Authors:
Donna Lee Wong (ONA
#02)
Connie Morain Baker
The validity, reliability, and preference of 6 pain assessment scales were investigated on a sample of 150 hospitalized children ages 3 to 18 years. Children's perception and pain ratings of procedures/bodily symptoms were also analyzed. This study attempts to provide the basis for selecting suitable research scales for pain assessment.
The purposes of the study were to (1) investigate reliability, validity, and preference of the six assessment scales; (2) determine the relationship of colors to pain rating and the child's favorite color, and (3) identify those events hospitalized children perceive as painful. In analyzing the data of painful events the following additional questions were explored: do children consider the same procedures as painful?; does the average pain rating of painful events differ?; does sex or age influence children's rating of pain intensity?; do some conditions involve significantly more bodily pain than other diagnoses?; and, do children's previous experiences with pain affect their ratings of painful events?
A convenience sample consisted of 150 hospitalized children in three age groups: 3 to 7 (N=52), 8 to 12 (N=52), and 13 to 18 years (N=46); 79 subjects were retested. Criteria for eligibility included: (1) the children were alert and not in pain during testing; (2) had no developmental delays; (3) spoke English, and (4) agreed to participate in the project. Parental permission was also a prerequisite. The sample was drawn from the pediatric units of Hillcrest Medical Center and Saint Francis Hospital, Tulsa.
During a time when no painful procedures were being performed, children were asked to list those events they had experienced since being hospitalized that were painful and to rank them from the most to the least painful. The children then rated the events using six scales: simple descriptive, numeric, faces, glasses, chips, and color scale. Children under 5 were not given the first two scales unless they demonstrated an understanding of the scales.
Concurrent validity was determined by comparing the consistency between the ranking of the listed procedures with the pain rating. A test-retest method was used to measure reliability. Preference was determined by asking the child to rank the scales from most to least preferred. A chi square test was performed on the relationship between the scales for validity, reliability, and preference and for relationship of colors to pain intensity.
The chi squares for preference ranking for all age groups were statistically significant at probability less than .001. The most preferred scale for all children was the faces scale. For children 8 to 18 years, faces was followed by colors, chips, glasses, numeric, and simple descriptive scales. In the 3 to 7 year age group the order was the same except that colors and glasses scales were ranked fourth and second The chi square for differences in validity or reliability for the scales and age groups was not statistically significant at probability less than .05. However, validity increased with advancing age for all scales. Reliability for all scales increased in the 3 to 12 year age group, but decreased in the 13 to 18 year age group for all but two scales.
No one color scale predominated. The color chosen most often for least pain was orange and for most pain was black. The chi square was significant at probability less than .001 for choice of least and most pain colors. Children's favorite colors showed variable relationship to choice of pain colors; orange and black were least favorite colors. Blue was the favorite color and the second color to be associated with no pain.
Subjects reported 116 painful events (77 procedures and 39 bodily symptoms). Average number of total painful events was three per child. The percent of bodily symptoms to total number of reported painful events was 22%. The most commonly reported painful events were venipuncture for drawing blood, insertion of peripheral intravenous lines, injections, stomach hurting, leg pain, removal of peripheral intravenous lines, pain when moved, postoperative pain, head pain, and fingersticks. However, many children experienced these procedures and did not report them as painful. The pain intensity was less for these procedures than for less commonly performed procedures, such as bone marrow aspiration, spinal tap, arterial puncture for blood gases, or chest tube insertion. There were no sex differences in pain rating of these events, but a trend toward decreasing pain rating with age for procedure pain and increasing pain rating for body pain was observed. The number of painful events experienced did not affect the identification or rating of perceived painful procedures or bodily pain. However, diagnosis did influence the number and type of painful events, especially orthopedic conditions which were associated with a higher average number of painful events (3.8) and a higher percentage of bodily symptoms (41%).
This study was partially supported by a grant from the Oklahoma Nurses Foundation and the National Association of Pediatric Nurse Practitioners and Associates (NAPNAP) Foundation.
Note: the complete research report was published as follows: Wong, D. and Baker, C.: Pain in children: comparison of assessment scales, Pediatric Nursing, 14 (1): 9-17,1988.
March 15, 2002
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