A further three children indicated that besides pain medi-

cations being administered, nonpharmacological interven-

tions were used:

A nurse would give me ice pack or medicine, unless I asked for

something in particular. (Case 1)

They asked if I needed like pain medication or some kind of warm

blanket. (Case 7)

As five (62�5%) of the eight children interviewed had had

oral surgery, this may have had an impact on the number

stating they had used nonpharmacological interventions as

the postoperative orders for these patients included the use

of cold packs for the first 24 hours after surgery.

Things that could have been done differently. Six partici-

pants felt nothing needed to be done differently. Three chil-

dren indicated they felt the nurses had done as much as

possible to manage their pain:

They [the nurses] would do anything they could. (Case 8)

The nurses were great at minimising pain asmuch as possible. (Case 1)

I don’t really know, they do a good job already. (Case 5)

Three participants indicated the nurses and hospital were

great:

Everything was great. I loved all the nurses and everyone that was

around. Everyone was super nice and friendly. (Case 8)

Thank you all [the nurses] for your nice work from [child’s name].

(Case 2)

You can tell them it is a very good hospital. (Case 7)

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 evi-

dence 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) indi-

cated 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

you would like them to?

Child: I guess (hesitantly). It got kinda of annoying after a while.

Interviewer: Why was it annoying?

Child: After the first few times

Interviewer: I’m quite interested about the fact that it got a bit

annoying to be asked about your pain

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

I was trying to sleep so that’s probably why it was annoying…..

Interviewer: So you didn’t like them waking you up?

Child: Yeah, yeah

A lack of preparation preoperatively was apparent for

one child. The picture in Fig. 4 indicates that one child,

admitted for planned surgery, did not understand what

would happen to her. This is supported by her statement:

When I was in the hospital I did not know what they would do to

me. So I just figured out in my head that it was surgery. (Case 2)

Parents’ perceptions

How information was provided. Table 4 provides informa-

tion on whether or not the nurses or doctors talked to the

Table 3 Who asked children about their pain (n = 7)

Response Number

Parents 2

Nurses 7

Doctors 5




parents or child about how pain would be managed postop-

eratively and whether this information was easy to under-

stand. Table 5 details when this discussion took place and

how the information was provided. The nine parents who

remembered getting information on pain management indi-

cated that it was easy to understand.

Children’s response to pain medications. The second sec-

tion of the questionnaire is related to parents’ observation

of their child’s response to pain medications and whether

they experienced any side effects (Table 6).

Amount of pain experienced by children and what hap-

pened when child was in pain. Parents’ perceptions relating

to the amount of pain their child was in at the time they com-

pleted the questionnaire, and the child’s worst pain since sur-

gery on a scale of 0–10, as well as parental expectations of

their child’s postoperative pain are detailed in Table 7. Wil-

coxon’s statistical tests were carried out to examine whether

there were any significant differences between parents’ expec-

tations 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 experi-

enced when lying quietly (z = �1�201, p = 0�2299) or

between expected pain and the worst pain experienced when

moving or out of bed (z = 0�110, p = 0�9121).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 par-

ents 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

child’s 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 nurse–parent communi-

cation about pain:

Table 4 Did the nurses or doctors talk to you or your child about

the treatment of pain after surgery? (n = 10)

Response

Did the nurses or doctors

talk to you or your child

about the treatment of

pain after surgery? (n = 10)

Was the information

easy to understand?

(n = 9)

Yes 9 9

No 0 0

Other response 1

Can’t remember

–

Figure 4 Drawing (Case 2).

Table 5 Information about pain (n = 10)When nurses or doctors talked

to parents/child about pain

management (n = 10) Number

How information about

pain was provided (n = 9) Number

Before surgery 1 Someone talked to me 8

After surgery 0 I was given something

to read

4

Both times 8 Video 0

Couldn’t remember 1 Other 1 (informed by

doctors and nurses)




Mum was particularly concerned that one nurse (she said she

wasn’t 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 shouldn’t 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 couldn’t get to sleep) that the nurse was

ignoring her wishes and wasn’t 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

day and that some patients would need them to protect her from

their parents. (Case 5)

Nine of the 10 parents indicated they would want their

child’s pain managed the same way if they had surgery

again. Indeed, eight of the 10 parents could think of no

improvements that could be made (Table 11). The response

relating to a need for faster pain relief in Table 11 is from

a parent who indicated they had to wait 30–60 minutes for

pain medications; other negative responses are from the

parent who sought out the researcher to discuss their dissat-

isfaction with the pain care.

