Journal for Specialists in Pediatric Nursing

ORIGINAL ARTICLE

The use of nonpharmacological methods for childrens

postoperative pain relief: Singapore nurses perspectives

jspn_268

27..38

Hong-Gu He, Tat-Leang Lee, Riawati Jahja, Rajammal Sinnappan, Katri Vehvilinen-Julkunen, Tarja Plkki,
and Emily Neo Kim Ang
Hong-Gu He, PhD, RN, MD, is an Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore; Tat-Leang Lee, MMed, MBBS, FANZCA, FAMS, is a Professor, Department of Anesthesia, National University Hospital, Singapore;
Riawati Jahja, MMed, MD, is a Research Assistant, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore,
Singapore; Rajammal Sinnappan, BN, MW, RN, is a Nurse Clinician, Division of Nursing, K.K. Women s and Children s Hospital, Singapore; Katri
Vehvilinen-Julkunen, PhD, RN, is a Professor, Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Finland and Research Unit,
Kuopio University Hospital, Kuopio, Finland; Tarja Plkki, PhD, RN, is an Adjunct Professor, Department of Nursing Science and Health Administration,
Institute of Health Sciences, University of Oulu, Oulu, Finland; and Emily Neo Kim Ang, PhD, RN, is Deputy Director, Clinical and Oncology Nursing, National
University Hospital, Singapore, and Adjunct Associate Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore

Search terms
Children, nonpharmacological methods, nurses,
pain relief, postoperative.
Author contact
nurhhg@nus.edu.sg, with a copy to the Editor:
roxie.foster@UCDenver.edu
Acknowledgments
This study was funded by the National Medical
Research Council, Institutional Blockvote Grant,
Singapore (Grant number: R-545-000-003-214)
and the National University of Singapore (Grant
number: R-545-000-003-750). We would like to
express our appreciation to Dr Moon Fai Chan
(PhD, CStat, Assistant Professor, National
University of Singapore) for his advice on
statistical analysis. We also wish to acknowledge
Ms. Laura Mei Lian Tan (Senior Nurse Clinician,
National University Hospital, Singapore) for her
assistance in data collection and all participants
for their support.

Abstract
Purpose. The purpose of this study was to examine nurses use of nonpharmacological methods for school-age childrens postoperative pain
relief.
Design and Methods. A survey was conducted in 2008 with a convenience sample of 134 registered nurses from 7 pediatric wards in Singapore.
Results. Nurses who were younger, had less education, lower designation,
less working experience, and no children of their own used nonpharmacological methods less frequently.
Practice Implications. Nurses need training and education on nonpharmacological pain relief methods, particularly on methods that have been
shown to be effective in prior research but that were less often used by
nurses in this study: massage, thermal regulation, imagery, and positive
reinforcement.

First Received August 11, 2009; Revision

received August 8, 2010; Accepted for
publication September 19, 2010.
doi: 10.1111/j.1744-6155.2010.00268.x

Nonpharmacological methods of pain relief are

being more commonly reported in the refereed
literature, and evidence is growing that nurses need
a more eclectic approach to pain management rather
than just relying on pharmacological methods. In
the context of pain being recommended as the
fifth vital sign to be assessed by nurses in all SinJournal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

gapore hospitals in 2004, and a lack of information

about Singapore nurses use of nonpharmacological
methods, it was decided to conduct a replication
of two studies that yielded encouraging results in
China (He, Plkki, Vehvilinen-Julkunen, & Pietil,
2005) and Finland (Plkki, Vehvilinen-Julkunen,
& Pietil, 2001).
27

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

LITERATURE REVIEW
Pediatric pain

Pediatric pain is complex and multidimensional

and involves the interaction of physiological, psychological, behavioral, developmental, and situational factors (American Academy of Pediatrics,
2001). Assessing and managing postoperative pain
in children is a challenge (Hegyvary, 2004). Recent
studies suggest that postoperative pain in children is
often poorly managed (He, Vehvilinen-Julkunen,
Plkki, & Pietil, 2007; Kankkunen et al., 2009;
Sutters et al., 2007; Twycross, 2007). The reasons for
this may include nurses undermedicating for
postoperative pain despite adequate prescription
(Ericsson, Wadsby, & Hultcrantz, 2006), nurses
inadequate pain assessment and monitoring, and
inadequate use of other pain relief methods due to
lack of time, knowledge, skills, and organizational
support (He et al., 2005; Plkki, Laukkala,
Vehvilinen-Julkunen, & Pietil, 2003). It is nevertheless reassuring that in recent years studies
and reports about the experiences of children with
postoperative pain are appearing in the refereed
literature, and the evidence is convincing that
nonpharmacological approaches should be in daily
use, in tandem with pharmacological approaches
(Caty, Tourigny, & Koren, 1995; Lassetter, 2006;
Plkki, Pietil, Vehvilinen-Julkunen, Laukkala, &
Kiviluoma, 2008).
Nurses use of nonpharmacological methods
for pain relief

Nonpharmacological methods refer to a variety of

approaches that do not involve the use of drugs but
make pain more tolerable and give children a sense
of control over the situation (Caty et al., 1995).
Other terms used by researchers in the refereed
pediatric nursing literature to classify these methods
include nondrug approaches (Jonas, Day, & Binns,
1998), mindbody therapies (Gerik, 2005), complementary and alternative medical therapies (Lassetter, 2006; Lin, Lee, Kemper, & Berde, 2005), and
psychological interventions/therapies (Eccleston,
Palermo, Williams, Lewandowski, & Morley, 2009).
These methods can be used independently for
the relief of mild pain or in conjunction with pain
medication for the relief of moderate to severe
pain (Sutters et al., 2007). Plkki et al. (2001) suggested these methods be categorized as cognitive
behavioral methods, physical methods, emotional
28

H.-G. He et al.

