Hospitalized children's descriptions of their experiences with postsurgical pain relieving methods

International Journal of Nursing Studies 40 (2003) 33–44

Hospitalized children’s descriptions of their experiences with postsurgical pain relieving methods . Tarja Polkki*, Anna-Maija Pietil.a, Katri Vehvil.ainen-Julkunen Department of Nursing Science, University of Kuopio, P.O. Box 1627, 70211 Kuopio, Finland Received 22 October 2001; received in revised form 1 February 2002; accepted 29 April 2002

Abstract The purpose of this study was to describe children’s (aged 8–12 yr) experiences with postsurgical pain relieving methods, and their suggestions to nurses and parents concerning the implementation of pain relief measures in the hospital. The data were collected by interviewing children (N ¼ 52) who were inpatients on a pediatric surgical ward in the university hospital of Finland. Content analysis was used to analyze the data. The children rated the intensity of pain on a visual analogue scale. The results indicated that all of the children used at least one self-initiated pain relieving method (e.g. distraction, resting/sleeping), in addition to receiving assistance in pain relief from nurses (e.g. giving pain killers, helping with daily activities) and parents (e.g. distraction, presence). The children also provided suggestions, especially as it relates to nurses (e.g. creating a more comfortable environment), regarding the implementation of effective surgical pain relief. However, some cognitive-behavioral and physical methods were identified that should be implemented more frequently in clinical practice. Furthermore, most children reported their worst pain to be severe or moderate, which indicates that pain management in hospitalized children should be more aggressive. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Pain relieving methods; Child; Experience; Surgical pain

1. Introduction The experience of pain is common among children undergoing surgery (Gauthier et al., 1998; Palermo et al., 1998; Tesler et al., 1998). Several studies have dealt with the methods of relieving children’s pain during acute, short-term painful procedures (Broome et al., 1994; French et al., 1994; Vessey et al., 1994; Sclare and Waring, 1995; Ebner, 1996) and described the nurses’ viewpoints in children’s pain relief regimen (Caty et al., 1995; Broome et al., 1996; Coffman et al., 1997; Salanter.a et al., 1999). However, the topic of postoperative pain management has not attracted similar interest (Woodgate *Corresponding author. Kallioputaankatu 9, 95420 Tornio, Finland. Tel.: +358-16-431-496.. . E-mail address: tarja.polkki@nic.fi (T. Polkki).

and Kristjanson, 1996a; Rheiner et al., 1998). Furthermore, children’s self-reports would be the most reliable source on how their pain is assessed and managed, due to the individualized nature of the pain experience. It is well documented that children are able to describe their pain and preferred methods of pain relief (Savedra et al., 1982; Ely, 1992; Harbeck and Pederson, . 1992; Bossert et al., 1996; Polkki et al., 1999; Pederson et al., 2000), although the ability to do this is affected by the developmental level of the child. For example, according to Vessey and Carlson (1996) some pain relief strategies, such as hypnosis and imagery, require a certain level of cognitive maturity that is achieved during the school-aged period. This means that at this age it would be appropriate to implement a much broader array of non-pharmacological methods in conjunction with pain medication.

0020-7489/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 3 0 - 5

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T. Polkki et al. / International Journal of Nursing Studies 40 (2003) 33–44 .

The purpose of this study is to describe children’s (aged 8–12 yr) experiences with postsurgical pain relieving methods utilized in the hospital setting. The study describes both the children’s self-initiated pain relieving strategies, as well as the strategies utilized by the nurses and the parents that were deemed to be helpful from the children’s perspective. Furthermore, the purpose is to describe the children’s suggestions to nurses and parents concerning the implementation of effective pain relief measures. The obtained information about children’s self-reports enables better understanding of what helps the children achieve more effective pain management in a hospital setting.

