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Children's pain on the first post-operative day Miller, Lori-Mae 1990

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CHILDREN'S PAIN ON THE FIRST POST-OPERATIVE DAY by LORI-MAE MILLER B . S . N . , The Univers i ty of B r i t i s h Columbia, 1983 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept th i s thes is as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA Ju ly 1990 © Lori-Mae M i l l e r , 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of A / C / A S / I J 6 The University of British Columbia Vancouver, Canada DE-6 (2/88) i i ABSTRACT CHILDREN'S PAIN ON THE FIRST POST-OPERATIVE DAY A review of the l i t e r a t u r e i d e n t i f i e d that few research studies have been published which examined the post-operative pain of children, p a r t i c u l a r l y those between the ages of 4 and 7 years. As a r e s u l t , t h e o r e t i c a l l i t e r a t u r e has been the major contributor to the understanding of the concept of children's post-operative pain. Therefore, the purpose of this study was to describe the post-operative pain of hospitalized children aged 4 to 7 years on the f i r s t post-operative day, through a self-reported measure of pain in t e n s i t y levels as well as descriptions of the children's overt behaviours used to express pain. Data were gathered on the pain i n t e n s i t y levels (using the PCT) and overt behaviours of 11 children between the ages of 4 and 8 years on the f i r s t post-operative day between the hours of 0800 and 2000. In addition, data regarding parental presence and the administration of analgesics were also collected for these children. Findings related to pain i n t e n s i t y scores provided the basis for three important conclusions. F i r s t , a l l of the children were able to place a value on their pain using the PCT. Second, a l l of the children were experiencing some degree of post-operative pain possibly related to the lack of consistent administration of analgesia. Third, parental presence did not influence the pain intensity scores reported by the children. i i i F i n d i n g s r e l a t e d to the overt behaviours e x h i b i t e d by c h i l d r e n a l s o provided the b a s i s f o r three important c o n c l u s i o n s . F i r s t , the most frequent behaviours i d e n t i f i e d were not those normally a s s o c i a t e d with f e e l i n g s of p a i n . The r e s e a r c h e r b e l i e v e d that t h i s lack of expected response was as a r e s u l t of the c h i l d r e n ' s a b i l i t y to adapt and cope with the p a i n . Second, b e h a v i o u r a l measurement of pain may not be a r e l i a b l e and v a l i d measure of p o s t - o p e r a t i v e p a i n . T h i r d , p a r e n t a l presence or absence d i d not i n f l u e n c e the overt behaviours e x h i b i t e d . iv TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS iv LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i CHAPTER ONE - Introduction 1 Background to Problem 2 Problem Statement 3 Purpose 3 Research Questions 3 Def i n i t i o n of Terms 4 Conceptual Framework 5 Assumptions 8 Summary 9 CHAPTER TWO - Literature Review 10 Childhood Pain 10 Predisposing Factors 11 Cognitive Development 11 Cognitive development and pain , perception 13 Situational Factors 14 Situat i o n - S p e c i f i c Child Factors 15 Environmental Non-Social Factors 15 Environmental Social Factors 16 Parental presence 16 Pharmacological pain management 19 Summary 24 Pain Assessment 24 Self-Report Pain Scales 24 Behavioural Assessment 26 Cognitive Development and Behaviour .... 27 Parental Presence and Behaviour 28 Conclusion and Summary 31 CHAPTER THREE - Study Methods 33 Study Methods 33 Study Design 33 Setting 34 Sample Selection 34 Method 34 Selection C r i t e r i a 34 Selection Procedure 37 Pre-Operative Selection 37 V Page Post-Operative Selection 39 Data Co l l e c t i o n 41 Overt Behavioural Observations 43 Pain Intensity Scores 44 Data Analysis 47 Pain Intensity Scores 47 Overt Behaviours 47 Demographic and Other Data 48 Et h i c a l Considerations: Protection of Human Rights 48 Limitations 49 Summary 51 CHAPTER FOUR - Research Findings and Discussion ... 52 Summary of Demographic Data 52 Age 53 Types of Surgery 53 Type and Route of Analgesic 53 Post-Operative Analgesia 53 Pain Intensity Scores: Findings 54 Discussion of Findings 57 Overt Behaviours: Findings 61 Vocalization and Verbal Behaviours 61 Fa c i a l Expressions 62 Motor A c t i v i t y 62 Child's A c t i v i t y 62 Overt Behaviours and Parental Presence 62 Discussion of Findings 64 Summary 66 CHAPTER FIVE - Summary, Implications, and Recommendations 68 Summary 68 Implications for Nursing Practice 70 Implications for Nursing Research 72 Recommendations 73 Recommendations for Nursing Practice & Education 73 Recommendations for Nursing Research 73 Conclusion 74 REFERENCES 7 5 Appendix A: Parental Consent Form 79 Appendix B: Doctor's Letter 80 Appendix C: Staff Letter 81 Appendix D: Pre-Operative Data Co l l e c t i o n Form .... 82 v i Appendix E: Post-Operative Data Co l l e c t i o n Form ... 83 Appendix F: D e f i n i t i o n of Terms of Behavioural Checklist 84 Appendix G: UBC Ethics Approval 86 v i i LIST OF TABLES Table I Frequency of Intens i t y Children's Scores Pain Page 55 Table II Frequency of Children's Pain Intensity Scores and the Number of Hours Since Last Analgesic Table III Frequency of Children's Pain Intensity Scores During Parental Presence and Absence 56 57 Table IV Frequency of Children's Exhibited Overt Behaviours 63 v i i i ACKNOWLEDGEMENTS Although i t often seemed to me that t h i s thesis would never be completed, personal perseverance and the assistance of others has f i n a l l y made i t so. I would l i k e to thank the Research Review Committees and the Nursing Departments of RCH and BH, in particular Jan Radford and Mrs. Wilensky, for their support and encouragement of this research project. Their understanding of the need for nursing research restored my waning f a i t h and b e l i e f about the future of nursing and nursing research. Thanks to my thesis committee members, Helen E l f e r t and Betty Davies, for providing the guidance to help me through the thesis process. To Helen, a special thank-you for supporting me 100% when others might have l e f t me to defend myself against those whose b e l i e f s about nursing d i f f e r e d with my b e l i e f s . I ' l l always be grateful to you. To my parents, I thank them for their never ending support and encouragement. F i n a l l y , for the friend who never complained about having to read and edit a l l my papers and most importantly this thesis, and who accepted payment in the form of cheesecakes, I thank-you, Inger. 1 CHAPTER ONE Introduction This is the report of a study which sought to describe the pain in tens i ty l eve ls and overt behaviours of hosp i ta l i zed ch i ldren aged 4 to 7 years on the f i r s t post-operative day. McCaffery (1972) states that "pain is whatever the experiencing person says i t i s , ex i s t ing whenever he says i t does" (p. 8). Nowhere is th i s statement more important than with c h i l d r e n . For too long, health care profess ionals have been guided by the misconceptions that ch i ldren e i ther do not experience pain or that they recover qu ick ly from pain (Eland & Anderson, 1977). These statements are now being recognized for what they are: myths. Chi ldren do experience pain; the questions that remain are: how much pain do ch i ldren experience, and how do they behavioural ly express that pain? Unfortunately , the l i t e r a t u r e y i e lds l i t t l e research examining these questions, p a r t i c u l a r l y , regarding post-operative pa in . Consequently, th i s study was designed to begin to address these questions about c h i l d r e n ' s post-operat ive pa in , by turning to the c h i l d r e n themselves for answers. This chapter introduces th i s research study through a descr ip t ion of the background to the problem, followed by the problem statement, an i d e n t i f i c a t i o n of the purpose of the study and the s p e c i f i c research questions addressed, a d e f i n i t i o n of s p e c i f i c terms, an explanation of the conceptual framework guiding th i s research, and f i n a l l y the 2 i d e n t i f i c a t i o n of assumptions which influence th i s research pro jec t . Background to Problem Post-operative pain is one of the most common types of acute pain experienced by ch i ldren (Beyer & L e v i n , 1987). However, despite the prevalence of post-operative pa in , the experience of th i s pain by ch i ldren is not well understood. In fac t , the researcher's review of published l i t e r a t u r e i d e n t i f i e d only l imi ted research in th i s area by health care profess iona l s . A consequence of th i s lack of research has been that health care profess iona l s , p a r t i c u l a r l y nurses, r e l y upon a combination of personal b e l i e f s , myths, and outdated, inadequate knowledge based on research of adul t s , to guide the i r care for ch i ldren experiencing acute post-operative pa in . Recent studies involv ing ch i ldren now s e r i o u s l y question th i s care , p a r t i c u l a r l y in the area of pain r e l i e f af ter surgery (Beyer, DeGood, Ashley, & R u s s e l l , 1983; Burokas, 1985; Eland, c i t e d in Eland & Anderson, 1977). S p e c i f i c a l l y , they conclude that nurses are under-medicating ch i ldren for pain af ter surgery. However, th i s conclusion is based on the amount of prescribed analgesics administered to ch i ldren pos t -operat ive ly in the s tudies , rather than an assessment of the r e l a t i o n s h i p between analgesia given and c h i l d r e n ' s reports of the i r l eve l of pain i n t e n s i t y . Therefore, these studies cannot a c t u a l l y claim that c h i l d r e n are suf fer ing undue discomfort . However, they c l e a r l y i d e n t i f y a need for a d d i t i o n a l research to understand 3 c h i l d r e n ' s p o s t - o p e r a t i v e p a i n and p a r t i c u l a r l y i t s i n t e n s i t y , i n order to draw c o n c l u s i o n s about the g e n e r a l care of c h i l d r e n p o s t - o p e r a t i v e l y and, more s p e c i f i c a l l y about p a i n r e l i e f . Problem Statement Pain i s n a t u r a l l y a s s o c i a t e d with s u r g e r y but r e l i e f from t h i s p a i n i s a l s o a n a t u r a l expectation-. However, i n order to make a judgement about pain r e l i e f , h e a l t h care p r o f e s s i o n a l s must have an understanding of c h i l d r e n ' s p o s t - o p e r a t i v e p a i n . T h i s understanding must i n c l u d e the l e v e l s of pain i n t e n s i t y r e p o r t e d by c h i l d r e n as w e l l as the c h i l d r e n ' s b e h a v i o u r a l e x p r e s s i o n s of t h a t p a i n . A review of the p u b l i s h e d l i t e r a t u r e has i d e n t i f i e d o n l y a l i m i t e d number of s t u d i e s t h a t a c t u a l l y d e s c r i b e these v a r i a b l e s . T h e r e f o r e , more r e s e a r c h to d e s c r i b e the pain experienced by c h i l d r e n p o s t - o p e r a t i v e l y i s imperative so t h a t f u r t h e r r e s e a r c h can be conducted i n the area of p a i n r e l i e f i n c h i l d r e n . Purpose The purpose of t h i s study i s to d e s c r i b e the p o s t - o p e r a t i v e pain of h o s p i t a l i z e d c h i l d r e n aged 4 to 7 years on the f i r s t p o s t - o p e r a t i v e day, through s e l f - r e p o r t e d measures of pain i n t e n s i t y l e v e l s as w e l l as d e s c r i p t i o n s of the c h i l d r e n ' s o v e r t behaviours used to express p a i n . Research Questions 1. What are the l e v e l s of p a i n i n t e n s i t y r e p o r t e d on the f i r s t p o s t - o p e r a t i v e day by h o s p i t a l i z e d c h i l d r e n aged 4 to 7 4 years who have undergone s u r g i c a l procedures? 2. What are the overt behaviours e x h i b i t e d at the time of pain i n t e n s i t y l e v e l measurement on the f i r s t p o s t - o p e r a t i v e day by h o s p i t a l i z e d c h i l d r e n aged 4 to 7 years who have undergone s u r g i c a l procedures? D e f i n i t i o n of Terms The f o l l o w i n g d e f i n i t i o n s w i l l be expressed i n (a) t h e o r e t i c a l and (b) o p e r a t i o n a l terms when a d i f f e r e n t i a t i o n i s r e q u i r e d . 1. L e v e l s of P a i n I n t e n s i t y (a) the p e r c e p t i o n of the magnitude of p h y s i c a l d i s c o m f o r t a r i s i n g from noxious s t i m u l i ( d e f i n i t i o n based on the t h e o r y of pain by Melzack and Wall, 1983). (b) a designated c o l o u r and number of poker c h i p s . (The Poker Chip Tool) (Beyer & Aradine, 1988). 2. F i r s t P o st-Operative Day (a) the f i r s t day a f t e r the day of surgery. (b) from 0800 to 2000 on the f i r s t day a f t e r the day of s u r g ery. 3. H o s p i t a l i z e d C h i l d r e n Aged 4 to 7 Years (b) any c h i l d aged 4 to 7 years who i s admitted to h o s p i t a l f o r surgery and who i s r e q u i r e d to remain i n h o s p i t a l no l e s s than 2 days a f t e r s u r gery. 4. S u r g i c a l Procedures (a) manual and o p e r a t i v e procedures f o r the c o r r e c t i o n of d e f o r m i t i e s and d e f e c t s , the r e p a i r of i n j u r i e s , and the d i a g n o s i s and cure of c e r t a i n d i s e a s e s 5 (Taber 1 s Cyclopedic Medical D ic t ionary , 1977). (b) any s u r g i c a l procedure conducted under general anesthesia that requires a hosp i ta l stay of no less than 2 days pos t -operat ive ly , but does not require admission to the Intensive Care Uni t . 5. Overt Behaviours (b) observable behavioural a c t i v i t i e s of the c h i l d which include: ( i ) Voca l i za t ions - a l l emitted sounds which are not language or are incomprehensible to an observer (McCaffery, 1972). ( i i ) Verbal - a l l emitted sounds which are language and comprehensible (McCaffery, 1972). ( i i i ) F a c i a l Expressions - the state of the forehead, eyes, and jaw muscles (McCaffery, 1972). ( iv) Motor A c t i v i t y - a l l body movement and muscle tone (McCaffery, 1972). (v) C h i l d ' s A c t i v i t y - those phys ica l a c t i v i t i e s in which the c h i l d is involved at the time of observat i on. Conceptual Framework Schechter (1985) states that pain is general ly ascribed with two components. The f i r s t component i s the sensation of pain , which is the "neurophysiologic message which acts as a warning and t e l l s us t i ssue damage is taking place" (Schechter, 1985, p. 8). The second component is the perception or experience of pa in , which is bel ieved to be 6 r e l a t e d to s o c i a l and p s y c h o l o g i c a l f a c t o r s of the i n d i v i d u a l . Consequently, any understanding of the concept of acute p o s t - o p e r a t i v e pain experienced by c h i l d r e n must i n c o r p o r a t e these two components. T h e r e f o r e , the conceptual framework f o r t h i s study i s based upon concepts from the Revised Gate C o n t r o l Theory of Pain (Melzack & Wall, 1983), which attempts to i n t e g r a t e the p h y s i o l o g i c a l and p s y c h o l o g i c a l components i n t o the hypothesis of pain (Whidden & F i d l e r , 1977). Pain a r i s e s from i n j u r y which may i n v o l v e a c t u a l or p o t e n t i a l t i s s u e damage (Bonica, 1979). In t h i s r e s e a r c h p r o p o s a l , the source of pain w i l l be the t i s s u e damage caused by surgery. In t h e i r Revised Gate C o n t r o l Theory of P a i n , Melzack and Wall (1983) b e l i e v e t h a t t h i s i n j u r y produces s i g n a l s which are t r a n s m i t t e d v i a c e r t a i n n o c i c e p t o r s (the s m a l l diameter f i b e r s known as A - d e l t a and C f i b e r s ) to the d o r s a l horns of the s p i n a l cord, where they then a c t i v a t e the t r a n s m i s s i o n c e l l s (T c e l l s ) t h a t w i l l p r o j e c t the s i g n a l s to the b r a i n . However, n e u r a l mechanisms i n the d o r s a l horns of the s p i n a l cord a c t l i k e a gate to modulate the flow of nerve impulses from these n o c i c e p t o r s to the c e n t r a l nervous system. The degree to which the gate modulates t h i s t r a n s m i s s i o n i s i n f l u e n c e d by the amount of a c t i v i t y i n the l a r g e diameter f i b e r s known as A-beta, and the s m a l l diameter f i b e r s ( A - d e l t a and C). S p e c i f i c a l l y , a c t i v i t y i n the A-beta f i b e r s i n h i b i t s the t r a n s m i s s i o n by a c t i v a t i n g c e l l s of the s u b s t a n t i a g e l a t i n o s a , which then modulate or " c l o s e the 7 gate" on the amount of i n f o r m a t i o n p r o j e c t e d to the b r a i n by the T c e l l s . In c o n t r a s t , s m a l l f i b e r a c t i v i t y f a c i l i t a t e s the t r a n s m i s s i o n and thereby "opens the gate" to the b r a i n . T h i s s p i n a l g a t i n g mechanism i s a l s o i n f l u e n c e d by impulses t h a t descend from the b r a i n . In the c e n t r a l c o n t r o l process, a system of l a r g e diameter, r a p i d l y conducting f i b e r s known as the c e n t r a l c o n t r o l t r i g g e r a c t i v a t e s s e l e c t i v e c o g n i t i v e p r o c e s s e s . These processes then i n f l u e n c e , by way of descending f i b e r s , the modulating p r o p e r t i e s of the s p i n a l g a t i n g mechanism. I t i s here t h a t an i n d i v i d u a l ' s thoughts, f e e l i n g s , and past experiences i n f l u e n c e whether or not the pain impulses reach the awareness l e v e l . P a i n occurs when the output of the T c e l l s i n the d o r s a l horns manages to reach or exceed a c r i t i c a l l e v e l . The t r a n s m i s s i o n i s then p r o j e c t e d to the s e n s o r y - d i s c r i m i n a t i v e system v i a the neospinothalamic f i b e r s and to the m o t i v a t i o n a l - a f f e c t i v e system v i a the paramedial ascending system. I t i s the combination and i n t e r a c t i o n of these two systems with the c e n t r a l c o n t r o l process which p r o v i d e s the p e r c e p t u a l i n f o r m a t i o n about the p a i n ( i n c l u d i n g i t s i n t e n s i t y ) , the m o t i v a t i o n a l tendency to escape or a t t a c k , and the c o g n i t i v e i n f o r m a t i o n . These systems then p r o j e c t to the motor system, and b e h a v i o u r a l a c t i o n by the organism occurs. I t i s t h i s b e h a v i o u r a l a c t i o n , as w e l l as c h i l d r e n ' s p e r c e p t u a l i n f o r m a t i o n about p o s t - o p e r a t i v e pain i n t e n s i t y , which i s the focus o f , t h i s study. 