support strategies, helping with activities of daily

living, and creating a comfortable environment. The
categories defined by Plkki et al. (2001) were used
to summarize relevant literature and the findings
from this study.
The literature review revealed substantial evidence to support the use of nonpharmacological
methods to provide complementary pain relief in
pediatric patients, and these strategies were reported
as efficacious. While this study focused on postoperative pain management in hospital, studies that
reported pain management strategies used at home
and for chronic pain were included, as they are considered techniques that can also be applied for acute
pain in hospital. There is a trend to differentiate
management of chronic and acute pain with some
strong evidence supporting nonpharmacological
methods in the former, including a Cochrane library
review on psychological therapies for chronic and
recurrent pain in children (Eccleston et al., 2009). It
was nevertheless considered important to look at all
the literature, as while it is still developing a critical
mass, removing a significant portion of work on
chronic pain would weaken the evidence. Several
studies examined the effectiveness of using one or a
combination of two or more nonpharmacological
methods for childrens pain relief (Ball, Shapiro,
Monheim, & Weydert, 2003; Kahler, 2003; Plkki
et al., 2008).
While intervention studies are scarce in some
areas, two surveys reported that nurses in Finland
(Plkki et al., 2001) and China (He et al., 2005) used
nonpharmacological methods for school-age childrens postoperative pain relief. The most commonly used methods were provision of preparatory
information, positioning, comforting/reassurance,
and creating a comfortable environment. Another
survey conducted in the United States on the use of
complementary and alternative medical therapies
by pediatric pain management services (Lin et al.,
2005) revealed that most institutions offered one
or more complementary and alternative medical
therapies to their patients. Those therapies included
biofeedback, guided imagery, relaxation therapy,
massage, hypnosis, acupuncture, art therapy, and
meditation. Idvall, Holm, and Runeson (2005)
reported that the nonpharmacological strategies
used most frequently to manage childrens pain
after tonsillectomy were thermal regulation and distraction. However, research shows an inconsistency
between nurses self-reported data and observations
of nurses behavior (Dihle, Bjlseth, & Helseth,
2006; Manias, Bucknall, & Botti, 2005).
Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

H.-G. He et al.

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

Cognitivebehavioral strategies

The cognitivebehavioral methods that revealed

good reported evidence in the literature for childrens pain relief included: distraction (Bellieni
et al., 2006; Dahlquist et al., 2002; Murphy, 2009),
imagery (Huth, Broome, & Good, 2004), relaxation
(Schaffer & Yucha, 2004), and preparatory information (Kain, Mayes, & Caramico, 1996; Kolk, van
Hoof, & Fiedeldij Dop, 2000). Although breathing
techniques are used by pediatric nurses, the bulk of
the evidence for their use comes from adult nursing
literature.
Fear and anxiety are common feelings for patients
who undergo surgery. Wennstrm, Hallberg, and
Bergh (2008) explored what it meant for 6- to
9-year-old children to be hospitalized for day
surgery, and found that the main concern for these
children was that they were put into an unknown,
unpredictable, and distressful situation, which had
to be endured. The provision of adequate preparatory information to children is thus crucial and
beneficial in helping them develop realistic expectations for the procedure and prevent distress from
medical procedures (Kolk et al., 2000); lessening
their anxiety and fear (Kain et al., 1996); increasing
trust between the child, parents, and healthcare providers; and enhancing childrens cooperation during
a procedure. Li and Lopez (2008) reported that the
provision of preoperative information, mostly procedural information, was the most common method
of preparing children for surgery in Hong Kong.
They recommended using therapeutic play intervention to prepare children for surgery. Allowing
the child to ask about and reflect on the situation in
a dialogue with the nurse, rather than having oneway communication with the nurse as the source of
information, might also enable the child to maintain
a sense of control despite being exposed to the
unknown (Wennstrm et al., 2008).
Physical methods and emotional support strategies

Physical methods have been well reported in the

adult nursing literature, but only few in the pediatric
nursing literature. This is an area that needs more
attention because while these interventions may
be taken for granted as common practice, there is
not as yet a good evidence base. Transcutaneous
electrical nerve stimulation (Erdogan, Erdogan,
Erbil, Karakaya, & Demircan, 2005), massage (Wang
& Keck, 2004), positioning (Kahler, 2003), cold
application (McCaffery, 1999; Saeki, 2002), as well
Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

as emotional support strategies such as touch (So,

Jiang, & Qin, 2008) were reported to be effective for
pain relief in adults, but there is little evidence for
their use with children (Kahler, 2003; Lander &
Fowler-Kerry, 1993).
The environment and activities of daily living

In Wiroonpanich and Stricklands (2004) study, Thai

children explained postoperative abdominal pain
as getting hurt, caused by daily activities (walking,
sitting, lying down, and changing their body position), medical procedures (injections and blood
drawing), and the environment (noise, light, separating the child from their favorite teddy bears, dolls,
or childrens games). Hence, helping with activities
of daily living and creating a comfortable environment may be useful in alleviating childrens postoperative pain.
Factors contributing to nurses use of
nonpharmacological methods

As to factors that influence nurses pain management practices, Caty et al. (1995) revealed that
nurses professional work experiences and their ages
had little influence on the pain management
process. However, Plkki et al. (2001) and He et al.
(2005) both reported that nurses who were older,
more educated, had longer professional work experience, had children of their own, and had earlier
experiences of being in hospital with their children,
were more likely to provide preparatory information. They also used nonpharmacological methods
more than those without those characteristics.
Pain management practice in Singapore

In 2004, following the recommendation made by

the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2000) in the United
States, all public hospitals in Singapore included
pain as the fifth vital sign to be assessed by nurses. It
was assumed, therefore, that the active involvement
of nurses in pain assessment would impact on their
management of childrens postoperative pain relief,
including use of nonpharmacological techniques
rather than relying on administering pain medication alone. In addition, staff nurses assumed the role
to provide some preparatory information to patients
prior to the surgery, for example, information of
pain medication, postoperative observation, and
limitations. Surgeons and anesthetists usually play
29