Additional comments from parents. Seven of the 10 par-

ents included comments on their child’s pain management

in the space provided at the end of the questionnaire. Simi-

lar responses were grouped together, and the key findings

are presented below. Two parents commented on the qual-

ity of nursing staff:

[The nurses] were wonderful with [child’s name]. Talked to her not

us (parents) to get the pain information. They checked on her con-

stantly and were very available when we needed them. (Case 3)

Nursing staff is amazing!! (Case 6)

Two parents commented on the effectiveness of morphine

infusions for managing postoperative pain (Cases 8 and 10):

I must say I am very impressed, this is the first time he has had

morphine after surgery, and it’s the best recovery he has ever had.

Very pleased. (Case 10)

Another parent commented that the changeover from

intravenous to oral morphine appeared seamless (Case 8).

One parent commented that:

Although there is nothing the staff can do about the flavour of the

medication that is the only complaint we have. Better flavour would

ensure the children would take the medication quickly. (Case 9)

However, another parent commented that:

Table 6 Parents’ perceptions of child’s response to pain medications (n = 10)

Response

Did the pain

medicine take

away most of

your child’s

pain?

Were you worried that

your child might come

to depend on the pain

medicine?

Did your child

itch a lot from

the pain

medicine?

Did the pain medicine

make your child feel

like throwing up?

Did it take a long

time for pain

medication to

work?

Did the pain medicine

make your child feel

sleepy?

Yes 10 1 1 5 0 1

No 0 9 9 5 9 8

Other

response

– – – – 1

Depends on

circumstances

1

Hard to tell

Table 7 Parents’ perceptions of the amount of pain experienced by

their child (n = 10)

Case

Pain

right

now

Worst pain

since surgery

when lying

quietly

Worst pain since

surgery when

moving or out

of bed

How much pain

did you expect

your child to have

after surgery

1 3 8 6 6

2 4 5 9 5

3 3 9 8 9

4 1 8 3 3

5 5 9 8 8

6 3 10 9 9

7 2 5 5 6

8 2 8 8 6

9 2 8 8 8

10 1 8 9 10

Table 8 Number of children in moderate to severe pain at any

time after surgery and whether nurses were told when child had

pain (n = 10)

Response

Children in moderate to

severe pain at any

time after surgery

Did you or your child tell

the nurse when he/she had

hurt or pain?

Yes 7 10

No 3 0




Overall was pleased with the results. Just wish it had worked a bit

quicker. (Case 2)

The use of ice packs was commented on by one parent:

Our daughter particularly found the ice packs soothing – she pretty

much kept them on all the time. I think this also helped with her

swelling and bruising. (Case 8)

The mother that had expressed her concerns to the

researcher stated that:

I agree that sometimes you need strong pain relief, but for not so

severe pain, natural way should be considered. (Case 5)

Comparison of children’s and parents’ ratings of

worst pain

Parents’ ratings of pain can only be considered estimates of

their child’s pain (Zhou et al. 2008, Royal College of

Nursing 2009). Parents’ and children’s ratings of the worst

pain experienced were therefore compared using Wilco-

xon’s statistical tests. No statistically significant difference

was found between children’s perceptions of the worst pain

they had experienced postoperatively and parents’ percep-

tions of their pain when lying in bed (z = �0�460,

p = 0�6454) and when moving or out of bed (z = 0�621,p = 0�5349).

Discussion

Most children experienced moderate to severe pain postoper-

atively although there were some individual discrepancies.

Generally, participants (children and parents) were satisfied

with the care provided, believing that nurses had done every-

thing 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 child’s 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.

