A universal and cardinal nursing responsibility is providing comfort through culturally competent care. To achieve comfort, optimal pain management is essential. However, without methods to assess pain, it is difficult to plan appropriate interventions and impossible to evaluate their effectiveness. Fortunately, pain intensity can be subjectively measured by children's use of quantitative self-report pain rating scales. One of the most commonly used self-report tools for children is the Wong-Baker FACES Pain Rating Scale (FACES). Although several studies have supported the psychometric properties of the scale, most of the subjects have been Caucasian children. Therefore, the purpose of this study was to establish the validity, reliability, and preference of the FACES as compared to a numeric (0-5) rating scale among three native Asian groups of children in three age groups (3 to 7, 8 to 12, and 13 to 21 years).
Data collectors were recruited through a notice published in Sigma Theta Tau International's (STTI) publication, Reflections, or through personal contact with the investigators. All of the data collectors were residents of the country and had a degree in nursing. They received detailed written instructions about the study and communicated via email with the principal investigators for additional information or clarification. They obtained appropriate approval from the hospitals they identified for use in the study; translated the data collection sheets and pain scales, explained the study to the parent and child, obtained written informed consent from the adult and verbal informed consent from the child younger than 7 years, and collected all the data. Completed packets were mailed to the investigators. Data collectors were paid for each completed packet through a grant from STTI.
The design was prospective, correlational, and descriptive. The subjects included the cultural groups of Chinese (n=132; mean age=10.48 years; 81 males), Japanese (n=173; mean age=10.77 years; 92 males), and Thai (n=151; mean age=10.74 years; 95 males). The subjects were asked to list events during their hospitalization that caused pain, such as procedures or body pain, for a maximum of five events. Subjects were asked to rank the events from most to least painful. The data collector randomly presented the FACES (coded A to F) or numeric scale (a line with equal vertical divisions numbered from 0-5) to each child and explained its use. For young children to use the numeric scale, they had to be able to count from 0 to 10 and to choose the larger of two numbers for three pairs.
The subjects were asked to select a face or number that reflected the amount of pain for each identified painful event that the data collector randomly described from the child's list. The same procedure was followed for the second scale. Subjects were then asked to choose the scale they like better.
The re-test occurred between 4 or 24 hours later. The data collector reminded the subjects of the identified painful events and their rank order. The same procedure as for the test was then repeated.
The data analyses were performed on pain scores for each procedure that the subjects identified as painful. The FACES codes of A to F were recoded from 0 to 5, respectively. The total number of procedures for each group was: Chinese 263, Japanese 479, and Thai 418. The correlation between the mean FACES pain scores and the mean numeric pain scores was used to determine concurrent validity. Correlation coefficient for test-retest scores was used for reliability of the FACES. Chi square analysis was applied to determine significant differences between preference of the two scales.
Concurrent validity was supported by significant correlations (p = .0001) between the mean FACES pain scores and the mean numeric pain scores for the total sample of each group: Chinese r = .80 ; Japanese r = .82 ; and Thai r = .77. Also, test-retest reliability was supported by significant correlations (p = .0001) between the mean FACES pain scores for the total sample of each group: Chinese (n=15) r = .94; Japanese (n=172) r = .80 ; and Thai (n=151) r = .79.
For both validity and reliability, the correlation coefficients for FACES were also significant for each age group of 3 to 7, 8 to 12, and 13 to 21 years and for both sexes for all three cultural groups. The validity correlation coefficients for Chinese children ranged from .65 to .89, for Japanese children from .63 to .93, and for Thai children from .68 to .86. The reliability correlation coefficients for Japanese children ranged from .72 to .90 and for Thai children from .70 to .87. The number of Chinese subjects with retest data was too small for age-group analysis.
Since one of the criticisms of the FACES has been that the anchor or initial face with a smiling expression may produce falsely high pain scores (Chambers and others, 1999), all means of the FACES and numeric scales for the total group and each age group by sex were compared. T tests revealed no significant differences between any pair of mean scores. In addition, no mean FACES score was higher than the corresponding mean numeric score for 36 pairs of data.
Chi square analysis (p = .0000) showed a significant difference in preference for FACES for the total sample of each group: Chinese 82%, Japanese 72%, and Thai 76%. This preference was also significant for each age group and for both sexes.
This study provides strong support for the validity, reliability, and preference of the FACES scale for native Chinese, Japanese, and Thai children ages 3 to 21 years. The finding that no mean FACES score was higher than the corresponding mean numeric score for the total group and each age group by sex provides evidence to refute the criticism that the FACES scale produces falsely elevated pain intensity scores.
Funded by a research grant from Sigma Theta Tau International, Inc., Honor Society of Nursing.
July 10, 2005
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