2. Literature review Children’s pain experiences may be reduced by a variety of means. Pharmacological treatment is an obvious source of pain relief, although many studies have indicated that children are frequently under medicated and endure unacceptable levels of pain during hospitalization (Cummings et al., 1996). For example, Gauthier et al. (1998) found that 46% of the children (N ¼ 48) reported having severe pain after surgery and half of the children (51%) were under medicated for postoperative pain. This is similar to the prior research (e.g. Alex and Ritchie, 1992; Johnston et al., 1992; Palermo et al., 1998) which indicated that the majority of children reported experiencing high intensity of pain after surgery, even while receiving analgesics. A variety of non-pharmacological pain relieving methods may be used independently or in conjunction with medication administration (Caty et al., 1995). Several studies have identified the efficacy of nonpharmacological methods of pain relief in hospitalized pediatric patients, such as hypnosis, imagery and distraction (Broome et al., 1994; French et al., 1994; Lambert, 1996; Steggles et al., 1997), as well as cold application (Ebner, 1996) and parental presence (Ross and Ross, 1984; Wolfram and Turner, 1996). Many of the non-drug methods may be administered by the children themselves, but effective relief often requires the assistance of a nurse or parent (Cummings et al., 1996; Vessey and Carlson, 1996). Many studies have examined children’s perceptions regarding what interventions help alleviate pain (Savedra et al., 1982; Ross and Ross, 1984) with a primary focus on children’s self-initiated pain relief strategies (Woodgate and Kristjanson, 1995; Bossert et al., 1996; Campbell and McGrath, 1999; Pederson et al., 2000) or coping strategies to deal with the pain (Ross and Ross, 1984; Ryan, 1989: Alex and Ritchie, 1992; RyanWenger, 1992; Olson et al., 1993; Sharrer and RyanWenger, 1994; Rudolph et al., 1995; LaMontagne et al., 1997; Reid et al., 1997). According to Hester (1993), the

most consistently reported strategies preferred by children have been determined to be medication and parental presence, but unfortunately these strategies often are not under the child’s control. The studies concerning children’s self-initiated strategies indicate that children are able to describe the methods that they themselves use to relieve their pain. For example, Bossert et al. (1996) demonstrated that all of the children with cancer examined in a study (ages 4– 16) were able to describe what interventions helped them manage their pain. This study determined that the most common pain management strategies reported by the children (semistructure interview, N ¼ 20) and parents were rest/sleep, analgesics, rubbing, distraction, social support and application of heat. Campbell and McGrath (1999) discovered that 98% of the adolescents aged 14–21 yr (questionnaire, N ¼ 289) reported using at least one non-pharmacological method (e.g. rest, heat, exercise, rubbing/massage, distraction) to manage menstrual discomfort. Methods perceived as being more than 50% effective in relieving pain were more physically oriented than psychologically oriented methods, but the mean perceived effectiveness of most of these methods was reported to be below 40%. Furthermore, Pederson et al. (2000) demonstrated that several children aged 5–17 undergoing bone marrow transplant (interview, N ¼ 20Þ used non-pharmacological pain relieving techniques such as distraction, play, relaxation tapes, breathing exercises, massage and music. Only a few studies have focused on inquiring about children’s perceptions regarding receiving assistance for pain relief from others (Alex and Ritchie, 1992; Bossert et al., 1996; Cummings et al., 1996; Woodgate and Kristjanson, 1996b; Pederson et al., 2000) or recommendations by children to health care providers concerning pediatric pain relief in the hospital setting (Alex and Ritchie, 1992). However, compiling knowledge especially concerning children’s experiences in receiving assistance for alleviation of pain would be important in order to be able to improve pain management in the pediatric population. The studies concerning children’s perspectives regarding receiving pain interventions provided by others indicate that the most commonly reported nursing action involves administration of analgesia, whereas the parents’ role is usually more psychological in nature. For example, in the study conducted by Woodgate and Kristjanson (1996b), children aged 21/2–61/2 yr (participant observation, interviews, N ¼ 11) were asked questions concerning the type and intensity of pain they had experienced, and what others could do to help stop the pain. ‘‘Taking good care’’ was the most important thing that hospital staff or parents could do for children, and four subcategories of good care were identified as ‘‘Mum and dad be with me’’ (i.e. sitting beside the child, touching, embracing the child) and ‘‘Doing things that

