Many professionals ask me if they can change the coding system for the FACES scale from 0 - 5 to 0 - 10. The answer is definitely YES. In fact, you should have the same coding system for every pain measurement instrument that is used in an agency. Imagine if various departments measured temperature with thermometers that had different measurement units. How would staff know the value of a recording if the number on the chart were from a thermometer with a measurement unit they thought meant something different?
The most common coding systems for measuring the intensity of pain are 0 - 5 or 0 - 10. Obviously, if one department uses a 0 - 10 scale, the recording of a pain score of 5 has a very different meaning than a department that uses a 0 - 5 scale. If different coding ranges are used, one way to avoid confusion is to record the pain score as a fraction, with the numerator as the patient's self-report and the denominator as the upper limit of the range, such as 5/10.
The appropriate coding of the six faces is with the numbers 0,2,4,6,8,10. I do not give permission for all 10 units to be used, such as 1 - 2, 3 - 4, etc., because if a person chooses the second face, either a 2 or a 3 can be chosen for documentation. This variability in serial scores can make it appear that the pain has increased or decreased when actually the score remains the same face. Also, some agencies choose an acceptable level of pain or a level that triggers intervention that can change the course of action based on an arbitrary coding of one of the two numbers. If a person states that their pain is between two faces, then it is appropriate to use a midpoint measure. Therefore, if a person states his pain is between the second and third face, the recorded number is 3 for 0 - 10 and 1.5 for 0 - 5.
A survey of 37 subscribers to the Pediatric Pain Internet Mailing List found that 81% of the respondents endorsed adopting a common metric or measurement unit for pain scales. Among the possible numbering systems, 70% favored the 0 - 10 system. The next most popular option, 0 - 5, was selected as first choice by only 14% (von Baeyer and Hicks, 2000).
The FACES scale was originally coded with 0 - 5 because some of the other scales used in the original research had scoring ranges of 0 - 3 (Eland color tool) or 0 - 4 (Hester Poker Chip tool). Also, when we developed the glasses scale to represent a more concrete version of the visual analogue scale, we believed that a set of eleven "glasses" was too complex a choice for children. Therefore, we constructed six "glasses" with different amounts of "color" to represent no pain (no color) to worst pain (complete color). The child simply had to choose the cylinder filled with as much pain as the child felt (Wong and Baker, 1988).
In the "early days" of pediatric pain research, the emphasis focused on developing age-appropriate self-report instruments. Today, numerous self-report pain instruments exist, and the emphasis must shift to practical aspects of using these tools. Almost all healthcare facilities need to choose more than one pain measurement instrument to accommodate different age groups. In the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) new pain standards, four examples of self-report instruments are given: the 0 - 10 scale, the visual analogue scale (VAS), a word-descriptor scale, and the Wong-Baker FACES scale. In the numeric and VAS scales the number represents the person's reported intensity of pain, and simultaneously is the score that is documented. In the word scale and the FACES, the chosen word or facial expression represents the person's reported intensity of pain, and the number under each word or facial expression is used for documentation to represent the intensity of the pain.
Theoretically, the FACES scale could be used as three scales because it combines facial expression, numbers, and words. However, the reason we place numbers and words under the facial expressions is to simplify the scale's use. We use the word "hurt" rather than pain based on research that showed children as young as three years understood this word (Baker-Lefkowicz and others, 1996). However, if a child uses a word such as "owie" or "ouchie" for pain, these words can be substituted. The process of assessing pain intensity with the FACES scale is SIMPLE and EFFICIENT. The child looks at the faces, the professional or parent uses the simple words to describe the expression, and the number is used to record the score.
March 15, 2002
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