8 Although the Revised Gate C o n t r o l Theory of Pain (Melzack & Wall, 1983) i s the most commonly accepted p a i n theory because of i t s i n c o r p o r a t i o n of both the p h y s i o l o g i c a l and p s y c h o l o g i c a l components, i t has weaknesses which are p e r t i n e n t to t h i s study. F i r s t , t h i s theory does not c l e a r l y d e s c r i b e the s p e c i f i c p s y c h o l o g i c a l v a r i a b l e s which have an e f f e c t on the pain experience (Kim, 1980). Second, because t h i s t h e o r y i s based on i n f o r m a t i o n from the pain experiences of a d u l t s , i t does not i n c o r p o r a t e the e f f e c t of v a r y i n g l e v e l s of c o g n i t i v e development of c h i l d r e n (Stevens, Hunsberger, & Browne, 1987), which are b e l i e v e d to p l a y a major r o l e i n c h i l d r e n ' s p e r c e p t i o n of pain and which, i n t u r n , may i n f l u e n c e the experience of a given p a i n f u l s t i m u l u s (Schechter, 1985). To strengthen these i d e n t i f i e d weaknesses as they p e r t a i n s p e c i f i c a l l y to t h i s p r o j e c t , p a r t i c u l a r concepts from P i a g e t ' s t h e o r y of c o g n i t i v e development, as w e l l as s p e c i f i c s o c i a l / e n v i r o n m e n t a l v a r i a b l e s (which Melzack & Wall, [1983] i n c l u d e i n the o v e r a l l concept of p s y c h o l o g i c a l v a r i a b l e s ) , namely p a r e n t a l presence and pharmacological i n t e r v e n t i o n are i n c l u d e d i n t h i s study's conceptual framework. Assumptions The assumptions b a s i c to t h i s study are as f o l l o w s : (a) pain i s p e r s o n a l l y experienced and thus cannot be experienced by anyone other than the i n d i v i d u a l (McCaffery, 1972); (b) c h i l d r e n experience pain a f t e r surgery; (c) the p a i n experience i s d i f f e r e n t f o r every c h i l d even when the 9 s u r g i c a l experience i s the same; and (d) a l l c h i l d r e n i n t h i s age group w i l l be able to p l a c e a value on t h e i r p ain u s i n g the p a i n i n t e n s i t y s c a l e . The l i m i t a t i o n s of t h i s study w i l l be addressed i n the d i s c u s s i o n of the f i n d i n g s of the study. Summary T h i s chapter has introduced the r e s e a r c h study through a d i s c u s s i o n of the background to the problem; the i d e n t i f i c a t i o n of the problem statement, the purpose of the study, the s p e c i f i c q uestions to be addressed, and the d e f i n i t i o n of terms; a d i s c u s s i o n of the conceptual framework which w i l l guide t h i s study; and f i n a l l y a p r e s e n t a t i o n of the assumptions which i n f l u e n c e t h i s study. The f o l l o w i n g chapter p r o v i d e s a review of the l i t e r a t u r e which i s r e l e v a n t to t h i s study. 10 CHAPTER TWO Literature Review A review of the published l i t e r a t u r e has i d e n t i f i e d only limited research which s p e c i f i c a l l y addresses the subject of post-operative pain in children. As a r e s u l t , t h i s l i t e r a t u r e review w i l l r e f l e c t primarily upon the available t h e o r e t i c a l l i t e r a t u r e on children's pain, rather than upon empirical data which is limited and general in content. S p e c i f i c a l l y , t h i s l i t e r a t u r e review w i l l be divided into two main sections: (a) a consideration of children's pain in r e l a t i o n to the forces which may impact upon i t and how these forces may a f f e c t the perception and behavioural response of children to pain; and (b) a focus on the assessment of pain, s p e c i f i c a l l y s e l f - r e p o r t measures of pain and behavioural measurement, also considering the forces which may pr e v a i l upon the assessment of pain. Childhood Pain Pain i s not just the perception of noxious stimuli but rather a state of an individual which is subject to varying internal and external determinants encompassing that individual (Ross & Ross, 1988). These determinants or factors may a f f e c t a l l aspects of children's pain, including i t s perception, the behavioural reaction to pain, and i t s assessment. Consequently, in order to e f f e c t i v e l y comprehend the post-operative pain of children within the scope of t h i s study, the factors that may impact upon that pain must be understood. Although the l i t e r a t u r e focuses on the factors 11 which may impact upon c h i l d h o o d pain experiences g l o b a l l y , t h i s i n f o r m a t i o n can be used to understand a d i s t i n c t p a i n experience such as p o s t - o p e r a t i v e p a i n . In order to provide s t r u c t u r e f o r the understanding of the f a c t o r s impacting on c h i l d h o o d p a i n , Chapman (1985) has c l a s s i f i e d them i n t o two major c a t e g o r i e s : p r e d i s p o s i n g f a c t o r s and s i t u a t i o n a l f a c t o r s . P r e d i s p o s i n g F a c t o r s P r e d i s p o s i n g f a c t o r s are the g e n e r a l l y s t a b l e elements which each c h i l d b r i n g s to the p a i n experience (Chapman, 1985). These f a c t o r s i n c l u d e age, sex, p e r s o n a l i t y , p h y s i o l o g y and anatomy, s o c i a l i z a t i o n (both peer and p a r e n t a l ) , and c u l t u r a l background (Ross & Ross, 1988). They a l l p l a y a r o l e not o n l y i n the p e r c e p t i o n of p a i n , but a l s o i n the o v e r t behaviours with which a c h i l d expresses the p e r c e i v e d p a i n and, thus, i n the assessment of t h a t p a i n . Of these f a c t o r s , age and i t s corresponding stage of c o g n i t i v e development p l a y a major r o l e i n t h i s study on p o s t - o p e r a t i v e p a i n . S p e c i f i c a l l y , the c o g n i t i v e development of c h i l d r e n aged 4 to 7 years w i l l be a major i n f l u e n c i n g f a c t o r i n the c h i l d r e n ' s p e r c e p t i o n of p o s t - o p e r a t i v e pain and i t s measurement. Thus, an understanding of the c o g n i t i v e stage of development of these c h i l d r e n i s c r u c i a l . C o g n i t i v e Development C h i l d r e n between the ages of 18 months and 7 years are c o n s i d e r e d by P i a g e t to be i n the p r e - o p e r a t i o n a l stage of c o g n i t i v e development (Piaget & Inhelder, 1969). In t h i s 12 s t a g e , P i a g e t i d e n t i f i e s a t l e a s t s i x c h a r a c t e r i s t i c s of c h i l d r e n ' s thought p a t t e r n s ( P h i l l i p s , 1981), of which o n l y the c h a r a c t e r i s t i c s of c o n c r e t e n e s s , e g o c e n t r i s m , and t r a n s d u c t i v e r e a s o n i n g a r e of p r i m a r y c o n c e r n i n t h i s s t u d y ( S m i t h , 1976). C h i l d r e n i n the p r e - o p e r a t i o n a l s t a g e of c o g n i t i v e development a r e c h a r a c t e r i z e d by t h e i r c o n c r e t e t h i n k i n g ( P i a g e t & I n h e l d e r , 1969). As a r e s u l t , t h e s e c h i l d r e n are unable t o m e n t a l l y m a n i p u l a t e ( i . e . , a n a l y z e and s y n t h e s i z e ) what t h e y see or p e r c e i v e ( P h i l l i p s , 1981), and c o n s e q u e n t l y g e n e r a l l y p e r c e i v e o n l y what t h e y can see, t o u c h , and m a n i p u l a t e ( S m i t h , 1976). P r e - o p e r a t i o n a l c h i l d r e n a r e a l s o c o n s i d e r e d t o be e g o c e n t r i c i n t h e i r t h i n k i n g ( P i a g e t & I n h e l d e r , 1969), meaning t h a t t h e y n e i t h e r r e f l e c t nor ever q u e s t i o n p e r s o n a l t h o u g h t s , even when c o n f r o n t e d w i t h e v i d e n c e t h a t i s c o n t r a d i c t o r y t o t h o s e t h o u g h t s (Wadsworth, 1971). In the l a t t e r s i t u a t i o n s , c h i l d r e n u s u a l l y c o n c l u d e t h a t the e v i d e n c e must be wrong as t h e i r t h o u g h t s a r e always l o g i c a l and c o r r e c t (Wadsworth, 1971). Because of t h i s e g o c e n t r i s m , a c h i l d has d i f f i c u l t y g r a s p i n g the p o i n t of view of a n o t h e r c h i l d or an a d u l t and t h e r e f o r e cannot a n t i c i p a t e how a n y t h i n g w i l l l ook from a n o t h e r person's p o i n t of view (Mussen, Conger, & Kagan, 1979). F i n a l l y , p r e - o p e r a t i o n a l c h i l d r e n a l s o a p p l y t r a n s d u c t i v e r e a s o n i n g i n t h e i r t h i n k i n g ( P i a g e t & I n h e l d e r , 1969), which thus p r o g r e s s e s from p a r t i c u l a r t o p a r t i c u l a r 13 without any r e f e r e n c e to the general ( P h i l l i p s , 1981). They are unable to i n t e g r a t e a s e r i e s of events i n terms of a beginning-end r e l a t i o n s h i p (Wadsworth, 1971). In c o n c l u s i o n , these three c h a r a c t e r i s t i c s make f o r slow, c o n c r e t e , and r e s t r i c t e d thought t h a t i s c o n t r o l l e d by the immediate and the p e r c e p t u a l (Wadsworth, 1971). C o g n i t i v e development and pa i n p e r c e p t i o n . McBride (1977) s t a t e s t h a t c h i l d r e n p e r c e i v e p a i n f u l events d i f f e r e n t l y depending on t h e i r stage of development. For example, because of t h e i r e g o c e n t r i c i t y , c h i l d r e n i n the p r e - o p e r a t i o n a l stage of development tend to b e l i e v e t h a t they are the cause of t h e i r own pain (Abu-Saad, 1981). However, a recent study conducted by Hurley and Whelan (1988), i n which 48 c h i l d r e n i n the f i r s t through e i g h t h grades were interviewed to a s c e r t a i n t h e i r p e r c e p t i o n s of p a i n , r e s u l t e d i n the c o n c l u s i o n t h a t a c h i l d ' s e g o c e n t r i c i t y can a l s o lead him/her to hold someone e l s e accountable f o r h i s / h e r p a i n . The i n c o n s i s t e n c y of t h i s b e l i e f with t h a t of other t h e o r i s t s i s p o s s i b l y due to the study having been conducted with c h i l d r e n who were not e x p e r i e n c i n g p a i n , as w e l l as the i n c l u s i o n of c h i l d r e n who were o n l y i n the l a t t e r phase of the p r e - o p e r a t i o n a l stage of c o g n i t i v e development. G e n e r a l l y , there i s agreement i n the l i t e r a t u r e t h a t c h i l d r e n i n t h i s stage tend to b e l i e v e t h a t pain i s a form of punishment f o r something "bad" t h a t they have done (Abu-Saad, 1981; Hurley & Whelan, 1988). In a d d i t i o n to t h e i r e g o c e n t r i c i t y , c h i l d r e n ' s i n a b i l i t y 14 to a t t e n d to t r a n f o r m a t i o n s ( i . e . , t h e i r i n a b i l i t y to i n t e g r a t e a s e r i e s of events i n terms of a beginning-end r e l a t i o n s h i p [Wadsworth, 19711) prevents them from c o n c e i v i n g of the d i s c o m f o r t of p a i n having an end, nor can they understand how a p a i n f u l procedure may be r e l a t e d to the f u t u r e event of h e a l i n g (Abu-Saad, 1981). Because c h i l d r e n ' s thoughts i n t h i s stage are c o n t r o l l e d by the immediate and the p e r c e p t u a l (Wadsworth, 1971), they can b e l i e v e t h a t an i n j e c t i o n given to r e l i e v e p a i n , but which they p e r c e i v e d as a p a i n f u l event, caused the o r i g i n a l p a i n (Abu-Saad, 1981). F i n a l l y , c h i l d r e n b e l i e v e i n the magical disappearance of t h e i r pain (Hurley & Whelan, 1988). C h i l d r e n i n t h i s stage a l s o b e l i e v e t h a t the pain they are e x p e r i e n c i n g i s obvious to others (McCaffery, 1977). However, t h e i r language a b i l i t y enables them to v e r b a l i z e f e a r s and pains (McCaffery, 1977 ) . In summary, t h i s d i s c u s s i o n has centered on the impact that a c h i l d ' s stage of c o g n i t i v e development may have upon the c h i l d ' s p e r c e p t i o n of p a i n . Although t h e o r y on c h i l d r e n i n the pre-operationa1 stage of c o g n i t i v e development and t h e i r p e r c e p t i o n of p a i n i s r e a d i l y a v a i l a b l e , p u b l i s h e d r e s e a r c h to v a l i d a t e these b e l i e f s i s s t i l l minimal. S i t u a t i o n a l F a c t o r s Chapman's (1985) s i t u a t i o n a l f a c t o r s are those v a r i a b l e s r e l e v a n t o n l y to the immediate pain experience. They tend to be f l e x i b l e and thus may change depending on the s i t u a t i o n . These s i t u a t i o n a l v a r i a b l e s are of three types: s i t u a t i o n -15 s p e c i f i c c h i l d f a c t o r s , environmental n o n s o c i a l f a c t o r s , and environmental s o c i a l f a c t o r s . Each of these types w i l l be d i s c u s s e d g e n e r a l l y with a d e t a i l e d d i s c u s s i o n of the s p e c i f i c f a c t o r s which p e r t a i n d i r e c t l y to t h i s study. S i t u a t i o n - S p e c i f i c Chi Id F a c t o r s S i t u a t i o n - s p e c i f i c c h i l d f a c t o r s are those v a r i a b l e s which are r e l e v a n t to the context i n which the c h i l d i s e x p e r i e n c i n g p a i n (Ross & Ross, 1988). These v a r i a b l e s i n c l u d e the meaning each c h i l d a t t a c h e s to the pain experience ( f o r example, punishment f o r a previous misdeed, which could a l s o be r e l a t e d to the c h i l d ' s stage of c o g n i t i v e development as o u t l i n e d e a r l i e r i n t h i s c h a p t e r ) ; the degree of f e e l i n g s of c o n t r o l or i t s a n t i t h e s i s , h e l p l e s s n e s s , which the c h i l d experiences or at l e a s t b e l i e v e s he/she has over the p a i n s i t u a t i o n ; the presence i n the c h i l d of s t a t e a n x i e t y ; the a t t e n t i o n the c h i l d p l a c e s on the pain experience; and the c h i l d ' s b e l i e f i n h i s / h e r a b i l i t y to cope with the pain (Ross & Ross, 1988). Any and a l l of these f a c t o r s may attenuate or enhance the c h i l d ' s p e r c e p t i o n of pain (Ross & Ross, 1988). Environmental Nonsocial F a c t o r s Environmental n o n s o c i a l f a c t o r s are those inanimate f a c t o r s of the c h i l d ' s p h y s i c a l environment which are u s u a l l y the s i m p l e s t to change to a f f e c t the pain experience (Ross & Ross, 1988). Although these f a c t o r s may p l a y a s i g n i f i c a n t r o l e i n c h i l d r e n ' s p o s t - o p e r a t i v e p a i n , they are not d i r e c t l y under study i n t h i s r e s e a r c h . 