T. Polkki et al. / International Journal of Nursing Studies 40 (2003) 33–44 .

help’’ (i.e. giving the medicine, applying heat and cold). Cummings et al. (1996) also indicated that mothers and nurses were frequently identified as sources of help for pain relief in hospitalized children. In this study parent interviews were used for children o5 yr of age (N ¼ 102), and child interviews were used for children aged 5 yr and older (N ¼ 98). The subjects identified medications and non-pharmacological methods (i.e. talking, repositioning, touch, distraction, food/sleep, healing) as helpful in managing pain; however, the results indicated that pain prevention and management should be more aggressive. In summary, despite this recent surge in research interest, knowledge regarding pain relieving methods from the children’s perspective is limited (cf. Alex and Ritchie, 1992; Cummings et al., 1996). This means that more qualitative research is needed, especially concerning children’s experiences on the help received from nurses and parents during hospitalization, because as Pederson et al. (2000) have identified, children’s selfreports of pain often conflict with assessments of their pain as determined by others. The methods that are perceived by children to be helpful may provide health care workers with further insight and additional strategies to recommend in the relief of surgical pain in pediatric patients.

3. Research questions The following research questions were addressed from the children’s perspective: 1. Which self-initiated pain relieving methods do the children use to manage pain after surgery? 2. Which pain relieving methods described by the children as being effective do nurses and parents use to alleviate the child’s pain after surgery? 3. What suggestions do the children have to nurses and parents concerning the implementation of surgical pain relief measures in the hospital?

4. Method

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Sixty-two percent (N ¼ 32) of the children were male and 38% (N ¼ 20) were female. Their ages ranged from 8 to 12 yr old (M ¼ 10:2; SD=1.3 yr). Most of the children (56%) had previous experiences with hospitalization. Over half of the children (61%) had been admitted on an emergency basis, and the remainder (39%) for elective surgery. The mean length of hospitalization post surgery was 3 days, ranging from 1 to 22 days. Three-fourths of the children (75%) reported experiencing fear regarding their hospitalization. Orthopedic/traumatologic surgeries were the most common surgical procedures among the children (Table 1). The children assessed their worst pain subsequent to the surgical procedure and the present pain during the interview by making a vertical mark on a 10 cm Visual Analogue Scale (VAS). The scale was a single horizontal line with right angle stops at each end, and included the anchors ‘‘no pain’’ and ‘‘worst possible pain’’. The VAS has been identified as a valid and reliable tool in measuring perceptions of pain intensity by school-aged children (Abu-Saad and Holzemer, 1981; Abu-Saad, 1984). The children’s assessments of their pain intensity were defined as no pain (0 cm), mild (0.5–3 cm), moderate (3.5–6.5 cm) and severe (7–10 cm) pain (Alex and Ritchie, 1992). Most of the children reported to have their worst pain during the operative day (57%) or the first day after the operation (39%). The mean worst postoperative pain was 5.5 cm (SD=2.5 cm) and the mean present pain was 1.1 cm (SD=1.3 cm). Fig. 1 indicates that most of the children reported their worst pain to be severe (33%) or moderate (48%) after surgery.

4.2. Data collection The researcher personally interviewed all of the children during their hospitalization on the day of discharge (80%) or the day prior to discharge (20%). The data collection lasted 4 months on average beginning in August 1999, and concluding in December 1999. The researcher met the child and his/her parents before the day of the interview and introduced herself. At the beginning of the interview the researcher talked

4.1. Subjects The subjects consisted of 52 school-aged children who were inpatients in one of the two pediatric surgical wards in the university hospital of Finland. The selected children met the following criteria: (1) they were 8–12 yr old, (2) they were undergoing a surgery under anaesthesia, (3) they were all Finnish speaking, and (4) they had the cognitive ability to respond to the interview questions, which meant that the children in general were able to attend school age appropriately.

Table 1 Hospitalized children’s surgical procedures (N ¼ 52) Classification of surgical procedures

N

%

Orthopedic/traumatology Gastroenterology Urology Plastic surgery Thoracic surgery

30 14 6 1 1

58 27 11 2 2

T. Polkki et al. / International Journal of Nursing Studies 40 (2003) 33–44 .

36

70

60

Percent

50

no pain mild pain moderate pain severe pain

40

30

20

10

0

Worst pain

Present pain

Fig. 1. Children’s assessment of their worst pain and present pain using a 10 cm VAS (N ¼ 52).