Children’s experiences of pain

Most children reported experiencing severe pain at some

point during the postoperative period. This was supported

by the responses of their parents, whose perceptions of

the pain experienced were not statistically different from

children’s ratings of pain. The results of this study add to

the picture of pain management obtained from other stud-

ies demonstrating that a significant number of children

experience moderate to severe pain while in hospital (Tay-

lor et al. 2008, Shrestha-Ranjit & Manias 2010, Kozlow-

ski et al. 2012, Twycross & Collis 2012). It is clear that

despite the evidence to guide practice being readily avail-

able, children’s pain is not being managed effectively.

Given the consequences of unrelieved pain, this is of con-

cern. Indeed, emerging research demonstrating that mis-

managed acute pain can lead to chronic postoperative

pain (Fortier et al. 2011) means it is imperative to identify

strategies that promote the use of evidence in practice.

Knowledge translation strategies may offer a solution in

Table 9 Time children were in severe pain

and time taken to get pain medications

(n = 10)How much of the time

was your child in severe pain? Number

When your child needed

more pain medicine, how

long did it take to get it? Number

All the time 0 <5 minutes 7

Quite a bit of the time 1 5–30 minutes 1

Once in a while 6 30–60 minutes 2

Never 3 More than one hour 0

Table 10 Parental satisfaction with pain after surgery (n = 10)

Response Number

Very dissatisfied 1

Dissatisfied 0

Satisfied 1

Very satisfied 8

Table 11 How we could get an A+ for pain management (n = 10)

Response

Number

(%)

Better explanation of pain control method 1

Better pain relief 1

Faster pain relief 1

Using other methods of pain relief 1

Give parents and children more of a say in pain relief 1

Everything was fine, no improvement needed 8




this context. They have been used to improve pain man-

agement practices in one Canadian children’s hospital

(Zhu et al. 2012) and have also been shown to have some

impact on the management of cancer pain in adults (Cum-

mings et al. 2011). Further research is needed to identify

ways of promoting sustained change in practice.

Asking children about their pain

Seven of the eight children reported being asked about their

pain. Six of these children indicated that a numerical pain

assessment tool was used. This is in line with recommended

pain assessment tools for this age group although younger

children may have benefited from the use of the Faces Pain

Scale - Revised (Royal College of Nursing 2009). The find-

ing that most children were asked about their pain is inter-

esting given the results of other studies that indicated pain

assessments are not carried out consistently or always docu-

mented (Twycross 2007, Taylor et al. 2008). However, just

because a child was asked about their pain does not mean

nurses used this information when making decisions on

which pain-relieving interventions to implement. The results

of two studies suggest that even if pain scores are recorded

they are not always used to guide treatment choices (John-

ston et al. 2007, Twycross et al. 2013).

One child would have liked nurses to ask them about

their pain more often, concurring with the findings of other

studies (Polkki et al. 2003, Twycross & Collis 2012), while

another participant felt nurses should not wake them up to

ask them about their pain. These contrasting preferences

suggest nurses should discuss individual children’s pain

management with them and agree strategies and goals. The

one parent who expressed dissatisfaction with the pain care

provided felt the nurses had not taken their family beliefs

into account. Setting a pain goal with parents and children

has been used to enhance the management of children’s

cancer pain (Anghelescu & Oakes 2002, Oakes et al.

2008). The use of a pain goal may provide a structure

through which to improve communication between parents,

children and nurses as well as to ensure individual prefer-

ences are taken into account. This may overcome at least

some of the issues currently being debated about the impor-

tance that should be attributed to child’s self-report of pain

when making treatment decisions (Vincent et al. 2011,

Voepel-Lewis 2011).

Response to reports of pain

When children had pain, they reported being given pain

medications, with some of them also using nonpharmaco-

logical methods. This conforms to what would be

expected under current best practice guidelines (Associa-

tion of Paediatric Anaesthetists 2012). Parents indicated

most children received pain medications in less than five

minutes although two parents indicated they had had to

wait up to an hour. This is better than the findings of a

study carried out in Singapore where parents reported

having to ask several times before analgesic drugs were

administered (Lim et al. 2011). This difference can per-

haps be explained by the findings of a study focusing on

nursing practices in the same unit that found the main

focus of pain management was administering analgesic

drugs and that these were given regularly even if pre-

scribed prn (Twycross et al. 2013). Further evidence of

the impact of unit culture on pain assessment practices

was seen in an ethnographic study on two (adult) units

in one hospital in the USA (Lauzon Clabo 2008). Partici-

pants described a clear but different pattern of pain

assessment on each ward. Organisational (unit) culture

was also found to impact on the care provided in paedi-

atric acute settings in eight hospitals in Canada (Esta-

brooks et al. 2011). The impact of unit culture in this

context needs further exploration.