16 Environmental S o c i a l F a c t o r s Environmental s o c i a l f a c t o r s s p e c i f i c a l l y r e f e r to the behaviour or presence of other i n d i v i d u a l s d u r i n g the c h i l d ' s pain e x p e r i e n c e . These other i n d i v i d u a l s are g e n e r a l l y the c h i l d ' s parents, i n p a r t i c u l a r the mother; the p e d i a t r i c personnel c a r i n g f o r the c h i l d ; and other i n d i v i d u a l s w i t h i n the same environment but who are not d i r e c t l y i n v o l v e d with the c h i l d ( f o r example the parents of other c h i l d r e n ) (Ross & Ross, 1988). The f a c t o r s of p a r e n t a l presence and the behaviours of the p e d i a t r i c personnel c a r i n g f o r each c h i l d ( p a r t i c u l a r l y r e g a r d i n g the p r e s c r i p t i o n and a d m i n i s t r a t i o n of a n a l g e s i c s f o r pa i n r e l i e f ) are v a r i a b l e s w i t h i n t h i s study. T h e r e f o r e , these two s p e c i f i c v a r i a b l e s w i l l be d i s c u s s e d i n g r e a t e r d e t a i l . P a r e n t a l presence. "The experience of being h o s p i t a l i z e d f o r a s e r i o u s i l l n e s s or su r g e r y i s u s u a l l y a traumatic and a n x i e t y producing one, p a r t i c u l a r l y f o r c h i l d r e n " ( G o s l i n , 1978, p. 321). To a c h i l d , h o s p i t a l i z a t i o n means a s e p a r a t i o n from f a m i l y , home, and t h i n g s and experiences which are f a m i l i a r ( G i l d e a & Quirk, 1977). With h o s p i t a l i z a t i o n come u n f a m i l i a r and o f t e n p a i n f u l experiences t h a t must be d e a l t with by the c h i l d , sometimes alon e . The p o s i t i v e e f f e c t of parents on a c h i l d ' s a b i l i t y to cope with the a n x i e t y and fe a r of h o s p i t a l i z a t i o n i s now a w e l l known f a c t (Licamele & Goldberg, 1987). In a d d i t i o n , the p o s i t i v e e f f e c t of p a r e n t a l presence on a c h i l d ' s a b i l i t y to cope with a n x i e t y 17 and fear i n other s e t t i n g s where a v e r s i v e and u n f a m i l i a r experiences occur ( f o r example, immunizations and d e n t a l procedures) has a l s o been s t u d i e d to a l i m i t e d but i n c o n c l u s i v e degree ( F r a n k l , Shiere & F o g e l s , 1962; Shaw & Routh, 1982; Venham, 1979; Venham, Bengston & C i p e s , 1978). However, no s t u d i e s have been found which d i r e c t l y assess the e f f e c t of p a r e n t a l presence on a c h i l d ' s experience of p a i n ( p o s t - o p e r a t i v e or o t h e r w i s e ) . E x i s t i n g t h e o r e t i c a l l i t e r a t u r e r e g a r d i n g the e f f e c t of p a r e n t a l presence c e n t e r s around a proposed r e l a t i o n s h i p between pa i n and a n x i e t y . The Revised Gate C o n t r o l Theory of pain suggests t h a t a n x i e t y i s a c o g n i t i v e a c t i v i t y which can i n f l u e n c e the p a i n experience a t the e a r l i e s t l e v e l s of sensory t r a n s m i s s i o n (Melzack and Wall, 1983). Meinhart and McCaffery (1983) b e l i e v e t h a t fear and a n x i e t y may i n c r e a s e the p e r c e p t i o n of pain because they compete with an i n d i v i d u a l ' s methods of coping with p a i n . Thus, a c h i l d who i s f e a r f u l or anxious i s rendered unable to use h i s coping a b i l i t i e s to g a i n a measure of c o n t r o l over the pain and i s t h e r e f o r e l i k e l y to experience more p a i n . I t i s proposed that the presence of a parent may a l l e v i a t e the fear and a n x i e t y to a degree which allows the c h i l d to gain a measure of c o n t r o l over the p a i n . G i l d e a and Quirk (1977) s t a t e t h a t the s e n s a t i o n of pain can o f t e n be l i n k e d to f e e l i n g s of s e p a r a t i o n a n x i e t y experienced by a c h i l d whose parents are absent d u r i n g h o s p i t a l i z a t i o n or h u r t f u l procedures. These authors s t a t e that p a i n caused by f e e l i n g s of a n x i e t y i s as r e a l to the 18 c h i l d as p h y s i c a l pain and thus may e l i c i t the same types of response as p h y s i c a l p a i n . The need f o r parents to help cope with pain i s g e n e r a l l y c o r r o b o r a t e d by c h i l d r e n i n s t u d i e s conducted by J e r r e t (1985) and Ross and Ross (1984). To o b t a i n t h e i r view of pa i n , J e r r e t (1985) used drawings and i n t e r v i e w s with c h i l d r e n aged 5 to 9 years i n an ambulatory c l i n i c . In answering the qu e s t i o n of what the c h i l d r e n d i d to help themselves f e e l b e t t e r when having p a i n , behaviours r e l a t e d to the presence of a parent ( f o r example, h o l d i n g hands with a parent) were i d e n t i f i e d by these c h i l d r e n as being the most b e n e f i c i a l i n a l l o w i n g them to cope with t h e i r p a i n . In an e a r l i e r study, Ross and Ross (1984) interv i e w e d 994 c h i l d r e n age 5 to 17 years i n s c h o o l s , h o s p i t a l s , and c l i n i c a l s e t t i n g s . They found that 99.2% of the c h i l d r e n b e l i e v e d t hat p a r e n t a l presence was what helped the most when they were i n p a i n , even i f they knew there was nothing t h a t t h e i r parent could do about the p a i n . However, Ross and Ross (1988) have a l s o r e c o g n i z e d t h a t p a r e n t a l presence may have a d e t r i m e n t a l r a t h e r than p o s i t i v e e f f e c t on a c h i l d ' s p a i n . They suggest t h a t i f parents f a i l to a c t i n a r e a s s u r i n g manner ( p o s s i b l y as a r e s u l t of t h e i r own heightened f e e l i n g s of a n x i e t y [ G i l d e a & Quirk, 19773), and thus do not provide the sense of comfort and s e c u r i t y needed and expected by the c h i l d , the c h i l d ' s f ear and a n x i e t y may not be a l l e v i a t e d . As w e l l , a parent who i s pe r c e i v e d by the c h i l d as causing the pain or h e l p i n g another 19 to i n f l i c t the pain (as o f t e n occurs when the parent helps the h e a l t h p r o f e s s i o n a l by r e s t r a i n i n g the c h i l d ) may cause the c h i l d to lose the sense of s e c u r i t y normally experienced with p a r e n t a l presence (Ross & Ross, 1988). In both i n s t a n c e s , the c h i l d ' s f ear and a n x i e t y are heightened and coping with the pa i n may become impo s s i b l e , thus r e s u l t i n g i n heightened pain p e r c e p t i o n and the experience of more p a i n . The t o t a l absence of parents has a s i m i l a r e f f e c t to that which occurs when a parent i s with the c h i l d but does not provide a sense of s e c u r i t y . Without a parent's presence, the c h i l d i s l e f t to face alone the pain and i t s accompanying u n c e r t a i n t y and f e a r (Ross & Ross, 1988). Once again, the c h i l d w i l l experience fear and a n x i e t y , r e s u l t i n g i n a p o t e n t i a l l y heightened p a i n p e r c e p t i o n . In c o n c l u s i o n , because the i n f o r m a t i o n r e g a r d i n g the e f f e c t of p a r e n t a l presence on the pain experienced by c h i l d r e n i s almost e x c l u s i v e l y t h e o r e t i c a l and thus cannot be con s i d e r e d c o n c l u s i v e , . t h e need to i n c l u d e the presence or absence of a parent as a v a r i a b l e i n any study of c h i l d r e n ' s p o s t - o p e r a t i v e p a i n i s imperative. Pharmacological pain management. Although a l t e r n a t i v e nonpharmacological pain management i n t e r v e n t i o n s are g a i n i n g i n p o p u l a r i t y with the h e a l t h care community, c h i l d r e n ' s pain ( p a r t i c u l a r l y p o s t - o p e r a t i v e p a i n ) , i s s t i l l commonly t r e a t e d with the t r a d i t i o n a l a d m i n i s t r a t i o n of n a r c o t i c a n a l g e s i c s , n o n - n a r c o t i c a n a l g e s i c s , or a combination of both (Ross & Ross, 1988). 20 The goal of th i s pain management is to markedly decrease or completely re l i eve pa in , thus providing comfort to the c h i l d and maximizing the possible s u r g i c a l outcome (Hawley, 1984) without i n t e r f e r i n g with the other senses (Ross & Ross, 1988). The r e a l i z a t i o n of th i s goal w i l l obviously p o s i t i v e l y af fect the pain experience and thus impact upon pain i n t e n s i t y and pain behaviours, the var iables under study in th i s pro jec t . The choice of analgesic agents to meet the desired goal of pain r e l i e f general ly depends s o l e l y upon the prescr ib ing phys ic ian . However, there i s bel ieved to be no s ingle idea l choice of agent (Ross & Ross, 1988). As a r e s u l t , a v a r i e t y of analgesic agents can be prescribed and administered for c h i l d r e n ' s post-operative pa in . However, questions ex i s t about what is a c t u a l l y being prescribed for c h i l d r e n ' s post-operative pa in , as well as what is being administered. S p e c i f i c a l l y under examination i s the p o s s i b i l i t y of c h i l d r e n being undermedicated af ter surgery, and thus poss ib ly su f fer ing needless pa in . Eland and Anderson (1977) reviewed the charts of 25 pos t - surg i ca l ch i ldren aged 5 to 8 years . This review revealed that 13 of the 25 c h i l d r e n had never received any analgesics for pain during t h e i r ent ire h o s p i t a l i z a t i o n . In fac t , of the 25 ch i ldren included in the study, only 12 ever received any analgesic at a l l , despite the fact that 21 of the ch i ldren had doctor 's orders for a n a r c o t i c , non-n a r c o t i c , or combination of both. 21 Beyer et a l . (1983) c a r r i e d the q u e s t i o n of a n a l g e s i c p r e s c r i p t i o n and a d m i n i s t r a t i o n f u r t h e r . Through a r e t r o s p e c t i v e c h a r t review, they compared, d u r i n g the f i r s t three days and f i f t h day p o s t - o p e r a t i v e , the a n a l g e s i c s p r e s c r i b e d and administered to a sample of 50 c h i l d r e n and 50 a d u l t s who had a l l undergone c a r d i a c surgery. T h e i r f i n d i n g s r e v e a l e d that d u r i n g the f i r s t three p o s t - o p e r a t i v e days there was no s i g n i f i c a n t d i f f e r e n c e between the c h i l d r e n or a d u l t s i n the type and number of p r e s c r i p t i o n s f o r a n a l g e s i c s . However, fewer of the a n a l g e s i c s p r e s c r i b e d f o r the c h i l d r e n were w i t h i n t h e r a p e u t i c range. On the f i f t h p o s t - o p e r a t i v e day, a d u l t s were s t i l l p r e s c r i b e d n a r c o t i c and n a r c o t i c / n o n - n a r c o t i c mixtures while almost a l l of the drugs ordered p o s t - o p e r a t i v e l y f o r the c h i l d r e n had been d i s c o n t i n u e d . F i n a l l y , d u r i n g the o b s e r v a t i o n p e r i o d , the c h i l d r e n r e c e i v e d only 30% of a l l a n a l g e s i c a d m i n i s t r a t i o n , while a d u l t s r e c e i v e d 70%. While these two s t u d i e s i n d i c a t e d a s e r i o u s concern r e g a r d i n g the p r e s c r i p t i o n and a d m i n i s t r a t i o n of a n a l g e s i c agents p o s t - o p e r a t i v e l y , the authors could not conclude t h a t c h i l d r e n were undermedicated. T h i s c o n c l u s i o n would r e q u i r e that an examination of the r e l a t i o n s h i p between the c h i l d r e n ' s l e v e l s of pain i n t e n s i t y and the a n a l g e s i c s ordered and p r e s c r i b e d . Mather and Mackie (1983) attempted to f u l f i l l t h i s requirement by l o o k i n g a t not o n l y the i n c i d e n c e of p o s t - o p e r a t i v e p a i n of 170 c h i l d r e n on the day of surgery and the f o l l o w i n g day, but a l s o a t the a n a l g e s i c s 22 prescribed and administered to these children. However, because the method used to at t a i n children's perceptions of their pain intensity was not r e l i a b l e or v a l i d , no s p e c i f i c conclusions about undermedication could be drawn. Nevertheless, the study confirmed what the previous two studies had found: children (a) were at times prescribed no analgesic (16% of the children in th i s study); (b) were being given a non-narcotic agent exclusively (29% of the children); and (c) of the narcotics prescribed by physicians, 31% of these were below therapeutic l e v e l s . Furthermore, the focus of these three studies was not on the reasons for prescribing and administering these drugs. These reasons, which w i l l guide the actions of the pedi a t r i c personnel, w i l l obviously a f f e c t the post-operative pain experienced by children. Thus, they are important facts for this study. Unfortunately, in reviewing the l i t e r a t u r e , the author could not ascertain any studies which evaluated the reasons physicians prescribe the analgesics they do for children's post-operative pain. However, a study done by Burokas (1985), and later replicated by Gadish, Gonzales and Hayes (1988), did examine the factors which influence nurses' decisions in the administration of analgesics to children post-operatively. In both studies, nurses from pediatric care areas were surveyed using the Pediatric Nurses Pain Relief Questionnaire (Burokas, 1985), which contained multiple choice questions and eight vignettes. These vignettes, which were similar to one another in that a l l the 23 f i c t i o n a l c h i l d r e n (a) had undergone major abdominal or t h o r a c i c s u r g e r y , (b) were between the ages of one and s i x , and (c) were no more t h a t t h r e e days p o s t - o p e r a t i v e , asked the nurse t o make a d e c i s i o n on the c h o i c e and dose of a n a l g e s i c based on the i n f o r m a t i o n p r o v i d e d . Face v a l i d i t y of t h i s q u e s t i o n n a i r e had been e s t a b l i s h e d t h r o u g h p a n e l e x p e r t r e v i e w . Burokas (1985) found t h a t i n these v i g n e t t e s 21% of the nurses (a t o t a l of 134 nurses responded t o the s u r v e y ) chose t o a d m i n i s t e r a n o n - n a r c o t i c agent. G a d i s h e t a l . (1988) r e p o r t e d s i m i l a r f i n d i n g s i n t h a t 15.2% of the n u r s e s (38 i n t o t a l responded) chose t o a d m i n i s t e r a non-n a r c o t i c agent. Of the nurses who chose a n a r c o t i c , t h o s e w i t h academic degrees s e l e c t e d h i g h e r doses of n a r c o t i c s , w h i l e t h o s e w i t h a s s o c i a t e degrees s e l e c t e d lower doses and the g r e a t e s t p r o p o r t i o n of n o n - n a r c o t i c a n a l g e s i c s . F u r t h e r m o r e , 42% of the nurses chose n o n - p h a r m a c o l o g i c a l i n t e r v e n t i o n s , l i k e r e p o s i t i o n i n g , t o r e l i e v e p a i n . In b oth s t u d i e s , the nurses were asked t o rank the f a c t o r s which i n f l u e n c e d t h e i r d e c i s i o n s t o m e d i c a t e . Each t i m e , the top f i v e f a c t o r s ( a l t h o u g h t h e i r o v e r a l l r a n k i n g s d i f f e r e d s l i g h t l y between s t u d i e s ) were (a) e v a l u a t i o n of v i t a l s i g n s (the top rank i n both s t u d i e s ) , (b) type of s u r g e r y , (c) s e v e r i t y of p a i n , (d) n o n v e r b a l b e h a v i o u r s , and (e) response t o the l a s t m e d i c a t i o n . Four of t h e s e f a c t o r s , e x c l u d i n g the type of s u r g e r y , t a k e i n t o a ccount the i n d i v i d u a l i z a t i o n of the p a i n e x p e r i e n c e , and t h e r e f o r e r e q u i r e each nurse t o have a knowledge base which r e f l e c t s 24 t h i s u n d e r s t a n d i n g i n o r d e r t h a t these f a c t o r s be a c c u r a t e l y i n t e r p r e t e d as cues of a c h i l d ' s p a i n . A foc u s „of the c u r r e n t s t u d y i s to det e r m i n e whether the s e cues are a c c u r a t e l y i n t e r p r e t e d r e s u l t i n g i n a p p r o p r i a t e i n t e r v e n t i o n s f o r the c h i l d ' s p a i n . Summary In t h i s s e c t i o n of the l i t e r a t u r e r e v i e w , the au t h o r sought t o e x p l a i n the c o m p l e x i t y of the p a i n e x p e r i e n c e of c h i l d r e n by p r e s e n t i n g t h o s e f a c t o r s , both p r e d i s p o s i n g and s i t u a t i o n a l , which may impact upon the p a i n e x p e r i e n c e . A l t h o u g h p r e s e n t e d i n d e p e n d e n t l y i n t h i s d i s c u s s i o n , when a s s e s s i n g the p a i n e x p e r i e n c e , t h e s e f a c t o r s must not be c o n s i d e r e d i n i s o l a t i o n . I t i s t h e i r i n t e r t w i n i n g which makes the p a i n e x p e r i e n c e m u l t i d i m e n s i o n a l and unique t o each i n d i v i d u a l . P a i n Assessment