about generalities with the child, and clarified the role the child was expected to play during the interview. The child was told that he/she was expected to discuss issues with the researcher that have helped him/her to experience less pain after the surgery, and that there were no right or wrong answers. The interviews took place in the child’s own room or in the ward’s admission room, and they lasted approximately 30–40 min. All interviews were audio recorded and coded so that the participant’s name could not be associated with the information contained on the audiotapes. The children were told that the purpose for taping was that the researcher could recall the children’s experiences without taking notes (Cf. Coyne, 1998; Docherty and Sandelowski, 1999). The parents were not present during the interviews. Each interview began with general demographic questions including the child’s age, sex, surgical procedure, the length of post surgery, the manner of admission to the hospital, possible fears regarding the hospitalization, previous hospitalizations, and the child’s assessment of his/her pain intensity using a 10 cm VAS. This information was filled into the demographic data schedule in which the researcher also marked the field notes of each interview. The interview questions consisted of three themes: (1) children’s selfinitiated use of pain relieving methods, (2) nurses and parents’ use of pain relieving methods as described by the children, and (3) children’s suggestions to nurses and parents concerning the implementation of surgical pain relief measures in the hospital. The use of open-ended questions and then more direct questions as needed enabled the researcher to obtain information on children’s subjective experiences (cf. Docherty and Sandelowski, 1999). For example, the researcher initially asked the child the following: ‘‘What has helped you when you have had pain after the surgical procedure?’’

After this she focused on the themes of the interview such as ‘‘How have nurses helped you when you have had pain after the surgical procedure?’’ This sentence was clarified as needed by more direct questions such as, ‘‘What have the nurses done with you or for you when you have had pain after the surgical procedure?’’ The face-to-face interview allowed clarification and rewording of questions that the children did not understand. The study was pilot tested with five hospitalized children who met the aforementioned study participation criteria. These interviews helped the researcher to clarify the content of the questions by determining more appropriate words and formulating more direct questions as needed in order to establish the child’s ability to understand the questions. Only one child refused to take part in the pilot study: conversely, none of the children refused to participate in the main study. All of the children willingly participated in the main study and had the support of their parents as well when they were provided with sufficient time to make a decision. 4.3. Ethical aspects According to the literature the consent of the parent or guardian is required for all aged children in order to participate in a study, and the child’s assent should be sought for all children aged seven and older (Coyne, 1998; Lindeke et al., 2000). In this study, both the children and their parents were given the consent form at the beginning of the child’s admission. The consent form consisted of information about the main points of the study, while emphasizing the confidentiality and the voluntary nature of participation. The consent form was developed considering the children’s cognitive ability to understand involvement in the study. On the day prior to the interview the children and their parents had an opportunity to discuss the study with the researcher

T. Polkki et al. / International Journal of Nursing Studies 40 (2003) 33–44 .

before deciding to sign the consent form. At the beginning of the interview the researcher clarified the purpose of the interview with the child, and emphasized the confidentiality of the study, while ensuring that the data were collected for the researcher and would not be revealed to the nurses or the child’s parents. Permission to carry out the study was guaranteed by a research committee in the hospital. 4.4. Data analysis The data were analyzed using the method of content analysis (Downe-Wamboldt, 1992; Burns and Grove, 1997; Polit and Hungler, 1999). The first step of this process after reading through the interviews was to identify the unit of analysis, which was defined as complete thought, ranging from one word to several sentences (Downe-Wamboldt, 1992). Secondly, the content of each interview was structured according to the themes (e.g. children’s self-initiated use of pain relieving methods) based on the research questions. After this the similar descriptions (e.g. reading, watching TV/videos, playing games, drawing, doing hobby crafts) were grouped into categories while making comparisons for similarities and differences between each pair of concepts under the themes. The categories were named through the process of abstraction (e.g. distraction) (Fig. 2). Finally, the data of content analysis were quantified within categories: the number of the children’s responses were reported to illustrate how many children responded to an item in a particular way (Cole, 1988; Polit and Hungler, 1999). Descriptive statistics were used as well to summarize the demographic characteristics of the children.