Children’s preoperative preparation

A lack of preparation was evident for one child in this

study, so some children may not have received sufficient

information on their pain and pain management preoper-

atively. Children have indicated they had more pain after

surgery than expected, suggesting preoperative preparation

is not always as effective as it could be (Sutters et al.

2007). Children have said they want information preoper-

atively about the pain they will experience (Smith & Cal-

lery 2005, Fortier et al. 2009). Preparing children for

surgery results in better outcomes for children (Kain et al.

2007, Li & Lopez 2008) but appears to be another area

where evidence is not always used in practice. This could

be due to several reasons such as children living a long

way from the hospital or because they are often admitted

on the day of surgery. Web-based resources have been

used to educate children with functional abdominal pain

(Sato et al. 2009) and arthritis pain (Stinson et al. 2012).

Similar strategies could be used to prepare children for

surgery.

Satisfaction with pain management

On the whole, children and parents were satisfied with the

care provided despite many of them experiencing moderate




to severe pain postoperatively. Similar findings have been

obtained in other studies (Twycross & Collis 2012, Vin-

cent et al. 2012). There appears to be a belief among both

parents and children that some pain is to be expected

postoperatively. Most parents anticipated their child’s pain

postoperatively would be � 6 (out of 10). There was also

no statistical difference between parents’ expectations of

how much pain their child would have and the worst pain

experienced. Statements from children indicating they

believed the nurses did everything they could to manage

children’s pain, as well as parents reporting they would

like their child’s pain managed in the same way if they

had surgery again, support this conjecture. This argument

is also supported by the results of a recent study where

only 2–7% of participants (children and parents) reported

being dissatisfied with their care, despite 40% of children

(medical and surgical diagnoses) experiencing moderate to

severe pain (Kozlowski et al. 2012). Children’s and parents’

relief that surgery has been completed safely may also

impact on their perceptions in this context. Satisfaction may

not be the best way of measuring perceptions of the quality

of pain care.

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 children’s and parents’ views on

the quality of their postoperative pain care, as well as

identify areas for future research.

Conclusion

Children are still experiencing moderate to severe pain post-

operatively despite the evidence to guide practice being read-

ily 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. Set-

ting 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.

Contributions

Study design: AT, GAF; data collection and analysis: AT

and manuscript preparation: AT.

Funding

The first author undertook this research while on an inter-

national research sabbatical funded by the Faculty of

Health and Social Care Sciences at Kingston University and

St George’s, University of London.

References

Anghelescu D & Oakes L (2002) Working

toward better cancer pain manage-

ment for children. Cancer Practice 10,

S52–S57.

Association of Paediatric Anaesthetists

(2012) Good practice in postoperative

and procedural pain management, 2nd

edition. Pediatric Anesthesia 22, 1–81.

Birnie KA, Chambers CT, Cummings EA,

Fernandez CV, Finley GA, Forgeron

PA, Latimer M & McGrath PJ (2011)

Patient- and Parent-Reported Pain

Prevalence and Management in a

Canadian Pediatric Hospital. British

Pain Society/Canadian Pain Society

Joint Meeting, Edinburgh.

Carter B (2004) Pain narratives and narrative

practitioners: a way of working “in-rela-

tion” with children experiencing pain.

Journal of Nursing Management 12,

210–216.

Creswell J (1998) Qualitative Inquiry and

ResearchDesign: Choosing Among Five

Traditions. Sage Publications, London.

Cummings GG, Armijo Olivo S, Biondo

PD, Stiles CR, Yurtseven O, Fainsing-

er RL & Hagen NA (2011) Effective-

ness of knowledge translation

interventions to improve cancer pain

management. Journal of Pain and

Symptom Management 41, 915–939.

Demyttenaere S, Finley GA, Johnston CC

& McGrath PJ (2001) Pain treatment

thresholds in children after major

surgery. Clinical Journal of Pain 17,

173–177.