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

the main role to provide information of type,

purpose, duration of the procedure, and the surgeon
who performs the procedure, type of anesthesia, and
possible complications of anesthesia. A review of the
Singapore literature showed that Acute Pain Services (APS) were established in most Singaporean
hospitals in the 1990s, focusing mainly on pharmacological methods (Phua, Leong, & Yoong, 2008).
The APS is a specialist-driven service with patients
reviewed on a daily basis by a dedicated pain management team, which usually comprises a trained
pain resource nurse, a pain consultant, and an anesthesiologist (Phua et al., 2008). The paucity of local
research and refereed literature on nurses roles in
pain management further stimulated the need for
this study.
A review of the literature showed that none of the
studies reviewed reported the extent to which nonpharmacological interventions have been incorporated into practice by registered nurses working in
pediatric wards in Singapore hospitals, in particular
those methods reported to be effective in managing
childrens pain following surgery. With the commencement of the first bachelor program in nursing
in 2006, there was a strong movement toward
evidence-based practice within the new curriculum,
which included nonpharmacological pain management in pediatric nursing.
In summary, little is known about how nurses
in Singapore use non-pharmacological methods
to relieve pain in pediatric patients. Therefore, the
purpose of this study was to examine Singapore
nurses use of nonpharmacological methods for
school-age childrens postoperative pain relief and
factors related to their use. Specifically, the following
research questions were posed: (a) What nonpharmacological methods do Singapore nurses use to
alleviate school-age childrens postoperative pain?
(b) What background factors are related to their use
of nonpharmacological methods?
METHODS
Design and sample

A descriptive questionnaire survey was conducted

with a convenience sample of 151 registered nurses
(RNs) in Singapore, which is a multicultural society,
where the official working language is English. All
RNs working in seven wards of two participating
hospitals and who met the following inclusion criteria were recruited: (a) being a registered nurse, and
(b) having at least 3 months work experience in the
30

H.-G. He et al.

participating wards at the time of data collection.

Among the seven wards, three were pediatric surgical wards in a womens and childrens hospital that
received pediatric patients for surgical procedures,
and four were pediatric wards in a restructured
general hospital that received pediatric patients who
needed either medical treatment or surgery. This
comprised the population of pediatric surgical beds
in Singapore.
Data collection

The study was approved by the institutional review

boards of the two participating hospitals. Written
informed consent was obtained from all participants.
A total of 151 questionnaires were distributed to participants through the nurse managers or nurse clinicians in the seven participating wards in February
2008. Each participant received a folder containing
a participant information sheet (PIS), a consent
form, a questionnaire, and an empty envelope. The
PIS described the purpose and procedure of the
study, the benefits and risks of participation, voluntary participation, privacy and confidentiality, and
the contact information of the researchers. Two
boxes were placed in each ward for participants to
return the completed questionnaires and consent
forms separately. Nurses were given 2 weeks to
complete the questionnaires. One hundred and
forty-two questionnaires were returned in sealed
envelopes, resulting in a response rate of 94%. Eight
of the returned questionnaires were excluded as
they were judged incomplete, having more than
75% of the items uncompleted. A total of 134
questionnaires were finally analyzed.
Questionnaire validity and reliability

A questionnaire developed by Plkki et al. (2001)

was used in this study with permission from the
authors. The questionnaire contained two sections.
Section 1 included nurses background data (7
items) and the description of pain assessment and
management at the working unit (2 items). Section
2 inquired about nurses use of nonpharmacological
methods for childrens postoperative pain management (14 items). This section was divided into five
subcategories: cognitivebehavioral methods (6
items, the first item was preparatory information,
which contained 24 subitems), physical methods
(3 items), emotional support (3 items), helping
with activities of daily living (1 item), and creating
a comfortable environment (1 item). Responses
Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

H.-G. He et al.

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

were recorded on a 5-point Likert scale ranging from

never, very seldom, sometimes, to nearly always and
always. The questionnaire took approximately 15
minutes to complete.
Although the questionnaire had already been
validated in Finland (Plkki et al., 2001) and China
(He et al., 2005), an expert panel that consisted of
an anesthetist, a pain consultant, two pain resource
nurses, and a senior pediatric nurse clinician
reviewed the English version of the questionnaire
provided by Plkki et al. in order to further assess
its face and content validity. Some changes were
made to tailor the contents to the Singapore context
and make the language more understandable. For
example, in Section 1, educational level was
changed into five categoriesdiploma/certificate,
advanced diploma/post basic certificate, bachelors
degree, masters degree, and PhD/doctorateto
reflect the range of qualifications in Singapore,
compared with the original, which contained childrens nurse, registered nurse, and clinical specialist.
Nurses designation was added as an additional
background variable and comprised staff nurse (SN),
senior staff nurse (SSN), and nurse manager (NM)/
nurse clinician (NC). In Singapore, SNs are responsible for providing direct care to patients. The more
senior nurses (SSNs, NMs, and NCs) have other
responsibilities, such as administration, patient education, and staff training, in addition to attending
to patients. In Section 2, transcutaneous electrical
nerve stimulation was excluded from the category of
physical methods as in both hospitals it was only
administered by physiotherapists for chronic pain
relief and not for postoperative pain relief.
A pilot test was conducted on 35 RNs from the
pediatric intensive care units (PICUs) of both hospitals prior to the formal study. Minor revisions were
made in response to the pilot study. Cronbachs
alpha was used to assess the internal consistency of
the instrument in the formal study. The alpha values
for preparatory information (24 sub-items) and
the rest of the nonpharmacological methods (13
items) were 0.89 and 0.87, respectively. Both met
an acceptable reliability coefficient level (Burns &
Grove, 2005), indicating good internal consistency
of the instrument.
Data analysis

The software SPSS 16.0 for Windows (SPSS Inc.,

Chicago, IL, USA) was used to analyze the data.
Descriptive statistics were used to summarize the
nurses background variables and their use of nonJournal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

pharmacological methods. The frequency with

which nursing staff used each method was recoded
into three response categories to provide an
adequate sample size in each cell for the various statistical analyses: 1 = never or seldom, 2 = sometimes, 3 =
nearly always or always. Because the data were not
normally distributed, the relationship between
background factors and the use of nonpharmacological methods (three categories) were tested by the
nonparametric tests, MannWhitney U (MW; for
background factors divided into two groups) and
KruskalWallis (KW; for background factors
divided into three or more groups). The mean
scores for items measuring nonpharmacological
methods were calculated and compared with the
demographic variables. Where the KruskalWallis
test showed significant differences, further Mann
Whitney U tests were applied to test the differences
between pairs of groups with multiple comparison
adjustments by Bonferonni correction. p values of
less than .05 were considered statistically significant.