5. Results 5.1. Children’s self-initiated use of pain relieving methods The children reported 13 successful types of selfinitiated pain relieving methods. As shown in Table 2, most of the children reported using distraction, resting/ sleeping, positioning/immobility and asking for pain medication or help from nurses when they experienced pain. The most common methods of distraction by which the children tried to focus their attention away from pain included reading, watching TV/videos and playing games. For example, a 10-yr-old boy described his experiences as follows: ‘‘I have read Donald Duck comicsythis helps me to forget the pain. I can also get my thoughts elsewhere by playing Nintendo games. When I concentrate on

37

Reading through the interviews

Identifying the unit of analysis

Structuring the content of each interview according to the themes

Theme 1: Children’s self-initiated use of pain relieving methods

Theme 2: Nurses’ and parents’ use of pain relieving methods

Nurses’ use of pain relieving methods

Theme 3: Children’s suggestions to nurses and parents

Parents’ use of pain relieving methods

Suggestions to nurses

Suggestions to parents

The similar descriptions were grouped into categories and named through the process of clusteration and abstraction. The following types of categories were formed under each theme:

13 types of self-initiated pain relieving methods

10 types of pain relieving methods utilized by the nurses

14 types of pain relieving methods utilized by the parents

7 types of suggestions to nurses

4 types of suggestions to parents

Fig. 2. The process of data analysis in the study.

playing I don’t have much time to think about anything else’’. (7) Another method of drawing attention away from pain included the use of imagery in which the children reported thinking about some pleasant action/happening (e.g. getting home), important people (e.g. mother/ father, friends) or pets in order to forget the pain. The method of thought stopping was used by only one child. A 12-yr-old boy described this method as follows without utilizing specific replacement thoughts: ‘‘Then I have kept on thinking that I am not hurting, there is no pain, there is no pain’’. (11) Children who used positioning typically associated this method with immobility or restricting movement, as one 12-yr-old girl described after undergoing an appendectomy: ‘‘I have attempted to determine the best possible position to be inyeither on my side or in a crouched position. I have tried to be without moving so that it would not hurt more’’. (15)

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Table 2 Children’s self-initiated use of pain relieving methods after surgery (N ¼ 52) Pain relieving methods

N

%

51 42 27 27 16 11 10 6 4 1 1 1 1

98 81 52 52 31 21 19 12 8 2 2 2 2

‘‘How have you tried to manage pain/what have you done to help yourself when you have had pain?’’ Distraction Resting/sleeping Positioning/immobility Asking for pain medications/help from nurses Imagery Walking/moving/doing exercises Just being and trying to tolerate pain Eating/drinking Relaxation Thought-stopping Breathing technique Thermal regulation (cold application) Urinating often

Table 2 Children’s self-initiated use of pain relieving methods after surgery (N ¼ 52) that a combination of three methods was most All children reported using at least one self-initiated commonly utilized by the nurses. The mean number of pain relieving method. The majority of them claimed to strategies identified was 3.0 with a range of 2–5. use four of these strategies during their hospitalization. The mean number of strategies identified was 3.8 with a range from 1 to 8. 5.3. Parents’ use of pain relieving methods 5.2. Nurses’ use of pain relieving methods The children reported ten successful types of pain relieving methods utilized by the nurses (Table 3). The children reported that nursing actions involving the administration of pain medications, helping them with daily activities, and distraction most often minimized their pain. For example, a 9-yr-old boy described the method of receiving help with daily activities as follows: ‘‘The nurses helped me out of bed in the morning when it is difficult for me to get up. I am entirely lacking in strength. They have brought me food and taken the tray awayythey have brought my urinalyand helped with my morning bath’’. (18) As shown in Table 3 approximately three-fourths of the children reported that the nurses had given them instructions regarding what measures they could implement themselves to alleviate their pain. The most common strategies were the importance of positioning/ immobility after the surgical procedure, and distraction in which the child was instructed about meaningful activities (e.g. playing games, watching TV/videos, reading) that he/she could engage in during hospitalization. All of the children reported that the nurses used at least two pain-relieving methods. The children expressed