J u s t as a m u l t i t u d e of f a c t o r s make each c h i l d ' s p a i n e x p e r i e n c e u n i q u e , c e r t a i n f a c t o r s a l s o impact upon the assessment of each c h i l d ' s p o s t - o p e r a t i v e p a i n . The f o l l o w i n g d i s c u s s i o n w i l l o u t l i n e those s p e c i f i c f a c t o r s which a f f e c t the assessment of p o s t - o p e r a t i v e p a i n ( i n c l u d i n g a s e l f - r e p o r t measure of p a i n i n t e n s i t y and a b e h a v i o u r a l c h e c k l i s t ) . S e l f - R e p o r t P a i n S c a l e s With a d u l t s , s e l f - r e p o r t of p a i n i s c o n s i d e r e d t o be the most r e l i a b l e i n d e x or v a l u e d e v i d e n c e of p a i n (Beyer & B y e r s , 1985). Now, s e l f - r e p o r t measures of p a i n i n t e n s i t y 25 for use with children are gaining c r e d i b i l i t y . In fact, one reknowned pain researcher states that currently s e l f - r e p o r t measures of pain intensity are proving to be the most r e l i a b l e method available in the assessment of children's post-operative pain (Dr. P. McGrath, personal communication, June 16, 1989). However, cognitive development of the c h i l d plays an i n f l u e n t i a l role in the choice and use of s e l f -report measurement tools of pain intensity. For example, i t is not yet certain whether children in the pre-operational stage of cognitive development can express verbally the inten s i t y of their pain (Beyer & Byers, 1985). Moreover, young children, due to concrete thought processes, may have trouble t r a n s l a t i n g the inte n s i t y of their pain into the numerical scores required by visu a l analogue scales with numerical values (Lavigne, Hannan, Schulein, & Hahn, 1987). As well, Beyer and Knapp (1986) state that ongoing research by Beyer indicates that young children are not able to grasp the concept of the vi s u a l analogue when i t i s held ho r i z o n t a l l y . They hypothesize that this finding may be a res u l t of children's concrete thinking and limited command of symbolic reasoning in the pre-operational stage of cognitive development. Therefore, children cannot understand the horizontal li n e because they do not perceive the li n e as changing. In contrast, when held v e r t i c a l l y , the li n e appears to become bigger to the children. Wong and Baker (1988) using 150 hospitalized children in three age groups, compared six d i f f e r e n t pain assessment 26 scales: the simple descriptive scale, the numeric v i s u a l analogue scale, the faces scale, the glasses scale, the chips scale, and the colour scale. Findings indicated that children aged 3 to 18 years preferred the faces scale over the other scales, but that no one scale demonstrated su p e r i o r i t y in v a l i d i t y and r e l i a b i l i t y . However, t h i s study was based on a small sample size of 10 for each age group, which could l i m i t the r e l i a b i l i t y and v a l i d i t y of the findings. Only one published study (Mather & Mackie, 1983) was found which s p e c i f i c a l l y i d e n t i f i e d the incidence of post-operative pain in children, but the methods were questionable. The authors used questionnaires to assess pain r e l i e f in a l l children, even those in the pre-operational stage, and then converted the.responses to pain intensity scores. Not only is t h i s procedure questionable in terms of r e l i a b i l i t y and v a l i d i t y , but the s u i t a b i l i t y of using questionnaires for children in the pre-operational stage is also challenged. In conclusion, as the l i t e r a t u r e has shown, the choice of a measuring tool to assess pain i n t e n s i t y levels must be congruent with the chil d ' s cognitive development. Otherwise, the r e l i a b i l i t y and v a l i d i t y of the data c o l l e c t e d may be compromised. Behavioural Assessment Because of a lack of r e l i a b l e and v a l i d pain intensity measuring tools, c l i n i c i a n s have long r e l i e d upon behavioural 27 observations in order to determine or confirm the presence of pain in children. Unfortunately, the lack of research and understanding about children's expressions of pain, leads c l i n i c i a n s to evaluate i n c o r r e c t l y a c h i l d ' s behaviours based upon an adult perspective rather than taking into account the factors which make a c h i l d ' s expression of pain unique (Stevens, Hunsberger, & Browne, 1987). Two factors which can influence a c h i l d ' s behavioural responses to pain and which are pertinent to t h i s research study are: (a) a c h i l d ' s stage of cognitive development and (b) parental presence. Cognitive Development and Behaviour Just as a c h i l d ' s perception of pain i s s i g n i f i c a n t l y influenced by that c h i l d ' s stage of cognitive development, so the behaviours a c h i l d manifests to express pain also vary widely depending upon the stage of cognitive development. For example, children in the pre-operational stage have language a b i l i t y , but they may verbally deny pain because of fear of an i n j e c t i o n (McCaffery, 1977). As well, Hurley and Whelan (1988) state that because pre-operational children may hold someone else accountable for their pain, they may s t r i k e out verbally or physically, thus hurting those they f e e l are responsible for hurting them. In addition, children in the pre-operational stage of development may cease to interact with their environment because the pain enforces an increased preoccupation with their bodies (McBride, 1977). Children may also adapt their behavioural responses to pain by c o n t r o l l i n g behaviour and 28 thereby e x h i b i t i n g no overt response to pain (McCaffery, 1977). They may, f o r example, a c t u a l l y s l e e p while s t i l l e x p e r i e n c i n g p a i n , or use s e l f - d i s t r a c t i o n methods, such as p l a y i n g , i n order to cope with p a i n (Hawley, 1984). As can be seen from these examples, a c h i l d ' s stage of c o g n i t i v e development i n f l u e n c e s how the c h i l d p e r c e i v e s pain and then b e h a v i o u r a l l y responds to i t . However, once again, t h i s f a c t o r must not be con s i d e r e d i n i s o l a t i o n when a s s e s s i n g the b e h a v i o u r a l response to p a i n . P a r e n t a l Presence and Behaviour The presence of a parent may a l s o i n t e r a c t with the c h i l d ' s stage of c o g n i t i v e development to provide another range of behaviours a c h i l d may e x h i b i t when e x p e r i e n c i n g p a i n . I t has a l r e a d y been presented t h a t the main r o l e of parents i n the c h i l d ' s pain experience i s to al l o w or support the c h i l d ' s a b i l i t y to cope with the pain by r e l i e v i n g any a n x i e t y the c h i l d may be f e e l i n g . However, i f parents are not present or do not r e l i e v e the c h i l d ' s f e e l i n g s of a n x i e t y , the c h i l d may e x h i b i t some type of dependent behaviour such as c r y i n g , an u n w i l l i n g n e s s to i n t e r a c t with o t h e r s , or r e f u s i n g to eat ( G i l d e a & Quirk, 1977; Smith, 1976). I t can be d i f f i c u l t to determine whether these behaviours are a s i g n of pa i n or of fear and a n x i e t y . As w e l l , the s u p p o r t i v e presence of a parent does not a u t o m a t i c a l l y r e s u l t i n a c h i l d who i s able to cope and thus who i s p l a c i d and content, i n c o n t r o l of the pa i n being experienced. S t u d i e s by Shaw and Routh (1982) and Brunke 29 (1989) a c t u a l l y refute t h i s b e l i e f . Shaw and Routh (1982) examined the eff e c t of maternal presence or absence on the behaviour of a group of children aged 18-months and 5-years during an immunization. They found that for both age groups, children whose mothers were present during the immunization tended to cry longer during the i n j e c t i o n and then continued to fuss more afterward. The researchers defended t h i s r e s u l t by interpreting that the presence of the mothers a c t u a l l y encouraged the children to express their true fee l i n g s . In examining the e f f e c t of parental presence in the recovery room on the behaviour of preschool children aged 3 to 6 years after strabismus repair, Brunke (1989) found similar results to that of Shaw and Routh (1982). Using video taping and comparing two groups of children, 10 children whose parents were present and 10 children whose parents were absent, Brunke found that children whose parents were present in the recovery room (a) demonstrated crying and sobbing for a greater duration, (b) screamed and exclaimed more frequently, (c) demonstrated grimacing and frowning with less frequency but with greater duration, (d) complained of pain more frequently, and (e) demonstrated more refusal behaviours than the group of children whose parents were not present. This researcher did not, however, a c t u a l l y measure each c h i l d ' s pain in t e n s i t y . Instead, coding of the video tapes was done using a behavioural checklist of the o r e t i c a l c h i l d pain behaviours. Thus, these behaviours could be 30 interpreted i n c o r r e c t l y as pain behaviours when they may ac t u a l l y have been a response to fear and anxiety. Herein l i e s the problem of behavioural assessment of children's pain. In an attempt to bring greater accuracy and r e l i a b i l i t y to the assessment of pain by categorizing and enumerating pain behaviours, behavioural measuring tools such as the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), which measures pain expression (Stevens, Hunsberger, & Browne, 1987), have been developed. However, because the range of possible behaviours a c h i l d may exhibit in response to pain is so wide and varied, many researchers such as Beyer & Byers (1985) are doubtful about the usefulness of these tools. Moreover, recent research conducted by Dr. Patrick McGrath of the Children's Hospital of Eastern Ontario and Dr. Judith Beyer has found that the CHEOPS does not accurately r e f l e c t children's behavioural responses to long-term pain such as post-operative pain (Dr. P. McGrath, personal communication, June 16, 1989). In fact, Dr. McGrath states that to his knowledge there is no behavioural measuring tool yet available which w i l l accurately r e f l e c t post-operative pain, and he believes t h i s i s due to children's a b i l i t y to adapt to pain which is experienced over a period of time (Dr. P. McGrath, personal communication, June 16, 1989). However, Abu-Saad (1984) sought and found, in her study of ten 9 to 15-year-olds who had undergone surgical procedures, that a relati o n s h i p does exist between behavioural indices and 31 c h i l d r e n ' s r esponses on the p a i n s c a l e . U n f o r t u n a t e l y , t h i s s t u d y was based on c h i l d r e n aged 9 t o 15 y e a r s , which may r e f l e c t d i f f e r e n t f i n d i n g s than w i t h a younger age group such as t h a t used f o r t h i s s t u d y . I t has been i d e n t i f i e d i n the l i t e r a t u r e t h a t c h i l d r e n i n the p r e - o p e r a t i o n a l s t a g e of development may e x h i b i t p a i n b e h a v i o u r s t h a t may appear t o be i n c o n g r u e n t w i t h the e x p e c t e d . I t has a l s o been i d e n t i f i e d t h a t the u s e f u l n e s s of b e h a v i o u r a l measuring t o o l s i s s t i l l c o n t r o v e r s i a l . T h e r e f o r e , i n t h i s s t u d y , the c h i l d r e n ' s b e h a v i o u r s were noted when a s s e s s i n g the l e v e l of p a i n i n t e n s i t y . C o n c l u s i o n and Summary In c o n c l u s i o n , t h i s l i t e r a t u r e r e v i e w has r e v e a l e d t h a t t h e r e a r e few e m p i r i c a l s t u d i e s which examine the p o s t -o p e r a t i v e p a i n of c h i l d r e n , p a r t i c u l a r l y those between the ages of f o u r and seven. As a r e s u l t , the t h e o r e t i c a l l i t e r a t u r e has c o n t r i b u t e d the i n f o r m a t i o n n e c e s s a r y t o b e g i n t o u n d e r s t a n d c h i l d r e n ' s p o s t - o p e r a t i v e p a i n . S p e c i f i c a l l y , t h i s l i t e r a t u r e r e f l e c t e d on c h i l d h o o d p a i n i n g e n e r a l and the f a c t o r s which make any p a i n e x p e r i e n c e unique f o r each c h i l d . These f a c t o r s were c a t e g o r i z e d i n t o two c l a s s i f i c a t i o n s , p r e d i s p o s i n g f a c t o r s which each c h i l d b r i n g s t o a p a i n s i t u a t i o n , and s i t u a t i o n a l f a c t o r s which a r e g e n e r a l l y p a r t of each c h i l d ' s p h y s i c a l and s o c i a l e nvironment. These f a c t o r s impact upon each c h i l d ' s p e r c e p t i o n of p a i n , the b e h a v i o u r a l e x p r e s s i o n of p a i n , and assessment of t h a t p a i n . 32 Three s p e c i f i c f a c t o r s which were examined i n t h i s study were the stage of c h i l d r e n ' s c o g n i t i v e development, p a r e n t a l presence, and p e d i a t r i c personnel's pharmacological pain management. T h i s focus of t h i s l i t e r a t u r e review has been on these three f a c t o r s and the r o l e they p l a y i n each c h i l d ' s o v e r a l l p e r c e p t i o n and e x p r e s s i o n of p a i n . As w e l l , t h i s review has d i s c u s s e d the impact of c o g n i t i v e development and the r o l e of p a r e n t a l presence on the assessment of p a i n , through measures of s e l f - r e p o r t and b e h a v i o u r a l assessment. Two m i t i g a t i n g f a c t o r s have been r e v e a l e d : the stage of c o g n i t i v e development and the i n f l u e n c e of p a r e n t a l presence. These v a r i a t i o n s i n behaviour make i t d i f f i c u l t to c a t e g o r i z e behaviours which i n d i c a t e p a i n , p a r t i c u l a r l y p o s t - o p e r a t i v e p a i n . Because of t h i s , b e h a v i o u r a l o b s e r v a t i o n cannot stand alone i n a s s e s s i n g c h i l d r e n ' s p o s t - o p e r a t i v e p a i n . Consequently, a measure of s e l f - r e p o r t p a i n i n t e n s i t y should be i n c o r p o r a t e d with any assessment of p o s t - o p e r a t i v e p a i n . However, as the l i t e r a t u r e review i d e n t i f i e d , t h i s type of measure must a l s o be compatible with the p r e - o p e r a t i o n a l c h i l d ' s c o g n i t i v e a b i l i t y . 33 CHAPTER THREE Study Methods Two important f a c e t s of p o s t - o p e r a t i v e p a i n were conf i rmed i n the rev iew of the l i t e r a t u r e i n the p r e v i o u s c h a p t e r . F i r s t , there e x i s t s a l a c k of r e s e a r c h - s u p p o r t e d i n f o r m a t i o n r e g a r d i n g c h i l d r e n ' s p o s t - o p e r a t i v e p a i n ; and second , such p a i n cannot be c o n s i d e r e d i n i s o l a t i o n , but r a t h e r i s dependent upon many f a c t o r s both i n h e r e n t i n the c h i l d and i n the s i t u a t i o n . T h i s s t u d y was des igned i n accordance wi th these two f a c e t s of c h i l d r e n ' s p o s t - o p e r a t i v e p a i n . S p e c i f i c a l l y , i t was des igned to examine the p o s t -o p e r a t i v e p a i n of c h i l d r e n aged 4 to 7 y e a r s through a measure of s e l f - r e p o r t p a i n i n t e n s i t y l e v e l s and through a d e s c r i p t i o n of b e h a v i o u r s e x h i b i t e d by the c h i l d r e n . In a d d i t i o n , da ta were a l s o c o l l e c t e d r e g a r d i n g two f a c t o r s which have been t h e o r i z e d to i n f l u e n c e c h i l d r e n ' s p a i n : p a r e n t a l presence and a n a l g e s i a a d m i n i s t r a t i o n . P r e s e n t e d i n t h i s c h a p t e r w i l l be a rev iew and d i s c u s s i o n of the methods of t h i s s t u d y . The d e s i g n , sample s e l e c t i o n , s e t t i n g , da ta c o l l e c t i o n p r o c e s s , methods of data a n a l y s i s , and e t h i c a l c o n s i d e r a t i o n s are d i s c u s s e d . The c h a p t e r conc ludes w i t h the l i m i t a t i o n s of the s t u d y . Study Des ign A d e s c r i p t i v e d e s i g n which i n c o r p o r a t e d the use of r epea ted measures as w e l l as s t r u c t u r e d o b s e r v a t i o n s was used to address the f o l l o w i n g two q u e s t i o n s : 1. What are the l e v e l s of p a i n i n t e n s i t y r e p o r t e d on 34 the f i r s t post-operative day by hospitalized children aged 4 to 7 years who have undergone surgical procedures? 