Estabrooks CA, Squires JE, Hutchinson

AM, Scott S, Cummings GG, Kang

SH, Middizi WK & Stevens B (2011)

Assessment of variation in the alberta

context tool: the contribution of unit

level contextual factors and speciality

in Canadian pediatric acute care set-

tings. BioMed Council Health Services

Research 11, 1–17.

Fortier MA, Chorney JM, Zisk Rony RY,

Perret-Karimi D, Rinehart JB, Camilon

FS & Kain ZN (2009) Children’s desire

for perioperative information. Anesthe-

sia and Analgesia 109, 1085–1090.

Fortier MA, Chou J, Maurer EL & Kain

ZN (2011) Acute to chronic postopera-

tive pain in children: preliminary find-

ings. Journal of Pediatric Surgery 46,

1700–1705.

Foster RL & Varni J (2002) Measuring the

quality of children’s postoperative pain

management: Initial validation of the

child/parent total quality pain manage-

ment (TQPM) instrument. Journal of

Pain and Symptom Management 23,

201–210.

Gauthier JC, Finley GA & McGrath PJ

(1998) Children’s self-report of post-

operative pain intensity and treatment:

threshold: determining the adequacy

of medication. Clinical Journal of Pain

14, 116–120.

He H-G, Vehvilainen-Julkunen K, Polkki T

& PietilaA-M(2007)Children’spercep-

tions on the implementation of methods

for their post-operative pain alleviation:

an interview study. International Jour-

nal ofNursingPractice13, 89–99.

Joelsson M, Olsson LE & Jakobsson E

(2010) Parents experience of pain and

pain relief following hip replacement

surgery. Journal of Clinical Nursing

19, 2832–2838.

Johnston CC, Gagnon AJ, Rennick J, Ros-

mus C, Patenaude H, Ellis J, Shapiro

C, Filion F, Ritchie J & Byron J (2007)

One-on-one coaching to improve pain

assessment and management practices

of pediatric nurses. Journal of Pediat-

ric Nursing 22, 467–478.

Kain ZN, Caldwell-Andrews AA, Mayes LC,

Weinberg ME, Wang S-M, MacLaren

JE & Blount RL (2007) Family-centered

preparation for surgery improves

perioperative outcomes in children.

Anesthesiology 106, 65–74.

Kortesluoma R-L, Nikkonen M & Serlo

W (2008) “You just have to make the

pain go away” – children’s experi-

ences of pain management. Pain Man-

agement Nursing 9, 143–149.

Kozlowski LJ, Kost-Byerley S, Colantouni

E, Thompson CB, Vasquenza KJ, Roth-

man SK, Billett C, White ED, Yaster M

& Monitto CL (2012) Pain prevalence,

intensity, assessment and management

in a hospitalized pediatric population.

Pain Management Nursing, in press.

Doi:10.1016/j.pmn.2012.04.003.

Lauzon Clabo LM (2008) An ethnography of

pain assessment and the role of social

context on two postoperative units. Jour-

nal of AdvancedNursing 61, 531–539.

Li HCW & Lopez V (2008) Effectiveness

and appropriateness of therapeutic

play intervention in preparing children

for surgery: a randomized controlled

trial study. Journal for Specialists in

Pediatric Nursing 13, 63–73.

Lim SH, Mackey S, Liam JLW & He H-G

(2011) An exploration of Singaporean

parental experiences in managing school-

aged children’s post-operative pain: a

descriptive qualitative approach. Journal

of Clinical Nursing 21, 860–869.

Ljusegren G, Johansson I, Gimbler Bergl-

und I & Enskar K (2012) Nurses’

experiences of caring for children in

pain. Child: Care, Health & Develop-

ment 38, 464–470.

McCaffery M (1972) Nursing Management

of the Patient in Pain. Lippincott,

Philadelphia, PA.

Morison M, Moir J & Kwansa T (2000)

Interviewing children for the purposes

of research in primary care. Primary

Health Care Research and Develop-

ment 1, 113–130.

Oakes LL, Anghelescu DL, Windsor KB &

Barnhill PD (2008) An institutional

quality improvement initiative for

pain management for pediatric cancer

inpatients. Journal of Pain and

SymptomManagement 35, 656–669.