The children reported 14 successful types of pain relieving methods utilized by their parents (Table 4). The children described that the methods of distraction, presence, positive reinforcement and helping with daily activities were the most popular strategies how the parents helped them in pain. Positive reinforcement included rewarding the child in a concrete way during the hospitalization or promising to do so after discharge. The children related that their parents had brought them something good to eat (e.g. sweets, ice cream) or had rewarded them by buying something pleasant (e.g. books, toys). For example, one 9-yr-old boy described this method in the following way: ‘‘When I lay in bed suffering my parents have brought me sweets for comfort or something else like a book or other things’’. (40) Seven children reported that their mothers served as advocates by requesting help or pain medications from nurses on behalf of the child. Some children also related that their parents had brought them personal belongings (e.g. bear, magazines) from home in order to create a more comfortable environment. As shown in Table 4, two-thirds of the children expressed that their parents had given them instructions regarding measures they could implement themselves in order to alleviate their surgical pain during hospitalization. The most commonly utilized strategies included

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Table 3 Nurses’ use of pain relieving methods after surgery according to children (N ¼ 52) N

%

50 46 27 16 9 4 3 1 1 1

96 88 52 31 17 8 6 2 2 2

No, they have not given instructions

14

27

Yes, they have given instructions. What instructions were given?

38

73

Distraction Positioning/immobility Walking/moving/doing exercises Resting/sleeping Relaxation Asking for help from nurses Eating/drinking Supporting the wound area Imagery Thought-stopping Breathing technique

24 15 7 6 3 3 2 2 1 1 1

46 29 13 12 6 6 4 4 2 2 2

Pain relieving methods ‘‘How have nurses helped you/what have they done with you or to you when you have had pain?’’ Giving pain killers Helping with daily activities Distraction Inquiring about the child’s condition/need for pain medications Positioning Presence Thermal regulation (cold application) Touch Giving information Changing bandages ‘‘Have nurses given you instructions about what you could do to alleviate your pain?’’

Table 3 Nurses’ use of pain relieving methods after surgery according to children (N ¼ 52) crying children), and making the child’s room more distraction and resting/sleeping, whereby the parents comfortable (decoration, entertainment, equipment, urged the child to engage in some meaningful activities friends). Many of the children also wished that the (e.g. reading, playing games, watching TV/videos), but nurses would have arranged more meaningful activities also to rest or sleep adequately in order to promote for them, either by doing something nice with the child recovery after surgery. (e.g. playing, doing hobby crafts) or offering the child All of the children reported that their parents used at some meaningful things to do. Furthermore, the least one method in order to help alleviate the child’s children wished that the nurses would have given them pain during hospitalization. According to the children’s more or stronger pain medication without delay, descriptions the parents most commonly utilized a because many of them experienced pain, even when combination of four methods. The mean number of receiving pain medication after surgery. strategies identified was 3.7 with a range of 1–6. Ten children reported that the nurses should regularly visit the child’s room or allocate more time to stay with 5.4. Children’s suggestions to nurses and parents the child. For example, an 11-year-old boy described his experiences as follows after orthopedic surgery: Most of the children had suggestions to the nurses concerning the implementation of effective pain relief ‘‘I guess I would have wanted those pain medications measures in the hospital, but only a few had suggestions more often, but I did not always dare to ask for them, to the parents (Table 5). and sometimes I was ashamed to press the call button Creating a more comfortable environment in the since it made such a loud noise and my roommate hospital was the most common suggestion among the was sleeping. I would have liked it if the nurses would children This included such suggestions to the nurses as round every hour so that I would not have to suffer minimizing noise problems (especially those caused by

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Table 4 Parents’ use of pain relieving methods after surgery according to children (N ¼ 52) N

%

51 38 35 32 7 7 5 5 6 3 3 1 1 1

98 73 67 62 13 13 10 10 12 6 6 2 2 2

No, they have not given instructions

17

33

Yes, they have given instructions. What instructions were given?

35

67

Distraction Resting/sleeping Walking/moving/doing exercises Positioning/immobility Imagery Thought-stopping Informing others when in pain/asking for help from nurses Taking pain medication Obeying the nurses

18 10 7 6 3 1 1 1 1

35 19 13 12 6 2 2 2 2

Pain relieving methods ‘‘How have parents helped you/what have they done with you or to you when you have had pain?’’ Distraction Presence Positive reinforcement Helping with daily activities Inquiring about the child’s condition/need for pain medications Advocating for the child Positioning Touch Arranging a comfortable environment Massage Comforting Thermal regulation (cold application) Asking the child for preferred pain relief method Giving information ‘‘Have parents given you instructions about what you could do to alleviate your pain?’’