2. What are the overt behaviours exhibited at the time of pain i n t e n s i t y l e v e l measurement on the f i r s t day post-operative by hospitalized children aged 4 to 7 years who have undergone su r g i c a l procedures? As these questions require a descriptive answer with no manipulation of the variables, a descriptive design was deemed appropriate (Burns & Grove, 1987). Setting Data c o l l e c t i o n began on two units (cardiac surgery and general surgery) of a children's hospital in Western Canada. However, due to the u n a v a i l a b i l i t y of a s u f f i c i e n t number of subjects meeting a l l s p e c i f i e d c r i t e r i a within a reasonable time frame (only 2 subjects within a 6 week period), alternative s i t e s were selected. Two general pediatric wards in two acute care general hospitals within the same metropolitan area were used. Sample Selection Method The subjects for t h i s study were selected through convenience sampling, which i s considered a nonprobability form of sampling (Burns & Grove, 1987). Selection C r i t e r i a In order to participate in this study, subjects were required to be children who: 1. were aged 4 to 7 years admitted to hospital for 35 s u r g e r y . (However, t h i s c r i t e r i o n was l a t e r expanded t o i n c l u d e two c h i l d r e n under the age of 8 y e a r s 6 months, i n order t o o b t a i n an adequate sample s i z e . ) 2. had an ex p e c t e d h o s p i t a l s t a y of no l e s s t h a t one day p o s t - o p e r a t i v e . 3. were a b l e t o speak and und e r s t a n d E n g l i s h . 4. had no c h r o n i c p a i n syndrome p r e s e n t . 5. were not m e n t a l l y handicapped, d e v e l o p m e n t a l l y d e l a y e d , n e u r o l o g i c a l l y i m p a i r e d , or had l e a r n i n g d i s a b i l i t i e s . 6. had no p o s t - o p e r a t i v e c o m p l i c a t i o n s . 7. were a l e r t p o s t - o p e r a t i v e l y and a b l e t o f o l l o w d i r e c t i o n s . 8. were a d m i t t e d d i r e c t l y from PAR t o ward p o s t -s u r g e r y . 9. were a d m i t t e d o n l y t o p a r t i c i p a t i n g wards. 10. were a b l e t o a p p r o p r i a t e l y use the Poker C h i p T o o l (PCT). The f o l l o w i n g r a t i o n a l e g u i d e d the s p e c i f i c a t i o n of these c r i t e r i a . A l t h o u g h the type of s u r g e r y may a f f e c t the c h i l d r e n ' s p o s t - o p e r a t i v e p a i n , no s p e c i f i c t y pe of s u r g e r y was s e l e c t e d f o r t h i s s t u d y because the r e s e a r c h q u e s t i o n s demanded o n l y an answer t o whether c h i l d r e n were e x p e r i e n c i n g p a i n and how t h e y were b e h a v i o u r a l l y e x p r e s s i n g i t . However, because of the s e t t i n g s i n v o l v e d , c e r t a i n t y p e s of s u r g e r y ( n e u r o s u r g e r y or s u r g e r y f o r c a n c e r ) were e x c l u d e d from the s t u d y . These o m i s s i o n s may l i m i t the g e n e r a l i z a t i o n of the 36 f i n d i n g s w i t h r e g a r d t o n e u r o l o g i c a l and ca n c e r p a t i e n t s . I n i t i a l l y , i n the p r o p o s a l s t a g e , c h i l d r e n whose expected h o s p i t a l s t a y was l e s s than two days were e x c l u d e d from p a r t i c i p a t i o n i n t h i s s t u d y . However, a f t e r d a t a c o l l e c t i o n began, i t was r e c o g n i z e d t h a t the average l e n g t h of h o s p i t a l i z a t i o n i s one day p o s t - o p e r a t i v e or l e s s . T h e r e f o r e , t o o b t a i n an adequate sample s i z e w i t h i n a r e a s o n a b l e amount of t i m e , i t was d e c i d e d t o change the l e n g t h of h o s p i t a l i z a t i o n c r i t e r i a t o one day p o s t - o p e r a t i v e ( i . e . , t he a c t u a l day of d a t a c o l l e c t i o n ) . Because t h i s s t u d y r e q u i r e d t h a t the c h i l d r e n be a b l e t o f o l l o w d i r e c t i o n s i n o r d e r t o f u l l y p a r t i c i p a t e , o n l y c h i l d r e n who spoke and und e r s t o o d E n g l i s h were i n c l u d e d . C h i l d r e n whose m e d i c a l h i s t o r i e s i d e n t i f i e d the presence of c h r o n i c p a i n syndrome ( p a i n which i s p e r s i s t e n t and s t a b l e , g e n e r a l l y not t h e r a p e u t i c a l l y c o n t r o l l e d , and has become a d i s t i n c t e n t i t y r a t h e r than a symptom of an o r i g i n a l c o n d i t i o n [Ross & Ross, 19881) were e x c l u d e d . The presence of t h i s syndrome c o u l d i n f l u e n c e the p e r c e p t i o n of a c u t e p a i n . F i n a l l y , c h i l d r e n who were not a l e r t p o s t - o p e r a t i v e l y , or who were m e n t a l l y handicapped, d e v e l o p m e n t a l l y d e l a y e d , n e u r o l o g i c a l l y i m p a i r e d or who had l e a r n i n g d i s a b i l i t i e s or e x p e r i e n c e d s u r g i c a l c o m p l i c a t i o n s , were e x c l u d e d from t h i s s t u d y because, as p r e v i o u s l y s t a t e d , the s u b j e c t s were r e q u i r e d t o be f u l l y a l e r t and a b l e t o understand and f o l l o w d i r e c t i o n s . 37 Selection Procedure  Pre-Operative Selection Children who met the c r i t e r i a were i d e n t i f i e d by two d i f f e r e n t methods due to the change in se t t i n g . S p e c i f i c a l l y , the two children selected from the children's hospital were i d e n t i f i e d by the researcher on d i f f e r e n t days from the surgical slate the evening before th e i r surgeries. A discussion with the charge nurse or nurse caring for each c h i l d determined that the sp e c i f i e d c r i t e r i a (one through five) were met by each c h i l d . The researcher then i n d i v i d u a l l y approached each c h i l d and his/her parents, introduced herself as a nurse and graduate student at the University of B r i t i s h Columbia School of Nursing conducting research study on children's pain after surgery, and asked i f they would be interested in hearing about the study. The parents of both children were interested and a verbal explanation of the study was provided. Following the explanation, any questions posed by the parents regarding the study were answered. F i n a l l y , each chil d ' s parents were asked by the researcher i f they would be w i l l i n g to allow their c h i l d to participate in the study. At t h i s time, prior to consent, these parents were also informed that their refusal to allow th e i r c h i l d to participate in the study and/or their withdrawal of the c h i l d or the child' s own withdrawal from the study at any time, i f they should consent to allow their c h i l d to p a r t i c i p a t e , would not af f e c t their c h i l d ' s care in any way. Both sets of parents agreed to the 38 inclusion of their children and written consent was obtained from the parents (see Appendix A). A t o t a l of three written consents were signed by each c h i l d ' s parents and witnessed by the researcher. One copy remained with the parents, another remained with the researcher, and a t h i r d copy was placed on the chart. Because the two children chosen from the children's hospital were approached on the evening prior to surgery, each c h i l d was given an opportunity to practice with the PCT during t h i s i n i t i a l meeting. This practice session enabled the researcher to determine i f each c h i l d understood the word "hurt" and i t s association to pain, and whether the c h i l d understood what the researcher was asking of him/her. During this practice session, each c h i l d was asked to r e c a l l two previous pain experiences, and then to rate the int e n s i t y of the pain of these experiences using the PCT. S p e c i f i c a l l y , each c h i l d was asked to show the researcher using the " l i t t l e b i t s of hurt" ( i . e . , the PCT) (Hester, 1979) how much the affected body part hurt at the time. The c h i l d was told that one white chip meant "no hurt" (Beyer & Aradine, 1988); one red chip meant "a l i t t l e b i t of hurt", (Hester, 1979); two red chips meant "more hurt"; three red chips meant "even more hurt"; and four red chips meant "the biggest hurt you could ever have" (Beyer & Aradine, 1988). If the c h i l d could not r e c a l l an episode, parents were asked to a s s i s t in the r e c a l l . Following these ratings, the children were asked to use the PCT to show how much "hurt" ( i . e . , pain) they were 39 e x p e r i e n c i n g a t t h a t moment. Having c o m p l i e d ( i . e . , r e p o r t i n g no p a i n ) , t h e y were then asked i f t h e y would be w i l l i n g t o i n d i c a t e the amount of t h e i r " h u r t " a g a i n a f t e r t h e i r o p e r a t i o n s . Both c h i l d r e n v e r b a l l y c onsented t o do so. I f the r e s e a r c h e r had d e t e r m i n e d d u r i n g t h i s p r a c t i c e s e s s i o n t h a t e i t h e r of the c h i l d r e n was unables t o use the PCT a p p r o p r i a t e l y t o r a t e h i s / h e r p a i n , t h a t c h i l d would have been e x c l u d e d from the s t u d y . However, both of the c h i l d r e n had no d i f f i c u l t y u s i n g the PCT and thus were i n c l u d e d i n the s t u d y . F i n a l l y , when a l l q u e s t i o n s had been answered and both the r e s e a r c h e r and the p a r e n t s were s a t i s f i e d t h a t each c h i l d c o u l d p a r t i c i p a t e , the i n i t i a l meeting was c o n c l u d e d . The r e s e a r c h e r then p l a c e d i n the c h a r t one copy of the p a r e n t a l c o n s e n t and a l e t t e r which informed the c h i l d ' s surgeon of the s t u d y (see Appendix B ) . P o s t - O p e r a t i v e S e l e c t i o n With the change of s e t t i n g t o two o t h e r h o s p i t a l s , the s u b j e c t s e l e c t i o n procedure was a l t e r e d . In the new s e t t i n g s few e l e c t i v e s u r g e r i e s a re s c h e d u l e d t h a t r e q u i r e a h o s p i t a l s t a y of a t l e a s t one day p o s t - o p e r a t i v e . T h e r e f o r e , the m a j o r i t y of c h i l d r e n who were a b l e t o meet the c r i t e r i a were a d m i t t e d f o r emergency s u r g e r i e s which d i d r e q u i r e a h o s p i t a l s t a y of a t l e a s t one day. As a r e s u l t , t h e s e c h i l d r e n were not a v a i l a b l e p r e - o p e r a t i v e l y f o r s e l e c t i o n t o the s t u d y and i n s t e a d were s e l e c t e d on the day a f t e r s u r g e r y ( i . e . , the f i r s t p o s t - o p e r a t i v e d a y ) . 40 Each morning at 0800 hours, the researcher telephoned the p a r t i c i p a t i n g units and with the Head Nurses or the charge nurses, i d e n t i f i e d the a v a i l a b i l i t y of children meeting a l l of the sp e c i f i e d c r i t e r i a . Suitable children and their parents were then approached by the researcher later during the morning of the f i r s t post-operative day (usually between 0930 and 1000 hours). The procedure for obtaining consents from parents and their children and for informing each c h i l d ' s surgeon did not change from the procedure used pre-operatively at the children's ho s p i t a l . However, because the children were being approached to par t i c i p a t e on the actual day of data c o l l e c t i o n , i t was not possible to provide each c h i l d with a practice session with the PCT. Instead, the researcher conversed with each c h i l d to not only f a m i l i a r i z e the c h i l d with the researcher and her role but also to ascertain whether the c h i l d understood the concept of "hurt". These dialogues always began with the researcher introducing herself to the c h i l d , then inquiring about his/her injury (e.g., "How did i t happen?") and/or operation (e.g., "How do you f e e l ? " ) . The researcher would then ask the c h i l d i f the s p e c i f i c body part operated upon hurt at that moment. A l l of the children involved indicated, usually with a nod, that the affected body part did hurt. At this point, the researcher would ask the c h i l d i f he/she could t e l l the researcher how much i t hurt using the " l i t t l e b i t s of hurt" ( i . e . , the PCT). An explanation of the meaning of each poker chip was 41 p r o v i d e d (see page 39 for e x p l a n a t i o n ) , and the c h i p s were handed to the c h i l d . I f the c h i l d chose any number of r e d c h i p s , the r e s e a r c h e r assumed t h a t the c h i l d unders tood the concept of "hurt" and was ab le to d e f i n e i t i n terms of the PCT. A l l c h i l d r e n were a b l e to d e f i n e the i n t e n s i t y of t h e i r p a i n i n terms of the PCT and thus a l l were i n c l u d e d i n the s t u d y . In a d d i t i o n , the r a t i n g s each c h i l d gave of h i s / h e r p a i n d u r i n g t h i s i n i t i a l meet ing were used as d a t a . Data C o l l e c t i o n Data c o l l e c t i o n began a f t e r the Head Nurses of a l l the wards i n v o l v e d agreed to p a r t i c i p a t e and when a l e t t e r had been r e c e i v e d , on each ward i n f o r m i n g the s t a f f about the s t u d y (see Appendix C ) . Data c o l l e c t i o n for the f i r s t two c h i l d r e n began on the even ing be fore s u r g e r y . At t h a t t ime , demographic data were r e c o r d e d u s i n g the p r e - o p e r a t i v e data c o l l e c t i o n form (see Appendix D) which i n c l u d e d the f o l l o w i n g d a t a : the date of c o l l e c t i o n and the s u b j e c t ' s code for da ta c o l l e c t i o n ; the s u b j e c t ' s sex , age , b i r t h d a t e , ward, and d i a g n o s i s ; the date a n d , r e a s o n for a d m i s s i o n ; the impending s u r g i c a l p r o c e d u r e ; whether the s u b j e c t met the p r e - o p e r a t i v e c r i t e r i a ; whether an e x p l a n a t i o n of the s tudy by the r e s e a r c h e r had been g i v e n ; whether a l l three consents had been comple ted; whether the s u b j e c t had p a r t i c i p a t e d i n a p r a c t i c e s e s s i o n ; and whether the s u b j e c t unders tood the d i r e c t i o n s for use of the PCT as i d e n t i f i e d i n the p r a c t i c e s e s s i o n . For c h i l d r e n o b t a i n e d from the a l t e r n a t i v e s i t e s , these da ta were c o l l e c t e d on the 42 f i r s t post-operative day. Data regarding the subject's meeting of pre-operative c r i t e r i a , the completion of a practice session, and the impending surgery were omitted for these children. Data pertaining to the variables under study commenced on the morning of the f i r s t post-operative day between the hours of 0800 and 2000. Data were collected only by the researcher. Data were collected at approximately four-hour intervals ( i . e . , 0800, 1200, 1600, and 2000 hours), for a t o t a l of four c o l l e c t i o n periods for each c h i l d . (This time frame was used in a s i m i l a r study by Abu-Saad [1984].) However, because a l l but the f i r s t two children were approached for p a r t i c i p a t i o n in the study on the actual day of testing, data c o l l e c t i o n for the other children a c t u a l l y began between 0930 and 1000 hours. As a r e s u l t , the f i r s t two data c o l l e c t i o n periods for the later children were less than 4 hours apart. The post-operative data c o l l e c t i o n form (see Appendix E) was used at each of the four c o l l e c t i o n times to record the following data: the subject's code number and ward; the te s t i n g date and times; the pain i n t e n s i t y scores; overt behavioural observations; the type and dose of analgesics ordered post-operatively; the time, type, route, and dose of the l a s t analgesic administered prior to testing; the actual su r g i c a l procedure performed; the presence of absence of parents; and any additional comments the researcher wished to note. 43 Overt Behavioural Observations The l i t e r a t u r e reviewed in Chapter Two revealed that behavioural assessment is probably not an accurate measure of post-operative pain. The researcher however believes that behavioural assessment may add depth to the understanding of t h i s post-operative pain in children, p a r t i c u l a r l y i f the behavioural assessment is structured so as to increase the r e l i a b i l i t y of recorded behaviours. Therefore, a behavioural c h e c k l i s t was developed by the researcher, s p e c i f i c a l l y for t h i s study (see Appendix E). This checklist was located on the Post-Operative Data C o l l e c t i o n Form and comprised a l i s t of behaviours categorized under the headings: (a) vocalizations, (b) verbal, (c) f a c i a l expressions, (d) motor a c t i v i t y , and (e) c h i l d ' s a c t i v i t y . The f i r s t four of these categories and the majority of s p e c i f i c