Polit DF & Beck CT (2012) Nursing

Research: Generating and Assessing

Evidence for Nursing Practice, 9th edn.

Wolters Kluwer: Lippincott, Williams

and Wilkins, Philadelphia, PA.

Polkki T, A-M. P, Vehvilainen-Julkunen K,

Laukkala H & Ryhanen P (2002)

Parental views on participation in

their child’s pain relief measures and

recommendations to health care pro-

viders. Journal of Pediatric Nursing

17, 270–278.

Polkki T, Pietila A-M & Vehvilainen K

(2003) Hospitalized children’s descrip-

tions of their experiences with

postsurgical pain relieving methods.

International Journal of Nursing Stud-

ies 40, 33–44.

Pridmore P & Bendelow G (1995) Images of

health: exploring beliefs of children

using the ‘draw-and-write’ technique.

Health Education Journal 54, 473–488.

Royal College of Nursing (2009) The Rec-

ognition and Assessment of Acute

Pain in Children – Recommendations:

Revised. RCN Publishing, London.

Sato A, Clifford L, Silverman A & Davies

W (2009) Cognitive-behavioral inter-

ventions via telehealth: application to

pediatric functional abdominal pain.

Children’s Health Care 38, 1–22.

Saxe G, Stoddard F, Courtney D, Cunning-

ham K, Chawla N, Sheridan R, King D

& King L (2001) Relationship between

acute morphine and the course of PTSD

in children with burns. Journal of the

American Academy of Child and Ado-

lescent Psychiatry 40, 915–921.

Schiavenato M & Craig KD (2010) Pain

assessment as a social transaction

beyond the “gold standard”. Clinical

Journal of Pain 26, 667–676.

Shrestha-Ranjit JM & Manias E (2010)

Pain assessment and management

practices in children following surgery

of the lower limb. Journal of Clinical

Nursing 19, 118–128.

Simons J & Roberson E (2002) Poor com-

munication and knowledge deficits:

obstacles to effective management of

children’s postoperative pain. Journal

of Advanced Nursing 40, 78–86.

Simons J, Franck L & Roberson E (2001)

Parent involvement in children’s pain

care: views of parents and nurses. Jour-

nal of AdvancedNursing 36, 591–599.

Smith L & Callery P (2005) Children’s

accounts of their preoperative infor-

mation needs. Journal of Advanced

Nursing 14, 230–238.

Stinson J, Yamada J, Kavanagh T, Gill N

& Stevens B (2006) Systematic review

of the psychometric properties and

feasibility of self-report pain measures

for use in clinical trials in children

and adolescents. Pain 125, 143–157.

Stinson J, McGrath PJ, Hodnet E, Feldman

BM, Duffy CM, Huber AM, Tucker

LB, Hetherington CR, Tse SM, Spiegel

LR, Campillo S, Gill NK & White ME




(2012) An internet-based self-manage-

ment program with telephone support

for adolescents with arthritis: a pilot

randomized controlled trial. The Jour-

nal of Rheumatology 37, 1944–1952.

Sutters KA, Savedra MC, Miaskowski C,

Holdridge-Zeuner D, Waite S, Paul

SM & Lanier B (2007) Children’s

expectations of pain, perceptions of

analgesic efficacy, and experiences

with nonpharmacological pain man-

agement strategies at home following

tonsillectomy. Journal of the Society

of Pediatric Nurses 12, 139–148.

Taddio A, Shah V, Gilbert-MacLeod C &

Katz J (2002) Conditioning and

hyperalgesia in newborns exposed to

repeated heel lances. Journal of American

Medical Association 288, 857–861.

Taylor EM, Boyer K & Campbell FA

(2008) Pain in hospitalized children: a

prospective cross-sectional survey of

pain prevalence, intensity, assessment

and management in a Canadian pedi-

atric teaching hospital. Pain Research

and Management 13, 25–32.

Twycross A (2007) Children’s nurses’ post-

operative pain management practices:

an observational study. International

Journal of Nursing Studies 44, 869–

881.