Table 4 Parents’ use of pain relieving methods after surgery according to children (N ¼ 52) . tric patients (Savedra et al., 1982; Polkki et al., 1999; from the pain because I didn’t dare to use the call Pederson et al., 2000). In order to achieve the children’s button. I could have told my father, but it was own perspective, however, the children should be asked already eleven o’clock and he wasn’t with me about the methods that could potentially alleviate their anymore’’. (31) pain, as well as their suggestions regarding the Only a few children had suggestions to the parents implementation of pain relief measures. Due to their concerning surgical pain relief measures in the hospital tendency to be independent, school-aged children may (Table 5). The most common suggestion among the conceal their pain and be reluctant to request help from children was simply the following: ‘‘Mum and dad, please others (cf. Lutz, 1986; Woodgate and Kristjanson, stay with me more’’. 1995). This phenomenon in the children requires specific attention, despite the fact that a certain level of cognitive maturity is achieved during the school-aged period, and a much broader array of non-pharmacological methods 6. Discussion are appropriate to use at this age (Vessey and Carlson, 1996). 6.1. Relevance of the results to nursing practice The children in this study reported using at least one self-initiated pain relieving method. Almost all of them This interview study indicated that hospitalized admitted to using distraction and resting/sleeping, which children, aged 8–12 yr old, are capable of describing are also commonly used strategies identified in other the methods for relieving their pain. The results are studies involving children (Bossert et al., 1996; Campbell consistent with earlier studies conducted among pedia-

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Table 5 Children’s suggestions to nurses (N ¼ 41) and parents (N ¼ 13) concerning the implementation of surgical pain relief measures Suggestions

N

%

16 15 13 10 8 7 6

31 29 25 19 15 13 12

11 1 1 1

92 8 8 8

‘‘What suggestions do you have to nurses/how could they alleviate your pain better?’’ Creating a more comfortable environment Arranging more meaningful activities Giving more/stronger pain medication without delay Visiting regularly/staying with the child more Familiar, friendly nurses, who offer good treatment ‘‘Getting home’’ Better food services ‘‘What suggestions do you have to parents/how could they alleviate your pain better?’’ Staying with the child more Arranging meaningful activities Helping the child according to his/her wishes Having an opportunity to give pain medications

Table 5 Children’s suggestions to nurses (N ¼ 41) and parents (N ¼ 13) concerning the implementation of surgical pain relief used at least one method. Almost all of the children and McGrath, 1999; Pederson et al., 2000). Watching related that administering pain medication and helping TV/videos, reading, and playing games were the most with daily activities were the methods most frequently popular ways of focusing the child’s attention away used by nurses to relieve their pain. Conversely, the from the pain according to the children’s descriptions. methods of distraction, presence, positive reinforcement The nurses and parents also most often provided and helping with daily activities were the most popular instruction to the children regarding the use of distracmethods used by the parents according to the children’s tion. Only some children reported using cognitivedescriptions. While 38 children reported that the behavioral methods such as imagery, relaxation and presence of their mother/father helped them to feel less breathing techniques, as well as some physical methods pain, only four children reported that this strategy was such as cold application, even though many of these implemented by nurses. This may be explained by the methods have been tested to be effective in children’s nurses’ lack of time to sit beside the child, but also by pain relief (Broome et al., 1994; Ebner, 1996; Lambert, different roles between the nurses and the parents in a 1996; Pederson, 1996; Peretz and Gluck, 1999). It is child’s care. On the whole the parents seemed to provide interesting to note that the parents and nurses instructed more emotional support to their hospitalized children the children less often or not at all about the use of the than the nurses. According to the study by Woodgate above techniques despite their efficacy, which may and Kristjanson (1996a), nurses primarily provided explain the minimal use of these strategies among the technical care for hospitalized young children experienchildren. The reasons for the nurses’ and parents’ lack of cing pain from surgical interventions, whereas care providing instructions to the children on certain provided by parents included comfort measures and evidence-based non-pharmacological techniques could vigilant monitoring of the children’s pain. In this study potentially be due to the following: the lack of knowlthe children also reported that the parents used some edge regarding how to use the techniques in children’s pain relieving methods (e.g. positive reinforcement, pain relief, or lack of time or resources to teach these creating a comfortable environment and massage) that techniques to the children especially concerning the use the nurses did not use to promote the child’ pain relief. of imagery, relaxation and breathing techniques (cf. Many children had suggestions to the nurses, but only Woodgate and Kristjanson, 1996a; Rheiner et al., 1998; . a few to the parents concerning the implementation of Polkki et al., 2001). In any case, the results of this study surgical pain relief measures. This may indicate that the indicate that health care providers should give more children expect the nurses to know how to care for them guidance about the use of various pain relieving and relieve their pain (cf. Alex and Ritchie, 1992), methods to hospitalized children, thereby providing whereas the children do not have specific expectations of the children with options for the most effective pain their parents other than simply to ‘‘stay with me more’’. relieving methods for their individual needs. In order to improve nursing care for children with All of the children reported that the nurses had used postoperative pain the recommendations provided by at least two pain-relieving methods and that parents