behaviours i d e n t i f i e d under each of them as well as their corresponding d e f i n i t i o n s , were based on the works of Abu-Saad (1984), Brunke (1989), McCaffery (1972), and McGrath et a l . (1985), which provided support for the content v a l i d i t y of these categories and behaviours. Based on the l i t e r a t u r e review and her own experience as a pe d i a t r i c nurse in a variety of c l i n i c a l settings, the researcher expanded the l i s t of behaviours for each of the four categories, and included the category "child's a c t i v i t y " , and i t s corresponding behaviours (see Appendix F for D e f i n i t i o n of Terms of Behavioural Ch e c k l i s t ) . As data c o l l e c t i o n progressed, i t became apparent that another behaviour, namely t e l e v i s i o n watching, 44 was pertinent to the category of chil d ' s a c t i v i t y . However, rather than amend the post-operative data c o l l e c t i o n form, thi s behaviour was recorded under the heading of "comments". At each four hour i n t e r v a l , the researcher, using the predetermined behavioural c h e c k l i s t , recorded on the post-operative data c o l l e c t i o n form the chil d ' s overt behaviours. This was done as unobtrusively as possible, and only for those children who were awake. Each observation of a child's behaviours took only 5 seconds, as recommended by McGrath et a l . (Ross & Ross, 1988). Following t h i s observation, the researcher noted on the post-operative data c o l l e c t i o n form the presence or absence of the child's parent(s), then approached the c h i l d and asked him/her to rate his/her pain using the PCT. Pain Intensity Scores The concept of pain i n t e n s i t y was measured using the Poker Chip Tool (PCT), a modified version of Hester's (1979) Poker Chip Tool (Beyer & Aradine, 1988) which was o r i g i n a l l y designed to assess the pain i n t e n s i t y of children aged 4 to 7 years. The PCT consists of one white poker chip which represents no pain, and four red poker chips which indicate increasing levels of pain (Aradine, Beyer, & Tompkins, 1988). Using t h i s instrument, the children were asked to choose the white chip i f they had no pain, or from one to four red chips to represent the amount of their pain ( i . e . , one red chip means "a l i t t l e hurt" and four red chips mean "the biggest hurt you could ever have" [Aradine, Beyer, & Tompkins, 1988, 45 p. 13] ) . Construct v a l i d i t y of the PCT has been supported through research conducted by Aradine, Beyer, and Tompkins (1988), and was examined by "obtaining children's reports of their post-operative pain intensity before and after analgesic administration" (p. 12) using the PCT, a vi s u a l analogue scale (VAS), and the Oucher (numerical s c a l e ) . It was hypothesized that children's pain i n t e n s i t y scores after analgesia would be lower than the pre-analgesia scores. The findings confirmed that post-analgesia scores using the PCT were lower than pre-analgesia scores. In addition, the scores from the three scales, the PCT, the VAS, and the Oucher, were a l l p o s i t i v e l y correlated, thereby confirming the convergent v a l i d i t y of the PCT. A study by Beyer and Aradine (1988) also provided support for the convergent v a l i d i t y as well as the discriminant v a l i d i t y of the PCT. In this study, the relati o n s h i p of the PCT, the VAS, and the Oucher (numerical scale) with the Hospital Fears Rating Scale (Melamed & Siegel, 1975) and with the Scare Scale was assessed, using a sample of 54 hospitalized children aged 5 to 12 years. A positive r e l a t i o n s h i p was reported between the VAS and the PCT (gamma c o e f f i c i e n t = 0.881), and between the PCT and the Oucher (gamma c o e f f i c i e n t = 0.946). The findings also revealed, as expected, a low negative c o r r e l a t i o n between the Hospital Fear Score and the PCT (gamma c o e f f i c i e n t = -0.004), and between the Scare Score and the PCT (gamma c o e f f i c i e n t = 46 -0.039). In t h i s study, each c h i l d was asked by the researcher to show, using the poker chips, how much pain or hurt, i f any, they were fee l i n g from the operative s i t e which was s p e c i f i c a l l y i d e n t i f i e d for each c h i l d . Each c h i l d was then handed the poker chips and was reminded of the meaning of the chips (see p. 39 for an explanation of the meaning of the PCT). The c h i l d then handed back to the researcher the colour and number of poker chips which he/she f e l t s i g n i f i e d the amount of hurt or pain. There was no further questioning of the c h i l d afterward. The score was immediately recorded on the post-operative data c o l l e c t i o n form. None of the children refused to p a r t i c i p a t e , although seven of the children were asleep during at least one testing period and were therefore not disturbed. None of the children appeared to be experiencing any d i f f i c u l t y in using the PCT and most took only a few seconds to think about their choices. However, four of the children, when choosing the colour and number of poker chips s i g n i f y i n g "a l i t t l e b i t of hurt" ( i . e . , one red chip) included the white chip with the single red chip, although they could not explain why when questioned by the researcher. F i n a l l y , the time, type, dose and route of the l a s t analgesic given to the c h i l d before testing was noted as reported in the nurses* notes. In addition, any added comments the researcher considered pertinent to the study regarding each pa r t i c u l a r c h i l d were also noted at that time. 47 Data c o l l e c t i o n for each time period took no more than 5 minutes in t o t a l . Data Analysis Both research questions require descriptive answers; Ordinal l e v e l data for pain in t e n s i t y scores and nominal level for behavioural scores were co l l e c t e d . Therefore, only summary s t a t i s t i c s were used (Burns & Grove, 1987), hand-calculated by the researcher. In addition, a l l data were assessed for suggested relationships and for the development of hypotheses for further testing. Pa in Intensity Scores For the children's reported pain i n t e n s i t y scores, the following are reported: grouped frequency d i s t r i b u t i o n of scores, percentage d i s t r i b u t i o n of scores, the range of scores c o l l e c t e d , and the mode and mean of the t o t a l scores. The reported pain i n t e n s i t y scores were also examined in r e l a t i o n to the amount of time ( i . e . , number of hours) which occurred between the la s t analgesic administered and each succeeding testing period. Grouped frequency d i s t r i b u t i o n s were noted for each i d e n t i f i e d analgesia time period. F i n a l l y , the reported pain i n t e n s i t y scores were examined in r e l a t i o n to parental presence. The frequency d i s t r i b u t i o n of pain i n t e n s i t y scores and the modes and means of scores were calculated for children whose parents were present and for those whose parents were absent. Overt Behaviours Behavioural actions were recorded in the form of nominal 48 l e v e l d a t a . As a r e s u l t , a n a l y s i s of t h i s da ta took the form of ungrouped f requency d i s t r i b u t i o n s and percentage d i s t r i b u t i o n s of the i d e n t i f i e d behav iours under each c a t e g o r y . Demographic and Other Data For a l l o ther nominal l e v e l d a t a , p a r t i c u l a r l y the t i m e , t y p e , and route of l a s t a n a l g e s i c and the demographic data of the p a r t i c i p a t i n g c h i l d r e n , summary s t a t i s t i c s of f requency and percentage d i s t r i b u t i o n s were c a l c u l a t e d . Means and modes for age of the p a r t i c i p a t i n g c h i l d r e n ' s ages were a l s o c a l c u l a t e d . E t h i c a l C o n s i d e r a t i o n s P r o t e c t i o n of Human R i g h t s The human r i g h t s of the c h i l d r e n and t h e i r parent s were p r o t e c t e d i n the f o l l o w i n g ways: 1. A p p r o v a l to conduct the r e s e a r c h s tudy was r e q u e s t e d and r e c e i v e d from the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee for Research and Other S t u d i e s I n v o l v i n g Human S u b j e c t s (see Appendix G ) . 2. Access was ga ined to the s t u d y s e t t i n g by s u b m i t t i n g the r e s e a r c h p r o p o s a l to the Research Review Committees of each p a r t i c i p a t i n g h o s p i t a l and r e c e i v i n g a p p r o v a l to conduct the r e s e a r c h s t u d y . 3. C o n f i d e n t i a l i t y of a l l i n f o r m a t i o n c o l l e c t e d was e n s u r e d . The p a r t i c i p a t i n g s u b j e c t s ' p r i v a c y was p r o t e c t e d through the omi s s i on of p a t i e n t names or i d e n t i f y i n g d e t a i l on any documents o ther than the consent forms. Data 49 collected were limited only to that necessary for the study. A l l data collected were accessed only by the researcher and the two members of the researcher's thesis committee and were stored in a locked desk. Upon completion and acceptance of the thesis, a l l recorded data w i l l be destroyed. 4. I f , during testing, the researcher i d e n t i f i e d a c h i l d who was experiencing pain, the researcher informed the charge nurse or Head Nurse. 5. The researcher respected the rights of the parents or l egal guardians to withdraw their c h i l d at any time from the study. This information was made known to them at the time of obtaining consent and was included in the consent form. 6. The researcher respected the rights of the c h i l d to refuse to part i c i p a t e at any time with or without the consent of the parent or legal guardian. As well, any c h i l d who was sleeping at the time of data c o l l e c t i o n was not disturbed. Limitations The f i r s t and most important l i m i t a t i o n of this study is the small sample size (11 children), which is d i r e c t l y related to the a v a i l a b i l i t y of subjects for the sample and therefore l i m i t s generalization of the findings. The a v a i l a b i l i t y of subjects was hampered by many factors, but p a r t i c u l a r l y the settings in which the study was conducted. For example, the i n i t i a l s e t t i n g , the children's hospital, was experiencing a shortage of available inpatient beds at the time of data c o l l e c t i o n , which often resulted in the 50 cancellation of inpatient surgeries. In addition, a number of children in that hospital who could have participated in the study were admitted to the Care by Parent Unit, to which the researcher did not have access. In the other two settings, d i f f e r e n t reasons existed for the lack of available subjects. Because only limited inpatient p e d i a t r i c surgery i s conducted at either of these hospitals, the researcher was forced to r e l y upon emergency admissions. Emergency admissions occurred less frequently than expected by the hospital s t a f f ; thus, there resulted a r e l a t i v e l y small sample. The second factor which limited the size of the sample was the c r i t e r i o n of length of hospital stay. The increased use of daycare surgery and the reduction in the length of hospital stay required for most children undergoing common types of surgery (e.g., children having tonsillectomies are now being discharged d i r e c t l y from daycare surgery or on the f i r s t post-operative day) prevented the p a r t i c i p a t i o n of many children who met a l l of the other c r i t e r i a but had hospital stays of less than one day post-operative. A second l i m i t a t i o n of this study was the researcher's i n a b i l i t y , due to limited physical resources, to measure pain in t e n s i t y during the night. This l i m i t a t i o n l e f t gaps in data for t h i s time period; the findings of t h i s study can only be generalized to the hours of the day between 0800 and 2000 hours. The f i n a l l i m i t a t i o n of thi s study was the repeated 51 testing of the children. It is possible that as the children continued to p a r t i c i p a t e , their a b i l i t i e s to comprehend and u t i l i z e the instrument may have increased with practice. This could confound the results of the study. Summary In t h i s chapter, a description of the methods and procedures used to investigate the post-operative pain of hospitalized children aged 4 to 7 years on the f i r s t post-operative day has been provided. This discussion included descriptions of the research design, the settings, subject s e l e c t i o n , methods of data c o l l e c t i o n , methods of data analysis, e t h i c a l considerations, and f i n a l l y the l i m i t a t i o n s of the methods used. A presentation and discussion of the findings of t h i s research study w i l l be presented in the following chapter. 52 CHAPTER FOUR Research Findings and Discussion In t h i s chapter, a presentation and discussion o£ the findings of this research study are presented. S p e c i f i c a l l y reported are the findings that relate to the two research questions : (1) What are the levels of pain i n t e n s i t y reported on the f i r s t post-operative day by hospitalized children aged 4 to 7 years who have undergone surgical procedures? (2) What are the overt behaviours exhibited at the time of pain i n t e n s i t y l e v e l measurement on the f i r s t day post-operative by hospitalized children aged 4 to 7 years who have undergone su r g i c a l procedures? Also included in this chapter is a summary of the demographic data. Summary of Demographic Data A t o t a l of 11 children participated in t h i s research study. However, one c h i l d a c t u a l l y participated twice in t h i s study as he underwent two surgeries over a 5 day period, thus bringing the actual number of subjects to 12. Although i t was possible that this c h i l d ' s repeated p a r t i c i p a t i o n could r e s u l t in increased f a m i l i a r i t y with the PCT thereby r e s u l t i n g in a difference in his reported scores, t h i s concern was negated by the fact that a l l of the children were familiar with the tool by the second te s t i n g . Of the children p a r t i c i p a t i n g in t h i s study, 7 were male and 4 were female. 53 Age As d i s c u s s e d i n Chapter Three, t h i s study was i n i t i a l l y designed to i n c l u d e only c h i l d r e n aged 4 to 7 years, but i t became necessary due to a lack of a p p r o p r i a t e s u b j e c t s to change t h i s c r i t e r i o n i n order to gather an adequate sample s i z e w i t h i n a reasonable time p e r i o d . Thus, 2 c h i l d r e n who were 8 years o l d and met of a l l the other c r i t e r i a were in c l u d e d i n the study. Consequently, the a c t u a l ages of the 11 p a r t i c i p a t i n g c h i l d r e n ranged from 4 years 1 month to 8 years 5 months. The mean age of the p a r t i c i p a t i n g c h i l d r e n was 6 years 0 months. Types of Surgery A number of the c h i l d r e n experienced abdominal (4) or o r t h o p e d i c (4) surgery. Two others underwent u r o l o g i c a l s u r g ery and one had p l a s t i c surgery. Type and Route of A n a l q e s i c A l l of the 11 c h i l d r e n were ordered a t l e a s t one n a r c o t i c a n a l g e s i c p o s t - o p e r a t i v e l y . S p e c i f i c a l l y , 4 c h i l d r e n were ordered Demerol Intramuscular (IM) and Acetaminophen Per Os (PO); 2 c h i l d r e n were ordered Codeine PO or IM and Acetaminophen PO; 2 c h i l d r e n were ordered Demerol IM, Codeine PO or IM, and Acetaminophen PO; 1 c h i l d was ordered Codeine IM and Acetaminophen with 15mg of Codeine PO; and f i n a l l y , 2 c h i l d r e n were ordered one of e i t h e r Demerol IM or Codeine IM only. P o s t - O p e r a t i v e A n a l g e s i a Data were a l s o c o l l e c t e d d u r i n g each c o l l e c t i o n p e r i o d 54 regarding the time, type, route and dose of analgesic administered to each p a r t i c i p a t i n g c h i l d within t h i s time frame. A l l of the children in t h i s study received at least one analgesic post-operatively between the hours of 0800 and 2000. C o l l e c t i v e l y , during this study period, the children received a t o t a l of 21 doses of analgesics (14 narcotics, 5 nonnarcotics, and 2 narcotic-nonnarcotic combinations). Pain Intensity Scores Findings Using the PCT, a l l of the children reported pain post-operatively during at least one data c o l l e c t i o n period on the f i r s t post-operative day between 0800 and 2000 hours. As can be seen from Table I, the actual pain scores reported by the children ranged from 0 to 4 (zero meaning no pain and 4 meaning the most pain the c h i l d had ever f e l t ) . Only one c h i l d on one occasion reported a pain score of 4, and 6 children reported a zero score at least once during data c o l l e c t i o n periods. Seven children were asleep during 8 data c o l l e c t i o n periods; pain scores are missing for these periods as these children were not disturbed. There were, in t o t a l , 48 testing periods, and scores were obtained for 40 of these. The most frequent score (the mode, 42.5% of t o t a l scores) was a score of 1, which indicated some pain or "a l i t t l e b i t of hurt" in children reporting t h i s score. The next most frequent score was 2 (30% of t o t a l scores), which indicated even more pain being experienced by the children. The mean t o t a l score was 1.35. Scores of 3 and 4 were 55 reported for a combined t o t a l of only 10% of the children. Table I Frequency of Children's Pain Intensity Scores Pain Scores Frequency % •0 7 • 17.5 1 17 42 . 