4 Children and Parent Perseptions of Post Op

CLINICAL ISSUES
Childrens and parents perceptions of postoperative pain

management: a mixed methods study
Alison Twycross and G Allen Finley
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
2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 22, 30953108, doi: 10.1111/jocn.12152
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
3095
A Twycross and GA Finley
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 childrens pain is not managed effectively

The complexity of assessing pain explains, at least in part,
why management remains suboptimal. Nurses struggle to
reconcile childrens 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 considered by nurses when assessing childrens 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 synonymous with administering analgesic drugs alone and may
not see the need to evaluate the effectiveness of interventions 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 comfortable (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 complain. Nurses aims may adversely impact on care.
Parents beliefs may also affect their childs pain management. 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 childs pain care even if the child experiences moder-
3096
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.
Childrens and parents views about the quality of pain

management
Childrens views on how well their pain was managed have
been explored in only a few studies. Children reported having difficulty convincing healthcare professionals they were
in pain (Carter 2004, Kortesluoma et al. 2008) and suggested nurses needed to take a more active role in pain
management. Nurses should, for example, discuss childrens pain management with them more often (He et al.
2007, Twycross & Collis 2012) and administer more analgesic 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 meaningful things to do to distract them from their pain (Polkki
et al. 2003).
Parents have indicated their involvement in their childs
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 childs pain management (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 provided 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 childrens and parents
perceptions of postoperative pain management.
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.

Journal of Clinical Nursing, 22, 30953108
Clinical issues
Pain management: children and parents perceptions
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).
Data collection tools

An adapted draw-and-write technique was used with younger 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 (010) 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 for

draw 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).
Children opting for

semi-structured
interview
Opening question:
Tell me what
happened when you
were in pain.
Prompts used as
necessary.
Children writing
answers to
interview questions
Same format as for

semi-structured
interviews except
children where given
a pen and paper to
write down
their responses.
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.
Figure 1 Procedure for different interview

strategies.

Asked:
What was the worst
pain you had while
you were in hospital?
3097
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 childs 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 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.
Construct validity of the tool has been demonstrated

previously through selected interitem relationships, and
the psychometric analyses support the initial measurement properties of the instrument (Foster & Varni
2002).
Procedure
Parents were asked to complete the questionnaire on the second 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 units reception
desk.
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.
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.
3098
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.
Figure 2 Process of consent.

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.
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 1530 minutes.
My pain while in hospital
Children were asked to indicate on a scale of 010 what their
worst pain had been postoperatively (Table 2; Fig. 3). In this
study, mild pain was considered to equate with a pain intensity score of 13, moderate pain to a score of 46 and severe
pain to a score of 710. This decision was made taking into
account the findings of studies on childrens perceptions
of bearable pain postoperatively (Gauthier et al. 1998,
Demyttenaere et al. 2001, Birnie et al. 2011).
10%
10%
Mild pain
Moderate pain
Parents perceptions
Severe pain
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
childs pain care. As only 10 parents completed the questionnaire, minimal statistical testing was carried out.
80%
Figure 3 Children experiencing mild, moderate and severe pain

postoperatively (n = 10).
Table 2 Childrens worst pain postoperatively (n = 10)
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
Table 1 Demographic data (n = 10)

Age
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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Table 3 Who asked children about their pain (n = 7)
They [the nurses] would do anything they could. (Case 8)
Response
Number
The nurses were great at minimising pain as much as possible. (Case 1)
Parents
Nurses
Doctors
2
7
5
I dont 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
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 110. 10 being
the worst. (Case 8)
They used the 110 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:
around. Everyone was super nice and friendly. (Case 8)

Thank you all [the nurses] for your nice work from [childs 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 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
Its not really been taken care of its excruciating. (Case 3)
you would like them to?
Four other children indicated they were given pain

medications:
Child: I guess (hesitantly). It got kinda of annoying after a while.
The nurses asked me if I wanted tylenol [paracetamol] or morphine
Child: After the first few times
and which ever, they gave to me. (Case 5)
Interviewer: Why was it annoying?
Interviewer: Im quite interested about the fact that it got a bit
Gave pain medicines. (Case 6)
annoying to be asked about your pain
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
A nurse would give me ice pack or medicine, unless I asked for
I was trying to sleep so thats probably why it was annoying..
something in particular. (Case 1)

Interviewer: So you didnt like them waking you up?
They asked if I needed like pain medication or some kind of warm
blanket. (Case 7)
As five (625%) 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.
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)
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).
Figure 4 Drawing (Case 2).
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
Did the nurses or doctors

talk to you or your child
about the treatment of
pain after surgery? (n = 10)
9
0
1
Cant remember
Was the information

easy to understand?
(n = 9)
9
0
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:
When nurses or doctors talked

to parents/child about pain
management (n = 10)
Number
Before surgery
After surgery
1
0
Both times
Couldnt remember
8
1
How information about

pain was provided (n = 9)
Someone talked to me
I was given something
to read
Video
Other
Number
8
4
0
1 (informed by
doctors and nurses)
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Table 6 Parents perceptions of childs response to pain medications (n = 10)
Response
Yes
No
Other
response
Did the pain

medicine take
away most of
your childs
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?
10
0
1
9
1
9
5
5
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
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
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
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
3102
Did it take a long

time for pain
medication to
work?
0
9
1
Depends on
circumstances
Did the pain medicine

make your child feel
sleepy?
1
8
1
Hard to tell
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

childs 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 3060 minutes for
pain medications; other negative responses are from the
parent who sought out the researcher to discuss their dissatisfaction with the pain care.
Additional comments from parents. Seven of the 10 parents included comments on their childs pain management
in the space provided at the end of the questionnaire. Similar responses were grouped together, and the key findings
are presented below. Two parents commented on the quality of nursing staff:
[The nurses] were wonderful with [childs name]. Talked to her not
us (parents) to get the pain information. They checked on her constantly 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 its 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:

Clinical issues
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?
All the time
Quite a bit of the time
Once in a while
Never
Table 10 Parental satisfaction with pain after surgery (n = 10)

Response
Number
Very dissatisfied
Dissatisfied
Satisfied
Very satisfied
1
0
1
8
Table 11 How we could get an A+ for pain management (n = 10)
Response
Number
(%)
Better explanation of pain control method

Better pain relief
Faster pain relief
Using other methods of pain relief
Give parents and children more of a say in pain relief
Everything was fine, no improvement needed
1
1
1
1
1
8
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 childrens and parents ratings of

worst pain
Parents ratings of pain can only be considered estimates of
their childs pain (Zhou et al. 2008, Royal College of
Nursing 2009). Parents and childrens ratings of the worst
pain experienced were therefore compared using Wilcoxons statistical tests. No statistically significant difference
was found between childrens perceptions of the worst pain
they had experienced postoperatively and parents perceptions of their pain when lying in bed (z = 0460,
Number
When your child needed

more pain medicine, how
long did it take to get it?
Number
0
1
6
3
<5 minutes
530 minutes
3060 minutes
More than one hour
7
1
2
0
p = 06454) and when moving or out of bed (z = 0621,

p = 05349).
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.
Childrens 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
childrens ratings of pain. The results of this study add to
the picture of pain management obtained from other studies demonstrating that a significant number of children
experience moderate to severe pain while in hospital (Taylor et al. 2008, Shrestha-Ranjit & Manias 2010, Kozlowski et al. 2012, Twycross & Collis 2012). It is clear that
despite the evidence to guide practice being readily available, childrens pain is not being managed effectively.
Given the consequences of unrelieved pain, this is of concern. Indeed, emerging research demonstrating that mismanaged 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
3103
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.
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 finding that most children were asked about their pain is interesting given the results of other studies that indicated pain
assessments are not carried out consistently or always documented (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 (Johnston 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 childrens 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 childrens
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 preferences are taken into account. This may overcome at least
some of the issues currently being debated about the importance that should be attributed to childs self-report of pain
when making treatment decisions (Vincent et al. 2011,
Voepel-Lewis 2011).
logical methods. This conforms to what would be

expected under current best practice guidelines (Association 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 perhaps 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 prescribed 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). Participants 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 paediatric acute settings in eight hospitals in Canada (Estabrooks et al. 2011). The impact of unit culture in this
context needs further exploration.
Childrens 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 preoperatively. 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 preoperatively about the pain they will experience (Smith & Callery 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.
Response to reports of pain
Satisfaction with pain management
When children had pain, they reported being given pain

medications, with some of them also using nonpharmaco-
On the whole, children and parents were satisfied with the

care provided despite many of them experiencing moderate
3104

Clinical issues
to severe pain postoperatively. Similar findings have been

obtained in other studies (Twycross & Collis 2012, Vincent 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 childs 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
childrens pain, as well as parents reporting they would
like their childs 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 27% 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). Childrens 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.
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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CLINICAL ISSUES

Childrens and parents perceptions of postoperative pain

2013 John Wiley & Sons Ltd

A Twycross and GA Finley

Reasons childrens pain is not managed effectively

Childrens and parents views about the quality of pain

2013 John Wiley & Sons Ltd

Pain management: children and parents perceptions

Data collection tools

Children opting for

Children opting for

Same format as for

Figure 1 Procedure for different interview

2013 John Wiley & Sons Ltd

A Twycross and GA Finley

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

Construct validity of the tool has been demonstrated

Posters placed in key places on surgical floor

Figure 2 Process of consent.

2013 John Wiley & Sons Ltd

Pain management: children and parents perceptions

data pertaining to the worst pain children had experienced

Data collected from the questionnaire completed by parents

Figure 3 Children experiencing mild, moderate and severe pain

Table 2 Childrens worst pain postoperatively (n = 10)

Table 1 Demographic data (n = 10)

2013 John Wiley & Sons Ltd

A Twycross and GA Finley

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

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

I dont really know, they do a good job already. (Case 5)

Three participants indicated the nurses and hospital were

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

What happened when I was in pain. When discussing

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

Its not really been taken care of its excruciating. (Case 3)

you would like them to?

Four other children indicated they were given pain

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

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

Child: After the first few times

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

Interviewer: Why was it annoying?

Interviewer: Im quite interested about the fact that it got a bit

Gave pain medicines. (Case 6)

annoying to be asked about your pain

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

I was trying to sleep so thats probably why it was annoying..

something in particular. (Case 1)

As five (625%) of the eight children interviewed had had

Child: Yeah, yeah

A lack of preparation preoperatively was apparent for

2013 John Wiley & Sons Ltd

Pain management: children and parents perceptions

Figure 4 Drawing (Case 2).

Did the nurses or doctors

Was the information

2013 John Wiley & Sons Ltd

When nurses or doctors talked

How information about

A Twycross and GA Finley

Did the pain

Were you worried that

Did your child