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children to the nurses, such as creating a more comfortable environment (especially minimizing noise problems), giving more or stronger pain medication without delay, as well as visiting regularly or staying with the child more, should be taken seriously into account in nursing practice. 6.2. Reliability and validity Use of the interview as a data collection method allowed the children to express their own perspectives regarding the methods of relieving their pain in the hospital; however, there were some defects that may potentially prevent the attainment of this purpose. First, some children may have tried to provide favorable answers during the interview even though the researcher reminded them that there were no right or wrong answers. Secondly, there were practical problems that may have disturbed some children’s ability to concentrate on relating their experiences. For example, practical issues independent of the researcher included conducting the interviews just prior to the child’s discharge, and use of the unfamiliar hospital room as the place for conducting the interviews. An interesting question is whether the results would have been different if the children had been asked open-ended questions as opposed to forced-choice questions regarding the methods of pain relief (cf. Branson et al., 1990). The use of triangulation, such as observing the children during their hospitalization, may have increased the validity of the results. Talking with the children after the data had been analyzed may also have increased the validity of the results (face-validity) (Downe-Wamboldt, 1992; Polit and Hungler, 1999). However, the children were asked during the interview to clarify unclear responses by questioning such as ‘‘What do you mean by this’’ or ‘‘Could you tell me more about this’’. The researcher also often summarized or paraphrased the responses to the children at the end of each theme in order to make valid interpretations of the data. In order to improve the validity and reliability of the study the researcher attempted to establish a confidential relationship with the child and minimized noise problems during the interview. The researcher personally collected and analyzed the data, and coded the formed categories three times at 1-month intervals (intrarater reliability). The discrepancies in the categories were resolved through discussion with two independent researchers (panel of experts). The data were quantified, which is justified in the use of content analysis, in order to give the reader a tangible basis for assessing what the analyst claims are the important patterns in the data and improve on impressionistic judgements of the frequencies of categories (Morgan, 1993). The validity of the formed categories in this study was supported by previous relevant research in the area

of pain relieving methods in pediatric patients (DowneWamboldt, 1992). 6.3. Challenges for future research This study provided new information regarding the implementation of pain relieving methods from the children’s perspective in a hospital setting; however, more research is required in this area in order to validate and expand on the discoveries of this study. More research is required on the children’s experiences regarding help received from nurses and parents for relieving pain. Also, it would be interesting to investigate the roles of the other family members and friends in the child’s pain relief. One of the challenges for future research is to test effective interventions for surgical pain relief in pediatric patients, which should not be restricted only to the non-pharmacological methods implemented by nurses in the hospital.

7. Conclusions This study indicated that hospitalized children, aged 8–12 yr old, are capable of describing the methods for relieving their pain, as well as providing recommendations regarding the implementation of effective surgical pain relief measures. This means that the children should be actively involved with the planning and implementation of their pain management regimen in the hospital. Furthermore, children, parents and nurses should more frequently utilize some cognitive-behavioral pain relieving methods, such as imagery, relaxation and breathing techniques, as well as some physical methods, such as cold-application and massage. Most children reported their worst pain to be severe or moderate, which indicates that pain management in hospitalized children should be more aggressive.

Acknowledgements The authors would like to thank the Emil Aaltonen Foundation for providing funding for this research, and the nursing staff of the university hospital in Finland for their assistance in data collection. Special appreciation is extended to the children who willingly participated in the study, and the parents who supported their children in this decision.

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