5 2 12 30.0 3 3 7 . 5 4 1 2.5 Total 40 100 Note. 7 children were asleep during 8 data c o l l e c t i o n per iods Mean Pain Intensity Score = 1.35 The children's reported pain i n t e n s i t y scores were also analyzed in combination with the amount of time ( i . e . , number of hours) which occurred between the la s t analgesic administered and each succeeding testing period. As can be seen from Table II, there was a difference in the mean score 0 to 2 hours post analgesic (0.92) and the mean scores both at 2 to 4 hours (1.50) and at greater than 4 hours (1.56) post analgesic. 56 Table II Frequency of Children's Pain Intensity Scores and the Number  of Hours Since Last Analges ic Analgesia Pain Scores Hours N 0 1 2 3 4 Mean 0 - 2 12 4 5 3 0 0 0.92 2 - 4 12 3 2 6 0 1 1.50 > 4 16 0 10 3 3 0 1.56 Note. 7 children were asleep during 8 data c o l l e c t i o n periods Although not included s p e c i f i c a l l y as a research question, the role of parental presence on the reported pain scores of children was of interest to the researcher, and the presence or absence of a parent was also recorded for each data c o l l e c t i o n period. Analysis of t h i s information indicated very l i t t l e difference in scores whether parents were present or absent (see1 Table I I I ) . S p e c i f i c a l l y , when parents were present during data c o l l e c t i o n periods the range of children's pain scores was 0 to 4, the mode was 1, and the mean pain score was 1.36. When parents were absent during data c o l l e c t i o n , the range of pain scores was 0 to 3, the mode was once again 1, and the mean was 1.33. 57 Table III Frequency of Children's Pain Intensity Scores Pur ing Parental  Presence and Absence Pain Scores Parents N 0 1 2 3 4 Mean Present 25 4 11 8 1 1 1.36 Absent 15 3 6 4 2 0 1.33 Note. 7 children were asleep during 8 data c o l l e c t i o n periods Discussion of Findings Findings related to pain in t e n s i t y scores provide the basis for three important conclusions about the children who participated in th i s study. F i r s t , a l l of the children were able to place a value on their pain using the PCT. A s c a r c i t y of research exists which substantiates the use of PCT for children in the pre-operational stage of development. Therefore, there was concern that because of the children's concrete thinking (Piaget & Inhelder, 1969) they would be unable, without t r a i n i n g , to translate their feelings of pain into a certain colour and number of poker chips (Dr. J. Lander, personal communication, A p r i l 11, 1989; Smith, 1976). 58 However, the children in this study were able to use the PCT, without t r a i n i n g , to express their pain i n t e n s i t y l e v e l s . This finding is a s i g n i f i c a n t point for the future use of the PCT as a sel f - r e p o r t measure of pain i n t e n s i t y by children in the pre-operational stage of development. Second, i t was concluded that the children were experiencing some degree of post-operative pain. This conclusion i s congruent those drawn by Mather and Mackie (1983) and Aradine, Beyer and Tompkins (1988) in their research studies which assessed the post-operative pain of children including those aged 4 to 7 years. The presence of the children's pain in t h i s study is possibly as a resu l t of undermedication with analgesics. Although the findings cannot provide d e f i n i t i v e proof of such a rel a t i o n s h i p , the data appear to point in that d i r e c t i o n . F i r s t , i s the presence of post-operative pain during a l l periods post analgesic administration as indicated by the mean scores at 0 to 2 hours (0.92), 2 to 4 hours (1.50) and greater than 4 hours (1.56) post analgesic. Second, although a l l of the children received at least one type of analgesic during the period of data c o l l e c t i o n , they c o l l e c t i v e l y received a t o t a l of only 21 doses. As a r e s u l t , i t is possible that the children in this study experienced pain due to undermedication r e s u l t i n g from the lack of consistent administration of analgesia ( i . e . , administered on a regular basis versus when the c h i l d requested i t or appeared to need i t ) . 59 Support for this conclusion is also r e f l e c t e d in the research of Mather and Mackie (1983). In that study, 40% of the 170 children were experiencing moderate to severe pain on the f i r s t post-operative day. Of these 170 children, only 77 received at least one dose of analgesic on the f i r s t post-operative day and only 39% of these were found to be pain free. In addition, for 27 of the 170 children (16%) no analgesic was ordered at a l l . As a r e s u l t , Mather and Mackie concluded that the because of the poor prescription and administration of analgesics, the children were experiencing poor analgesia which resulted in feelings of pain. Even though Mather and Mackie's (1983) method of pain measurement was questionable (as outlined in Chapter 2), their findings support the conclusion that the children's pain was related to i n s u f f i c i e n t post-operative medication. Although the focus of Aradine, Beyer and Tompkins' (1988) research was the construct v a l i d i t y of their pain tool (the "Oucher"), they reported similar findings to t h i s study regarding pain intensity scores post analgesic using the PCT. They reported that the pain i n t e n s i t y scores of 24 children (3.0 to 12.4 years of age) recorded during one day, between 1 and 5 days postsurgery, at hourly intervals for 4 hours post analgesic, ranged from 0 to 4 with a t o t a l mean of 1.5. The mean scores at the hourly intervals were 1.4 at 1 hour, 1.2 at 2 hours, 1.7 at 3 hours and 1.7 at 4 hours. These mean scores indicated the presence of pain in the majority of the children even after the administration of an analgesic. 60 Another possible reason for the children's reports of pain in t h i s study pertains to the data c o l l e c t i o n periods. Perhaps data were collected at times that coincided with times of analgesic administration ( i . e . , either prior to or past the peak effectiveness period of the analgesics that were administered [see Table I I ] ) . This explanation seems unli k e l y however because a l l of the 6 children reporting at least one zero score had received some type of analgesic within a 4 hour period prior to reporting that score. A f i n a l possible explanation for the children's reports of pain is that the PCT was not just r e f l e c t i n g the children's surgical s i t e pain. Ross and Ross (1988) state that the presence of general discomforts such as fear and anxiety may influence feelings of pain. S p e c i f i c a l l y , i t is theorized that fear and anxiety may a c t u a l l y increase the chil d ' s perception of pain (Meinhart & McCaffery, 1983). However, additional factors indicate that in t h i s study the PCT was measuring the children's pain i n t e n s i t y l e v e l s . F i r s t , rather than asking the children to show how much they hurt, the researcher s p e c i f i c a l l y asked the children to show, using the PCT, how much the s u r g i c a l s i t e (for example, the c h i l d ' s elbow) hurt. Second, the PCT was shown to have evidence of convergent and discriminant v a l i d i t y (Beyer & Aradine, 1988) and, t h i r d , these children did not appear to the researcher to be s u f f e r i n g from any anxiety, fear or other discomfort. Furthermore, i t i s interesting to note that the theorized role of the parent is generally to 61 minimize a c h i l d ' s f e e l i n g s of fear and a n x i e t y ( J e r r e t , 1985; Ross & Ross, 1984), yet the t h i r d c o n c l u s i o n drawn from the f i n d i n g s of t h i s study i s that the pain i n t e n s i t y s c o r e s r e p o r t e d by the c h i l d r e n appeared to be no d i f f e r e n t whether parents were present or absent. T h e r e f o r e , i f the PCT was a c t u a l l y r e f l e c t i n g f e e l i n g s of f e a r and a n x i e t y i n a d d i t i o n to or r a t h e r than f e e l i n g s of p a i n , a d i f f e r e n c e i n pain scores c o u l d l o g i c a l l y be expected a c c o r d i n g to the presence of absence of parents. However, pain s c o r e s were not r e l a t e d to p a r e n t a l presence. Overt Behaviours Findings Using the b e h a v i o u r a l c h e c k l i s t , the o v e r t behaviours demonstrated by the c h i l d r e n were recorded at each data c o l l e c t i o n p e r i o d . The most frequent behaviours e x h i b i t e d by the p a r t i c i p a t i n g c h i l d r e n d u r i n g the data c o l l e c t i o n p e r i o d s were behaviours which are normally not a s s o c i a t e d with e x p r e s s i o n s of pain (see Table IV). The f o l l o w i n g i s a p r e s e n t a t i o n of the frequency of observed s p e c i f i c behaviours. V o c a l i z a t i o n and V e r b a l Behaviours The most frequent behaviour e x h i b i t e d by c h i l d r e n i n the v o c a l i z a t i o n c a t e g o r y was the absence of c r y i n g (accounting f o r 97.5% of the t o t a l v o c a l i z a t i o n b e h a v i o u r s ) . C o r r e s p o n d i n g l y , w i t h i n the v e r b a l category, s i n c e most of the c h i l d r e n were not c r y i n g , the most frequent v e r b a l behaviour recorded was p o s i t i v e t a l k i n g (accounting f o r 52.5% 62 of the t o t a l verbal behaviours), where the children either made positive statements or talked of various things without complaint (McGrath et a l . , 1985). The next most frequent verbal behaviour observed was nonverbal ( i . e . , the children said nothing), which alone accounted for 40.0% of the t o t a l behaviours in this category. F a c i a l Expressions Smiling was the most frequent f a c i a l expression observed accounting for 47.5% of the t o t a l behaviours. This was followed c l o s e l y by a composed f a c i a l expression, which occurred in 37.5% of the t o t a l f a c i a l expressions. Motor A c t i v i t y The most frequent behaviour observed in t h i s category was neutral a c t i v i t y , which i s described as a relaxed and inactive body. This behaviour accounted for 92.5% of the t o t a l behaviours in th i s category. Child's A c t i v i t y In t h i s category, the observed behaviours were spread f a i r l y evenly across three a c t i v i t i e s . The most frequent a c t i v i t y was t e l e v i s i o n watching, which accounted for 41.7% of the observed behaviours, followed c l o s e l y by the a c t i v i t y of playing (37.5%) and taking f l u i d s or sol i d s (20.8%). Overt Behaviours and Parental Presence The majority of overt behaviours exhibited by the children were those not usually associated with pain. There was no apparent difference in pain in t e n s i t y scores according to parental presence or absence. The findings suggest 63 Table IV Frequency of Chi ldren ' s Exhibi ted Overt Behaviours Overt Behaviours Frequency V o c a l i z a t i o n No Cry Moaning Verbal Non Verbal Other Complaints Pain Complaints Pos i t ive F a c i a l Expression Composed Gr imace Frown Smile Motor A c t i v i t y Neutral Purposeless Tense C h i l d ' s A c t i v i t y Taking F l u i d s / S o l i d s Playing Watching Te l ev i s ion 39 1 16 2 1 21 15 1 5 19 37 1 2 5 9 10 97.5 2.5 40.0 5.0 2.5 52 . 5 37.5 2 . 5 12.5 47.5 92 .5 2.5 5.0 20.8 37.5 41.7 (table continues) 64 Note. Overt behaviours not recorded when c h i l d sleeping A l l non exhibited behaviours removed from table therefore that parental presence or absence did not make a difference in the behaviours exhibited by the children. Discussion of Findings The most frequent behaviours exhibited by the children were not those normally associated with feelings of pain, although an analysis of pain scores indicated that a l l but 6 children were experiencing pain at every data c o l l e c t i o n period (see Table I ) . In general, at the times of data c o l l e c t i o n the majority of the children were not crying; were either nonverbal or tal k i n g p o s i t i v e l y ; displayed smiles or composed faces; appeared to be relaxed and were generally inactive; and could be observed watching t e l e v i s i o n , taking f l u i d s , or playing qu i e t l y at the bedside. Only one c h i l d at just one data c o l l e c t i o n period exhibited signs which are normally associated with expressions of pain. S p e c i f i c a l l y , t h i s c h i l d was moaning, complaining of pain to his mother, grimacing, and moving purposelessly in the bed. At that time, the c h i l d reported a pain score of 3. The findings from th i s study suggest that behavioural measurement of pain may not be a r e l i a b l e and v a l i d measure of post-operative pain. This corroborates the b e l i e f s of Beyer & Byers (1985) and McGrath (personal communication, June 16, 1989) who express doubt regarding the usefulness of behavioural measurement of post-operative pain. In fact, i f 65 only a behavioural measurement tool had been used in t h i s study, the p a r t i c i p a t i n g children would probably have been categorized as being pain-free because they did not exhibit expected pain behaviours. However, th i s assumption would have been incorrect because the measurement of self-reported pain i n t e n s i t y indicated that the children were experiencing pain. The question, then, relates to why these children did not exhibit any behaviours associated with feelings of pain even though they were reporting feelings of pain using the PCT? It is possible that the PCT was not a c t u a l l y measuring pain intensity, and these children were therefore not a c t u a l l y experiencing any pain. However, McCaffery (1977) states that children in the pre-operational stage of development may be able to adapt their behavioural responses to pain by c o n t r o l l i n g behaviour and thereby exhibiting no overt response to pain. Furthermore, Hawley (1984) believes that these children may cope with the pain by using s e l f -d i s t r a c t i o n methods such as playing or sleep. Therefore, the researcher believes that a more l i k e l y explanation might be that the children had adapted or were coping with their pain, possibly through the a c t i v i t i e s i d e n t i f i e d during data c o l l e c t i o n ( i . e . , c h i l d ' s a c t i v i t y ) , and thus exhibited no overt pain behaviours. It was also suggested in the l i t e r a t u r e review that parental presence or absence may play a role in a chil d ' s a b i l i t y to cope with pain which then may r e s u l t in a range of 66 behaviours a c h i l d uses to exhibit pain (Gildea & Quirk, 1977; Ross & Ross, 1988). S p e c i f i c studies by Brunke (1989) and Shaw and Routh (1982) indicated that presence of parents appeared to allow the children in their studies to exhibit pain behaviours such as grimacing, crying, demanding to be held, and/or complaining of pain. However, unlike those studies which did not s p e c i f i c a l l y examine post-operative pain, parental presence or absence in thi s study did not appear to influence the children's overt behavioural response to their pain. As a r e s u l t , the conclusion drawn i s that parental presence or absence did not play a s p e c i f i c factor in the a b i l i t y of the children to express, cope, or adapt to the pain. Summary Based on the findings presented in t h i s chapter, i t is concluded that a l l of the children in this study were experiencing pain during at least one data c o l l e c t i o n period. The pain intensity levels of these children ranged from 0 to 4 with the mode being 1 and the mean 1.35. In addition, parental presence did not appear to be related to children's reported pain intensity l e v e l s . The presence of thi s pain was possibly related to undermedication of analgesics. Although the children did report feelings of pain, the majority of the children did not exhibit behaviours usually associated with pain. S p e c i f i c a l l y , at the time of data c o l l e c t i o n most of these children were not crying; were either nonverbal or talking p o s i t i v e l y ; displayed smiles or composed f a c e s ; appeared to be r e l a x e d and were g e n e r a l l y i n a c t i v e ; and could be observed p l a y i n g q u i e t l y at the bedside, t a k i n g f l u i d s , or watching t e l e v i s i o n . In the f o l l o w i n g chapter, a summary of the r e s e a r c h study with i t s major c o n c l u s i o n s w i l l be presented. In a d d i t i o n , i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e and r e s e a r c h generated by t h i s study, and recommendations for n u r s i n g p r a c t i c e , e d u c a t i o n , and r e s e a r c h w i l l be d i s c u s s e d . 