RESULTS
Participants

All participants (N = 134) were female (see Table 1),

and their ages varied from 20 to 61 years, with a
mean of 30.04 (SD = 8.38). The majority held a
diploma/certificate in nursing and most were staff
nurses. Their working experience in pediatric surgical nursing ranged from 4 months to 20 years and 10
months, with a median of 2 years, while 37% had
less than 2 years experience.
The majority (80%) reported that their wards
had written instructions for nurses concerning pain
relief interventions other than medication, and 74%
of them were aware of an appointed pain resource
nurse or acute pain nurse in their wards.
Use of nonpharmacological methods for childrens
postoperative pain relief

Table 2 shows the respondents reported use of

nonpharmacological methods for school-age childrens postoperative pain relief. Of the cognitive
behavioral methods that were always or nearly always
used, relaxation (89%), breathing technique (88%),
and distraction (75%) were more common. Of the
physical methods that were always or nearly always
used, positioning (61%) was used most often. With
regard to emotional support strategies, the majority
31

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

always or nearly always used comforting/reassurance

(79%) and touch (73%). The majority (82%)
reported that they always or nearly always helped
with childrens activities of daily living, such as
Table 1. Demographic Characteristics (N = 134)

Gender
Female
Age (years)
24
2533
34
Highest level of education
Basic education (certificate, diploma)
Higher education (advanced diploma, post basic
certificate, bachelors and masters degrees)
Designation
Staff nurse
More senior nurse (senior staff nurse, nurse
clinician, nurse manager)
Working experience (years)
<2
2.015
5.0110
> 10
Children
No children
One or more children
Previous experience of hospitalization of their
children
Yes
No

134

100

47
48
39

35
36
29

74
60

55
45

98
36

73
27

50
41
30
13

37
31
22
10

87
47

65
35

27
20

20
15

H.-G. He et al.

bathing and sponging. Seventy-six percent reported

that they always or nearly always created a comfortable environment for children postoperatively by
making efforts to minimize noise and adjusting the
lighting and temperature of the room.
About half (54%) responded that they always or
nearly always provided preparatory information to
the children (see Table 2). Details of the preparatory
information are shown in Table 3. The information
most frequently (more than 75%) given in preparation of the child (always or nearly always) included
nonpharmacological methods for pain relief, preoperative preparations, and postoperative monitoring.
For ways of giving information, 58% of the nurses
reported that they always or nearly always talked
openly about fear and anxiety if they noticed that
the child appeared anxious.

Relationship between nurses background factors

and their use of nonpharmacological methods

Statistically significant differences were found

between nurses in the less than 24-year-old age
group and the other two age groups (see Table 4).
Nurses in the 25- to 33-year-old age group reported
informing children about the duration of the procedure more frequently than those in the less than
24-year-old age group. Nurses in the 25- to 33-yearold and 34 and older age groups used the following
methods more frequently than those in the less

Table 2. Nurses Use of Nonpharmacological Methods for School-Age Childrens Postoperative Pain Relief (N = 134)
Nonpharmacological Methods
Cognitivebehavioral methods
Relaxation
Breathing technique
Distraction
Positive reinforcementa
Preparatory informationb
Imagery
Physical methods
Positioning
Thermal regulationc
Massage
Emotional support
Comforting/reassurance
Touch
Presence
Helping with activities of daily living
Creating a comfortable environment

Nearly Always/Always
n (%)

Sometimes
n (%)

Never/Very Seldom
n (%)

119
118
100
77
72
69

10
12
26
38
32
44

5
4
8
19
30
21

(89)
(88)
(75)
(58)
(54)
(51)

82 (61)
43 (32)
28 (21)
106
98
66
110
102

(79)
(73)
(49)
(82)
(76)

(7)
(9)
(19)
(28)
(24)
(33)

(4)
(3)
(6)
(14)
(22)
(16)

45 (34)
51 (38)
44 (33)

7 (5)
40 (30)
62 (46)

23
25
55
20
27

5
11
13
4
5

(17)
(19)
(41)
(15)
(20)

(4)
(8)
(10)
(3)
(4)

Note: aVerbal and material rewards; bInclusive of cognitive information, sensory information and ways of giving information; cCold and
heat application.

32

Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

H.-G. He et al.