Twycross A & Collis S (2011) Nurses’

views about the barriers and facilita-

tors to effective management of pedi-

atric pain. Pain Management Nursing,

in press. Doi:10.1016/j.pmn.2011.10.

007.

Twycross A & Collis S (2012) How well is

acute pain in children managed? a

snapshot in one english hospital. Pain

Management Nursing, in press.

Doi:10.1016/j.pmn.2012.01.003.

Twycross A & Finley GA (2013) Nurses’

aims when managing paediatric post-

operative pain: is what they say the same

as what they do? Journal for Specialists

in Pediatric Nursing, in press.

Twycross A, Finley GA & Latimer M

(2013) Pediatric nurses’ post-operative

pain management practices: an obser-

vational study. Journal for Specialists

in Pediatric Nursing 18, 189–201.

Vincent CVH & Denyes MJ (2004)

Relieving children’s pain; nurses’

abilities and analgesic administration

practices. Journal of Pediatric Nurs-

ing 19, 40–50.

Vincent CVH & Gaddy EJ (2009) Pediatric

nurses’ thinking in response to vignettes

on administering analgesics. Research in

Nursing & Health 32, 530–539.

Vincent CVH, Wilkie DJ & Szalacha L

(2010) Pediatric nurses’ cognitive rep-

resentations of children’s pain. The

Journal of Pain 11, 854–863.

Vincent CVH, Wilkie DJ & Wang E

(2011) Pediatric nurses’ beliefs and

pain management practices: an inter-

vention pilot. Western Journal of

Nursing Research 33, 825–845.

Vincent C, Chiappetta M, Beach A, Kiol-

basa C, Latta K, Maloney R & Van

Roeyen LS (2012) Parents’ manage-

ment of children’s pain at home after

surgery. Journal for Specialists in Pedi-

atric Nursing 17, 108–120.

Voepel-Lewis T (2011) Bridging the gap

between pain assessment and treat-

ment: time for a new theoretical

approach? Western Journal of Nursing

Research 33, 846–851.

Voepel-Lewis T, Piscotty RJ, Annis A &

Kalisch B (2012) Empirical review

supporting the application of the

“pain assessment as a social transac-

tion” model in pediatrics. Journal of

Pain and Symptom Management 44,

446–457.

Wadensten B, Frojd C, Swene CL, Gordh

T & Gunningberg L (2011) Why is

pain still not being assessed ade-

quately? Results of a pain prevalence

study in a university hospital in Swe-

den Journal of Clinical Nursing 20,

624–634.

Woodgate R & Kristjanson L (1996) A

young child’s pain: how parents

and nurses “take care”. International

Journal of Nursing Studies 33, 271–

284.

Zhou H, Roberts P & Horgan L (2008)

Association between self-report ratings

of child and parent, child and nurses

and parent and nurse dyads: meta-

analysis. Journal of Advanced Nursing

63, 334–342.

Zhu LM, Stinson J, Palozzi L, Weingarten

K, Hogan M-E, Duong S, Carbajal R,

Campbell FA & Taddio A (2012)

Improvements in pain outcomes in a

Canadian pediatric teaching hospital

following implementation of a multi-

faceted, knowledge translation initia-

tive. Pain Research and Management

17, 173–179.

Zisk RY, Grey M, Medoff-Cooper B &

Kain ZN (2007) Accuracy of parental-

global-impression of children’s acute

pain. Pain Management Nursing 8, 72

–76.

Zisk-Rony RY, Fortier MA, MacLaren-

Chorney J, Perrett D & Zain ZN

(2010) Parental postoperative pain

management: attitudes, assessment

and management. Pediatrics 125,

1372–1378.




The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of

clinically related scholarship which supports the practice and discipline of nursing.

For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://

wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1�316 – ranked 21/101

(Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reports� (Thomson Reuters, 2012).

One of the most read nursing journals in the world: over 1�9 million full text accesses in 2011 and accessible in over

8000 libraries worldwide (including over 3500 in developing countries with free or low cost access).

Early View: fully citable online publication ahead of inclusion in an issue.

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.

Positive publishing experience: rapid double-blind peer review with constructive feedback.

Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley

Online Library, as well as the option to deposit the article in your preferred archive.




children's and parents’ perceptions of postoperative pain management: a mixed methods study

Documents