68 CHAPTER FIVE Summary, I m p l i c a t i o n s , and Recommendations Summary The purpose of t h i s study was to d e s c r i b e the post-o p e r a t i v e pain of h o s p i t a l i z e d c h i l d r e n aged 4 to 7 years on the f i r s t p o s t - o p e r a t i v e day, through a s e l f - r e p o r t e d measure of pain i n t e n s i t y l e v e l s as w e l l as d e s c r i p t i o n s of the c h i l d r e n ' s overt behaviours used to express p a i n . A review of the l i t e r a t u r e i d e n t i f i e d t h a t few r e s e a r c h s t u d i e s have been p u b l i s h e d which examined the p o s t - o p e r a t i v e pain of c h i l d r e n , p a r t i c u l a r l y those between the ages of 4 and 7 y e a r s . As a r e s u l t , t h e o r e t i c a l l i t e r a t u r e has been the major c o n t r i b u t o r to the understanding of the concept of c h i l d r e n ' s p o s t - o p e r a t i v e p a i n . T h i s l i t e r a t u r e review d e l i n e a t e d three s p e c i f i c f a c t o r s which p l a y a major r o l e i n c h i l d r e n ' s p o s t - o p e r a t i v e p a i n : (a) the stage of c h i l d r e n ' s c o g n i t i v e development, (b) the presence or absence of parents, and (c) p e d i a t r i c personnel's pharmacological pain management. These f a c t o r s i n f l u e n c e not onl y c h i l d r e n ' s p e r c e p t i o n s of pain i n t e n s i t y but a l s o t h e i r overt b e h a v i o u r a l e x p r e s s i o n s of t h a t p a i n , and thus these p e r c e p t i o n s and b e h a v i o u r a l e x p r e s s i o n s can vary widely depending upon these f a c t o r s . A c c o r d i n g l y , t a k i n g these f a c t o r s i n t o c o n s i d e r a t i o n , t h i s study addressed the f o l l o w i n g q u e s t i o n s : 1. What are the l e v e l s of pain i n t e n s i t y r e p o r t e d on the f i r s t p o s t - o p e r a t i v e day by h o s p i t a l i z e d c h i l d r e n aged 4 69 to 7 years who have undergone s u r g i c a l procedures? 2. What are the overt behaviours e x h i b i t e d at the time of pain i n t e n s i t y l e v e l measurement on the f i r s t day post-o p e r a t i v e by h o s p i t a l i z e d c h i l d r e n aged 4 to 7 years who have undergone s u r g i c a l procedures? In order to answer these q u e s t i o n s , the r e s e a r c h e r gathered data on the pain i n t e n s i t y l e v e l s and overt behaviours of 11 c h i l d r e n between the ages of 4 and 8 years on the f i r s t p o s t - o p e r a t i v e day between the hours of 0800 and 2000. In a d d i t i o n , data r e g a r d i n g p a r e n t a l presence and the a d m i n i s t r a t i o n of a n a l g e s i c s were a l s o c o l l e c t e d f o r these c h i l d r e n . A n a l y s i s of the r e s e a r c h f i n d i n g s i n d i c a t e d t h a t a l l of the p a r t i c i p a t i n g c h i l d r e n were e x p e r i e n c i n g pain d u r i n g at l e a s t one data c o l l e c t i o n p e r i o d . The pain i n t e n s i t y scores of these c h i l d r e n ranged from 0 to 4, with a mode of 1 and a mean of 1.35. In a d d i t i o n , p a r e n t a l presence d i d not appear to i n f l u e n c e c h i l d r e n ' s r e p o r t e d p a i n i n t e n s i t y l e v e l s . In response to the q u e s t i o n of what overt behaviours were expressed by the c h i l d r e n , the vast m a j o r i t y of the c h i l d r e n i n t h i s study d i d not e x h i b i t expected pain behaviours. In f a c t , d u r i n g data c o l l e c t i o n , these c h i l d r e n g e n e r a l l y were not c r y i n g ; were e i t h e r nonverbal or t a l k i n g p o s i t i v e l y ; d i s p l a y e d smiles or composed f a c e s ; appeared to be r e l a x e d and were g e n e r a l l y i n a c t i v e ; or could be observed p l a y i n g q u i e t l y at the bedside, t a k i n g f l u i d s , or watching t e l e v i s i o n . 70 Findings related to pain intensity scores provided the basis for three important conclusions. F i r s t , a l l of the children were able to place a value on their pain using the PCT. Second, a l l of the children were experiencing some degree of post-operative pain possibly related to the lack of consistent administration of analgesia. Third, parental presence did not influence the pain intensity scores reported by the children. Findings related to the overt behaviours exhibited by children also provided the basis for three important conclusions. F i r s t , the most frequent behaviours i d e n t i f i e d were not those normally associated with feelings of pain. The researcher believed that t h i s lack of expected response was as a re s u l t of the children's a b i l i t y to adapt and cope with the pain. Second, behavioural measurement of pain may not be a r e l i a b l e and v a l i d measure of post-operative pain. Third, parental presence or absence did not influence the overt behaviours exhibited. Although the findings of t h i s study cannot be generalized due to the nature of the sample, s p e c i f i c implications for nursing practice and nursing research can be i d e n t i f i e d . Recommendations for nursing can also be delineated. Implications for Nursing Practice Because the findings of this study are based on a very small sample size that i s not representative of the population of hospitalized children aged 4 to 7 years who 71 have undergone s u r g i c a l p r o c e d u r e s , r e s u l t s are i n c o n c l u s i v e . However, t h e s e r e s u l t do suggest i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e . T h i s s t u d y r e v e a l s t h a t c h i l d r e n i n the p r e - o p e r a t i o n a l stage of development a r e a b l e t o communicate t h e i r p a i n and, more i m p o r t a n t l y , p l a c e a v a l u e on t h a t p a i n . Moreover, a c h i l d ' s s t a t e m e n t of h i s / h e r p a i n may not n e c e s s a r i l y be r e f l e c t e d i n the b e h a v i o u r s e x p r e s s e d by t h a t c h i l d . T h e r e f o r e , i t i s recommended t h a t n u r s e s c o n s i d e r the u t i l i z a t i o n of v a l i d and r e l i a b l e s e l f - r e p o r t p a i n measures when c a r i n g f o r p r e - o p e r a t i o n a l c h i l d r e n a f t e r s u r g e r y . However, i n o r d e r f o r s e l f - r e p o r t p a i n measures t o p r o v i d e some d i r e c t i o n f o r c h i l d r e n ' s c a r e , nurses must adopt the p h i l o s o p h y t h a t p a i n i s whatever a p a r t i c u l a r c h i l d says i t i s , e x i s t i n g whenever he/she says i t does ( M c C a f f e r y , 1972). S e l f - r e p o r t p a i n measures w i l l o n l y be s u c c e s s f u l i n the c l i n i c a l a r e a i f n u r s e s b e l i e v e and a c t upon what the c h i l d r e n a r e r e p o r t i n g . As the f i n d i n g s from t h i s s t u d y p r o v i d e p r e l i m i n a r y e v i d e n c e t h a t p r e - o p e r a t i o n a l c h i l d r e n a r e e x p e r i e n c i n g p a i n p o s t - o p e r a t i v e l y p o s s i b l y as a r e s u l t of u n d e r m e d i c a t i o n , the r e s e a r c h e r s u g g e s t s t h a t a r e v i e w of n u r s i n g management of c h i l d r e n ' s p a i n , p a r t i c u l a r l y a n a l g e s i c a d m i n i s t r a t i o n t o c h i l d r e n aged 4 t o 7 y e a r s , be c o n s i d e r e d . T h i s r e v i e w would ensure t h a t n u r s i n g p r a c t i c e i s meeting and c o n t i n u e s t o meet the needs of c h i l d r e n w i t h r e g a r d t o t h e i r p a i n management. 72 Implications for Nursing Research Although th i s research study has provided some information regarding the post-operative pain of children aged 4 to 7 years, i t has also raised many questions, p a r t i c u l a r l y regarding the v a l i d i t y and r e l i a b i l i t y of the PCT. More research is required before i t can be concluded that the PCT meets the requirements of a v a l i d and r e l i a b l e s e l f - r e p o r t measure of pain intensity. Three s p e c i f i c questions regarding the PCT which s t i l l need to be addressed, using a larger sample s i z e , are: (a) Can the PCT be used appropriately by a l l children aged 4 to 7 years? (b) What words best describe to the children the amount of pain each colour and number of poker chips represents ( i . e . , are "a l i t t l e b i t of hurt", "more hurt", "even more hurt", and "the biggest hurt you could ever have" the clearest message to the children in explaining the meaning of the chips?) and (c) Does the PCT have convergent and divergent r e l i a b i l i t y and v a l i d i t y ? Other questions of interest brought forth by the findings of this research study which relate d i r e c t l y to children's pain are: (a) Do children's reported pain intensity levels vary with the surgical procedure? (b) Is there a difference in the levels of post-operative pain i n t e n s i t y experienced by children hospitalized on a general ped i a t r i c ward versus a s u r g i c a l ward in a children's hospital? (c) How do the pain i n t e n s i t y levels d i f f e r between children's age groups? (d) What effect does parental presence 73 have on children's pain intensity levels? and (e) What overt behaviours do children exhibit before and after analgesic administration? Recommendations A number of recommendations s p e c i f i c to nursing practice, education, and research arise from the findings of th i s research study. Recommendations for Nursing Practice and Education The findings of this study suggest that children aged 4 to 7 years may be experiencing pain after surgery. The findings also reveal that these children are able to communicate their pain and place a value on i t . It i s therefore recommended that: 1. Nurses in practice consider the u t i l i z a t i o n of v a l i d and r e l i a b l e s e l f - r e p o r t pain measurement tools in the post-operative care of children. 2. Nurses in practice adopt the philosophy that pain is whatever a p a r t i c u l a r c h i l d says i t i s , existing whenever he/she says i t does (McCaffery, 1972). 3. Nurses in practice reasses their management of children's post-operative pain. 4. Nurses in educations systems ensure that content regarding pe d i a t r i c pain, s p e c i f i c a l l y i t s assessment and management, is provided to a l l nursing students. Recommendations for Nursing Research This research study represents a f i r s t step toward addressing the questions: How much pain do children 74 e x p e r i e n c e a f t e r s u r g e r y , and how do they b e h a v i o u r a l l y express t h a t p a i n ? I t i s t h e r e f o r e recommended t h a t : 1. The v a l i d i t y and r e l i a b i l i t y of p e d i a t r i c p a i n measurement t o o l s c o n t i n u e to be t e s t e d so t h a t they can a c c u r a t e l y a s s i s t nurses i n t h e i r assessment of c h i l d r e n ' s p a i n . 2. Researchers c o n t i n u e to e x p l o r e c h i l d r e n ' s p o s t -o p e r a t i v e p a i n and the r e l a t i o n s h i p s between i t and other f a c t o r s ( e . g . , p a r e n t a l presence and a n a l g e s i a ) . Conc lus ion In c o n c l u s i o n , t h i s r e s e a r c h s t u d y , which d e s c r i b e d the p a i n i n t e n s i t y l e v e l s and o v e r t b e h a v i o u r s of h o s p i t a l i z e d c h i l d r e n aged 4 to 7 y e a r s on the f i r s t p o s t - o p e r a t i v e day has begun an i n i t i a l c o n t r i b u t i o n to the knowledge base r e q u i r e d f o r a c c u r a t e n u r s i n g assessment of p e d i a t r i c p a i n . F u r t h e r r e s e a r c h i s mandatory i n the a r e a of p e d i a t r i c p a i n measurement and p a i n management i n order to p r o v i d e s u p p o r t for the f i n d i n g s from t h i s r e s e a r c h p r o j e c t . 75 References Abu-Saad, H. (1981). The assessment of pain in children. 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Appendix D Pre-Operative Data C o l l e c t i o n Form C o l l e c t i o n Date ; Subject #_ ; Sex ; Age ; Birth Date ; Ward ; Diagnosis ; Date of Admission Reason for Admission Surgery to be Performed ] Explanation Given ; Consents Signed: #1 ; #2 ; #3 ; Practice Session ; Subject Able to Use and Understand Tool Post-Operative Data Collection Form Subject # Ward Collection Date Surgery Performed Analgesic Ordered Overt Behaviours #1 #2 #3 #4 vocal lzations 1. No Cry 2. Moaning 3. Crying 4. Scream verbal 1. Non Verbal 2. Other Complaints 3. Pain Complaints 4. Both Complaints 5. Positive Facial Expressions 1. Composed 2. Grimace 3. Prown 4. Smile Motor Act ivi ty 1. Neutral 2. Purposeless 3. Tense 4. Kicking 5. Shivering 6. Not Touching 7. Touching 8. Rubbing 9. Grabbing Child 's Activi ty 1. Reaching lor Body Contact 2. Being Held 3. Talcing Fluids or Solids 4. Playing 0bs.#l Parents: Yes No Pain Rating - PCT Last Analgesic: Time Type Route Comments: Obs. #2 Parents: Yes No Pain Rating - PCT Last Analgesic: Time Type Route Comments: Obs.#3 Parents: Yes No Pain Rating - PCT Last Analgesic: Time Type Route Comments: Obs.#4 Parents: Yes No Pain Rating - PCT Last Analgesic: Time Type Route Comments: 84 Appendix F D e f i n i t i o n of Terms of Behavioural Checklist Vocalizations A l l emitted sounds which are not language or are incomprehensible to an observer (McCaffery, 1972). No Cry - c h i l d is not crying (McGrath et a l . , 1985). Moaning - c h i l d is moaning or qu i e t l y v o c a l i z i n g , s i l e n t cry with no tears (McGrath et a l . ) . Crying - c h i l d is crying with tears by the cry is gentle or whimpering (McGrath et a l . ) . Scream - c h i l d is in a full-lunged cry with tears; sobbing (McGrath et a l . ) . Verbal A l l emitted sounds that are language and comprehensible (McCaffery). Non Verbal - c h i l d not t a l k i n g . Other Complaints - c h i l d complains, but not about pain (McGrath et a l . ) . Pain Complaints - c h i l d complains about pain (McGrath et a l . ) . Both Complaints - c h i l d complains about pain and about other things (McGrath et a l . ) . Positive - c h i l d makes any positive statement or talks about other things without complaint (McGrath et al.) . F a c i a l Expressions The state of the forehead, eyes, and jaw muscles (McCaffery). Composed - neutral f a c i a l expression (McGrath et a l . ) . Grimace - pained expression r e s u l t i n g from d i s t o r t i o n of a l l f a c i a l features (Brunke, 1989). Frown - furrowing of the eyebrows and forehead (Brunke). Smile - a pleased or amused expression (Brunke). 85 Motor A c t i v i t y A l l body movement and muscle tone (McCaffery). Neutral - body is relaxed and inactive. Purposeless - tossing and turning in bed and/or random gross movements of arms and legs without intention to make aggressive contact (Brunke). Tense - body arched or r i g i d and/or limbs pulled t i g h t l y to body. Kicking - s t r i k i n g out with foot or feet (Brunke). Shivering - body is shuddering or shaking i n v o l u n t a r i l y (McGrath). Not Touching - c h i l d i s not touching or grabbing at wound (McGrath). Touching - c h i l d i s gently touching wound or wound area (McGrath). Rubbing - applying pressure to the wound or wound area with hand arm or bed linen (Brunke). Grabbing - c h i l d is grabbing vigorously at wound (Brunke). Chi Id's A c t i v i t y Those physical a c t i v i t i e s the c h i l d i s involved in at the time of observation. Reaching for Body Contact - behaviour i n i t i a t e d by the c h i l d intended to result in body contact with another individual (Brunke). Being Held - c h i l d i s held by another individual in bed or chair (Brunke). Taking Fluids or Solids - c h i l d i s drinking or eating. Playing - c h i l d engaged in a game; with toys or books. Watching Television - c h i l d watching a t e l e v i s i o n 

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