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

Table 3. Nurses Provision of Preparatory Information to School-Age Children (N = 134)

Preparatory Information Provided

Cognitive information
Nonpharmacological methods for pain relief
Postoperative monitoring
Preoperative preparations
Type of procedure
Location of procedure
Postoperative limitations
Pain medication
Purpose of the procedure
Postoperative location
Type of anesthesia
Duration of the procedure
Surgeon who performs the procedure
Complications of the procedure
Sensory information
Sensation after the procedure (e.g., pain, nausea)
Sensation during the procedure (e.g., pain)
Sensation before the procedure (e.g., fear, anxiety)
Ways of giving information
Discuss openly with the child if I notice s/he is in fear/anxiety
Encourage the child to ask questions
Make sure that the information given is understood
Inform the child honestly and openly
Take into account the childs age and developmental level
Tell the school-age child more about the procedure than a younger child
Materials used when informing the child
Books/booklets/instruction folders
Videos

Nearly Always/
Always
n (%)

Sometimes
n (%)

102
101
101
99
99
96
97
88
86
68
62
49
44

23
16
16
27
23
23
30
31
32
37
38
50
47

(76)
(75)
(75)
(74)
(74)
(72)
(72)
(66)
(64)
(51)
(46)
(37)
(33)

(17)
(12)
(12)
(20)
(17)
(17)
(22)
(23)
(24)
(27)
(28)
(37)
(35)

76 (57)
51 (38)
45 (33)

36 (27)
48 (36)
49 (37)

78 (58)
18 (13)
2 (2)
1 (1)
1 (1)

8
7
46
48
36
7

38 (28)
7 (5)

41 (31)
7 (5)

(6)
(5)
(34)
(36)
(27)
(5)

Never/Very
Seldom
n (%)
9
17
17
8
12
15
7
15
16
29
34
35
43

(7)
(13)
(13)
(6)
(9)
(11)
(5)
(11)
(12)
(22)
(25)
(26)
(32)

22 (16)
35 (26)
40 (30)
48
109
86
85
97
127

(36)
(81)
(64)
(63)
(72)
(95)

55 (41)
120 (90)

.018), breathing technique (U = 1,943, p = .028),

massage (U = 1,648, p = .006), positioning (U =
1,702, p = .007), presence (U = 1,639.5, p = .004),
comforting/reassurance (U = 1,845.5, p = .018), and
touch (U = 1,606.5, p = .000).
Similarly, there was a statistically significant
difference in the use of some nonpharmacological

than 24-year-old age group: positioning, presence,

comforting/reassurance, and touch.
Statistically significant differences were found
between nurses with basic and higher education in
nursing. Nurses with higher education in nursing
used the following methods more often than those
with basic education: imagery (U = 1,740.5, p =

Table 4. The Relationship between Nurses Age and Their Use of Nonpharmacological Methods (N = 134)
Age (Years)
24

2533

34

KruskalWallis Test

Nonpharmacological
Methods

Median
(Interquantile)

Median
(Interquantile)

Median
(Interquantile)

Statistics,
p Valueb

Information of duration of
the procedure
Positioning
Presence
Comforting/reassurance
Touch

2.0 (13)

3.0 (23)

3.0 (23)

7.84, .020

(.011c, .030, .857)

2.0 (23)
2.0 (23)
3.0 (23)
3.0 (23)

3.0 (23)
2.5 (23)
3.0 (33)
3.0 (33)

3.0 (23)
3.0 (23)
3.0 (33)
3.0 (33)

10.65, .005
9.49, .009
12.97, .002
12.33, .002

(.009c, .004c, .783)

(.044, .004c, .193)
(.004c, .004c, .758)
(.011c, .002c, .363)

MannWhitney U Test
Between Groups (A, B,
C),a p Valuec

Notes: aA: 24 versus 2533; B: 24 versus 34; C: 2533 versus 34; bOnly p values less than 0.05 are reported; cBased on the Bonferonni
correction, p value less than 0.017 is considered statistically significant.

Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

33

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

H.-G. He et al.

Table 5. The Relationship between Nurses Working Experience and Their Use of Nonpharmacological Methods (N = 134)
Experience (Years)

Kruskal
Wallis Test

MannWhitney
U Test Between
Groups (A, B,
C, D, E, F)a
p Valuec

Nurses Use of
Nonpharmacological
Methods

2.015

5.0110

> 10

Median
(Interquantile)

Median
(Interquantile)

Median
(Interquantile)

Median
(Interquantile)

Information of
postoperative
monitoring
Imagery

3.0 (23)

3.0 (33)

3.0 (33)

2.0 (13)

8.604, .035

(.261, .278, .078, .976,

.008c, .011)

2.0 (1.753)

3.0 (23)

3.0 (23)

3.0 (13)

10.346, .016

Distraction

3.0 (23)

3.0 (33)

3.0 (33)

2.0 (1.503)

10.632, .014

Massage

1.0 (12)

2.0 (12)

2.0 (1.753)

1.0 (12)

14.116, .003

Presence

2.0 (23)

3.0 (23)

3.0 (23)

3.0 (23)

12.753, .005

Touch

3.0 (23)

3.0 (33)

3.0 (33)

3.0 (2.503)

16.683, .001

(.068, .002c, .644, .103,

.563, .125)
(.505, .064, .053, .199,
.018, .002c)
(.046, .000c, .628, .090,
.389, .042)
(.020, .003c, .023, .366,
.366, .800)
(.029, .000c, .260, .024,
.825, .038)

Statistics,
p Valueb

Notes: aA: 2 versus 2.015; B: 2 versus 5.0110; C: 2 versus >10; D: 2.015 versus 5.0110; E: 2.015 versus >10; F: 5.0110 versus >10;
b
Only p-values less than 0.05 are reported; cBased on the Bonferonni correction, p values less than 0.0083 are considered statistically significant.

methods between the staff nurses and more senior

nurses. More senior staff reported that they more
frequently implemented the emotional support
strategies of comforting/reassurance (U = 1,647.5,
p = .035) and touch (U = 1,336.5, p = .006).
The length of work experience was statistically
significantly related to their use of several nonpharmacological methods (see Table 5). Those with 5.01
to 10 years of experience reported that they practiced methods of imagery, massage, presence, and
touch more frequently than those with less than 2
years work experience. They also used distraction
more often than those with more than 10 years of
experience. In addition, nurses with 2.01 to 5 years
of work experience provided information to children on postoperative monitoring more often than
those with more than 10 years experience.
There were statistically significant differences
between the scores for nurses with children of their
own compared with those without. Nurses with
children of their own reported that they informed
children more frequently about pain medication
(U = 1,619.5, p = .011), non-pharmacological pain
relief methods (U = 1,667.5, p = .018), and sensation
after the procedure (U = 1,581.5, p = .015). They also
reported that they used the following methods more
often: imagery (U = 1,381.5, p = .001), distraction
(U = 1,640.5, p = .013), breathing technique (U =
1,798.5, p = .041), positioning (U = 1,547, p = .007),
presence (U = 1,543, p = .009), comforting/
34

reassurance (U = 1,709, p = .027), touch (U = 1,629,

p = .013), and helping with activities of daily living
(U = 1,752.5, p = .041).
DISCUSSION

Given the high response rate and the nature of the

sample, the results generated are representative of
nurses working in pediatric wards in Singapore. The
findings revealed that a high percentage of the
Singapore nurses sampled routinely used various
nonpharmacological pain relief methods, especially
relaxation, breathing technique, and helping with
activities of daily living, in their clinical practice. This
provides useful data for comparison with the findings
from previous studies in China (He et al., 2005) and
Finland (Plkki et al., 2001), where the same instrument was used. The high usage of nonpharmacological methods may be explained by the inclusion of
pain as the fifth vital sign, which encourages nurses to
assess and subsequently manage pain more routinely. Also each ward in the study had standing
written instructions regarding such practices.
While most cognitivebehavioral methods in the
questionnaire were routinely practiced, only about
half of the nurses always or nearly always provided
preparatory information. This finding was noticeably less than the 97% in the Finnish sample (Plkki
et al., 2001) and 75% in the Chinese sample (He
et al., 2005). Further, the Singapore sample reported
Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

H.-G. He et al.

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

less frequent provision of adequate sensory information, paying enough attention to the ways of giving
information, and the use of materials to help with
informing children. This may be because the provision of preparatory information was mainly done by
surgeons/anesthetists and was not routine nursing
practice in the participating wards.
In contrast to Li and Lopez (2008) finding in
Hong Kong that the provision of preoperative
information was common when preparing children
for surgery, and the important use of dialogue as
proposed by Wennstrm et al. (2008), this study
showed that among ways of giving information, only
58% of nurses nearly always discussed observed fear
or anxiety openly with the child. Other aspects of
communication, such as encouraging the child to ask
questions, informing openly and honestly, tailoring
responses to the childs age, and validating the childs
understanding of information provided were frequently not done or seldom provided. These results
indicate a weakness in the communication process,
and may reflect the culture in which nurses defer to
the doctor for provision of information beyond the
basic. Clearly, there is a need to improve the adequacy
and the way information is provided to children
preoperatively.
In line with previous findings (He et al., 2005;
Plkki et al., 2001) positioning was the most commonly used physical method. This may be because
this approach is more routine and acceptable in
nursing, and less time-consuming and more easily
administered than other strategies, such as
TENS for example, which is within the scope of
nursing practice, but never used by nurses in
Singapore.
Nurses in Singapore commonly practiced most
of the emotional support strategies, helping with
activities of daily living and creating a comfortable
environment to soothe childrens postoperative
pain, which is in line with previous findings (He
et al., 2005; Plkki et al., 2001). However, presence
was less frequently used (49%) compared with the
Finnish sample (77%; Plkki et al., 2001). This discrepancy could be explained by the lack of time
pediatric nurses spent with patients (Bell & Duffy,
2009; He et al., 2005) or nurses lacked understanding of the actual meaning of presence, which is a
matter of being authentically present or in tune with
the patient when the nurse is there. The other
reason may be the cultural difference between
the two countries, for in Singapore, where about
75% of the population are Chinese, parents usually
stay with their children during hospitalization,
Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

and this may have reduced the frequency and duration of time spent by pediatric nurses with their
patients.
The participants in this study were mostly young
and had lower levels of education (Diploma or
Certificate), no children of their own, lower
designation (SNs), and less than 2 years of professional working experience. In other words, they
were less experienced in life and nursing. In Singapore, the majority of registered nurses up until
2006 were educated in polytechnics. They entered
the diploma program 2 years earlier than those
seeking university entrance. There were no specific
courses or lectures related to pediatric pain management, and they received fragmented education
in pain management, mainly in pharmacological
methods given by clinical educators during clinical
practice.
Statistically significant differences were found
among the nurses age, educational level, designation, duration of work experience, whether they
had children of their own, and their use of a
variety of nonpharmacological methods. These
results corresponded with the other studies (He
et al., 2005; Plkki et al., 2003). In Singapore, older
nurses as well as nurses with a higher level of education and designation, longer working experience
in the pediatric wards (especially those with 510
years of experience), and children of their own
used nonpharmacological methods for pain relief
more frequently. These findings are quite similar
with the Chinese (He et al., 2005) and Finnish
(Plkki et al., 2001) findings. It is worth noting
that it was not the nurses with the longest work
experience (more than 10 years), but those with
510 years experience, who most frequently provided nonpharmacological pain relief methods for
children. The reason for this might be that the most
experienced nurses spent more time doing administration or documentation than providing direct
patient care, according to the description of job
scope for each level of nurses in the hospitals. In
addition, nurses who had children of their own
were more likely to use a variety of nonpharmacological methods compared with their colleagues
who had no children of their own. The confidence
that comes with previous experiences of parenting
is a likely explanation.
An individual nurses adoption and use of
evidence-based pain management practices depends
on many factors, such as the practice environment,
the nurses knowledge, attitudes and skills, and
characteristics of the pain management practice
35

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

being adopted (Ellis et al., 2007). The personality

characteristics of the nurse, the communication
techniques, and the childs temperament are other
important factors that need to be considered.
Singapore nursing is in a transition phase. Until
2006, all nursing education was at the diploma level,
and the students were accepted at a younger age
than is the norm in university-based bachelors education. It seems likely that the respondents in this
study, being mainly Diploma graduates, had their
responses shaped by their education, their ages, and
relative inexperience. Clearly, there are curricular
issues related to knowledge level and skills in using
these methods in their practices.
Limitations

Several limitations need to be considered. First,

respondents being forced to respond to never
rather than having a not applicable option allows for
inflation of negative responses because the nurses
might not have had the opportunity to provide the
intervention, even if they had the desire. Second, as
surveys convey self-reported actions that may not
necessarily concur with actual clinical practice
(Manias et al., 2005), additional methods, such as
observational methods where nurses use of nonpharmacological methods to alleviate patients pain
can be directly and validly assessed (Dihle et al.,
2006), may have yielded different results. Last, there
was no comparison between the two hospitals;
however, the site, in terms of what practices are
encouraged and discouraged by the work culture,
might have confounded the nurses responses
(McDonald, Laporta, & Meadows-Oliver, 2007).

How Do I Apply This Evidence to Nursing Practice?

The use of nonpharmacological methods to

provide complementary pain relief in pediatric
patients has been widely demonstrated to be effective. In order to improve the effectiveness of pain
management in practice and enhance standards of
care, nurses should optimally use a variety of different methods for childrens postoperative pain
relief and focus on auditing their own practice.
Nurses should be encouraged to include methods
that have been shown effective in prior research
but that were less often used by nurses in this
study: massage, thermal regulation, imagery, and
positive reinforcement. Moreover, nurses should
provide more preparatory information to children

36

H.-G. He et al.

and pay more attention to ways of giving information,

for example, making sure the information given is
age-appropriate and understood.
Hospital administrators should be mindful of the
therapeutic effects of nonpharmacological procedures. Training and education on nonpharmacological pain relief methods need to be provided,
especially to those who are younger, less educated,
without children, with lower designation, and have
less professional experience. Young nurses need
help from more experienced staff members. Identifying nurses who do not use nonpharmacological
methods and identifying strategies to engage them
in the use of novel interventions in their practices
would be a valuable exercise. Observational and
interview studies on nurses, childrens, and their
parents practices of nonpharmacological methods
to relieve postoperative pain would help add substance to this survey, which has provided some
useful data in an otherwise poorly researched area.

References
American Academy of Pediatrics. (2001). The assessment
and management of acute pain in infants, children, and
adolescents. Pediatrics, 108(3), 793797.
Ball, T. M., Shapiro, D. E., Monheim, C. J., & Weydert, J. A.
(2003). A pilot study of the use of guided imagery for
the treatment of recurrent abdominal pain in children.
Clinical Pediatrics (Phila), 42(6), 527532. doi: 10.1177/
000992280304200607
Bell, L., & Duffy, A. (2009). Pain assessment and
management in surgical nursing: A literature review.
British Journal of Nursing, 18(3), 153156.
Bellieni, C. V., Cordelli, D. M., Raffaelli, M., Ricci, B.,
Morgese, G., & Buonocore, G. (2006). Analgesic effect
of watching TV during venipuncture. Archives of Disease
in Childhood, 91(12), 10151017. doi:10.1136/adc.
2006.097246
Burns, N., & Grove, S. K. (2005). The practice of nursing
research. Conduct, critique, and utilization (5th ed.).
Philadelphia: Elsevier Saunders.
Caty, S., Tourigny, J., & Koren, I. (1995). Assessment and
management of childrens pain in community hospitals.
Journal of Advanced Nursing, 22(4), 638645.
doi:10.1046/j.1365-2648.1995.22040638.x
Dahlquist, L. M., Busby, S. M., Slifer, K. J., Tucker, C. L.,
Eischen, S., Hilley, L., & Sulc, W. (2002). Distraction for
children of different ages who undergo repeated needle
sticks. Journal of Pediatric Oncology Nursing, 19(1), 2234.
doi:10.1053/jpon.2002.30009
Dihle, A., Bjlseth, G., & Helseth, S. (2006). The gap
between saying and doing in postoperative pain

Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

H.-G. He et al.

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

management. Journal of Clinical Nursing, 15(4), 469479.

doi:10.1111/j.1365-2702.2006.01272.x
Eccleston, C., Palermo, T. M., Williams, A. C.,
Lewandowski, A., & Morley, S. (2009). Psychological
therapies for the management of chronic and recurrent
pain in children and adolescents. Cochrane Database
of Systematic Reviews, (2), CD003968.
doi:10.1002/14651858.CD003968.pub2
Ellis, J. A., McCleary, L., Blouin, R., Dube, K., Rowley, B.,
MacNeil, M., & Cooke, C. (2007). Implementing best
practice pain management in a pediatric hospital.
Journal for Specialists in Pediatric Nursing, 12(4),
264277. doi:10.1111/j.1744-6155.2007.00121.x.
Erdogan, M., Erdogan, A., Erbil, N., Karakaya, H. K., &
Demircan, A. (2005). Prospective, randomized,
placebo-controlled study of the effect of TENS on
postthoracotomy pain and pulmonary function. World
Journal of Surgery, 29(12), 15631570.
Ericsson, E., Wadsby, M., & Hultcrantz, E. (2006).
Pre-surgical child behavior ratings and pain
management after two different techniques of tonsil
surgery. International Journal of Pediatric
Otorhinolaryngology, 70(10), 17491758. doi:10.1016/
j.ijporl.2006.05.017
Gerik, S. M. (2005). Pain management in children:
Developmental considerations and mind-body
therapies. Southern Medical Journal, 98(3), 295302.
doi:10.1097/01.SMJ.0000154772.49481.53
He, H. G., Plkki, T., Vehvilinen-Julkunen, K., & Pietil,
A. M. (2005). Chinese nurses use of
non-pharmacological methods in childrens
postoperative pain relief. Journal of Advanced Nursing,
51(4), 335342. doi:10.1177/000992280304200607
He, H. G., Vehvilinen-Julkunen, K., Plkki, T., & Pietil,
A. M. (2007). Childrens perceptions on the
implementation of methods for their postoperative pain
alleviation: An interview study. International Journal of
Nursing Practice, 13(2), 8999. doi:10.1111/j.1440172X.2007.00614.x
Hegyvary, S. T. (2004). Working paper on grand
challenges in improving global health. Journal of
Nursing Scholarship, 36(2), 96101. doi:10.1111/
j.1547-5069.2004.04020.x
Huth, M. M., Broome, M. E., & Good, M. (2004). Imagery
reduces childrens post-operative pain. Pain, 110(12),
439448. doi:10.1016/j.pain.2004.04.028
Idvall, E., Holm, C., & Runeson, I. (2005). Pain experiences
and non-pharmacological strategies for pain
management after tonsillectomy: A qualitative interview
study of children and parents. Journal of Child Health
Care, 9(3), 196207. doi:10.1177/1367493505054417
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2000). Pain management and assessment:
An organizational approach. Oakbrook Terrace, IL:
Author.

Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

Jonas, D., Day, A., & Binns, F. (1998). Management of

paediatric pain 1: Non-drug approaches. Community
Nurse, 4(2), 4445.
Kahler, B. M. W. (2003). The effect of distraction and
positioning for venous cannulation on pain responses in young
children (Doctoral dissertation). Manhattan, KS: Kansas
State University).
Kain, Z. N., Mayes, L. C., & Caramico, L. A. (1996).
Preoperative preparation in children: A cross-sectional
study. Journal of Clinical Anesthesia, 8(6), 508514.
doi:10.1016/0952-8180(96)00115-8
Kankkunen, P., Vehvilinen-Julkunen, K., Pietil, A. M.,
Korhonen, A., Nyyssnen, S., Lehikoinen, N. M., &
Kokki, H. (2009). Promoting childrens pharmacological
post-operative pain alleviation at home. Pediatric
Nursing, 35(5), 298303.
Kolk, A. M., van Hoof, R., & Fiedeldij Dop, M. J. (2000).
Preparing children for venepuncture. The effect of an
integrated intervention on distress before and during
venepuncture. Child: Care, Health and Development, 26(3),
251260. doi:10.1046/j.1365-2214.2000.00145.x
Lander, J., & Fowler-Kerry, S. (1993). TENS for childrens
procedural pain. Pain, 52(2), 209216. doi:10.1016/
0304-3959(93)90133-A
Lassetter, J. H. (2006). The effectiveness of complementary
therapies on the pain experience of hospitalized
children. Journal of Holistic Nursing, 24(3), 196208.
doi:10.1177/0898010106289838
Li, H. C., & Lopez, V. (2008). Effectiveness and
appropriateness of therapeutic play intervention in
preparing children for surgery: A randomized controlled
trial study. Journal for Specialists in Pediatric Nursing,
13(2), 6373. doi:10.1111/j.1744-6155.2008.00138.x
Lin, Y. C., Lee, A. C., Kemper, K. J., & Berde, C. B. (2005).
Use of complementary and alternative medicine in
pediatric pain management service: A survey. Pain
Medicine, 6(6), 452458. doi:10.1111/j.1526-4637.
2005.00071.x
McCaffery, M. (1999). Using superficial cooling
for pain relief. American Journal of Nursing, 99(3),
24.
McDonald, D. D., Laporta, M., & Meadows-Oliver, M.
(2007). Nurses response to pain communication from
patients: A post-test experimental study. International
Journal of Nursing Studies, 44(1), 2935. doi:10.1016/
j.ijnurstu.2005.11.017
Manias, E., Bucknall, T., & Botti, M. (2005). Nurses
strategies for managing pain in the postoperative setting.
Pain Management Nursing, 6(1), 1829. doi:10.1016/
j.pmn.2004.12.004
Murphy, G. (2009). Distraction techniques for
venepuncture: A review. Paediatric Nursing, 21(3),
1820.
Phua, D. S., Leong, W. M., & Yoong, C. S. (2008). The acute
pain service after ten years: Experiences of a Singapore

37

The Use of Nonpharmacological Methods for Childrens Postoperative Pain Relief: Singapore Nurses Perspectives

public hospital. Singapore Medical Journal, 49(12),

10071011.
Plkki, T., Laukkala, H., Vehvilinen-Julkunen, K., &
Pietil, A. M. (2003). Factors influencing nurses use of
nonpharmacological pain alleviation methods in
paediatric patients. Scandinavian Journal of Caring Science,
17(4), 373383. doi:10.1046/j.0283-9318.2003.00239.x
Plkki, T., Pietil, A. M., Vehvilinen-Julkunen, K.,
Laukkala, H., & Kiviluoma, K. (2008). Imagery-induced
relaxation in childrens postoperative pain relief: A
randomized pilot study. Journal of Pediatric Nursing,
23(3), 217224. doi:10.1016/j.pedn.2006.11.001
Plkki, T., Vehvilinen-Julkunen, K., & Pietil, A. M.
(2001). Nonpharmacological methods in relieving
childrens postoperative pain: A survey on hospital
nurses in Finland. Journal of Advanced Nursing, 34(4),
483492. doi:10.1046/j.1365-2648.2001.01777.x
Saeki, Y. (2002). Effect of local application of cold or heat
for relief of pricking pain. Nursing and Health Sciences,
4(3), 97105. doi:10.1046/j.1442-2018.2002.00112.x
Schaffer, S. D., & Yucha, C. B. (2004). Relaxation & pain
management: The relaxation response can play a role in
managing chronic and acute pain. American Journal of
Nursing, 104(8), 7576, 7879, 8182.
So, P. S., Jiang, Y., & Qin, Y. (2008). Touch therapies
for pain relief in adults. Cochrane Database of

38

H.-G. He et al.

Systematic Reviews, (4), CD006535. doi:10.1002/

14651858.CD006535.pub2
Sutters, K. A., Savedra, M. C., Miaskowski, C.,
Holdridge-Zeuner, D., Waite, S., Paul, S. M., &
Lanier, B. (2007). Childrens expectations of pain,
perceptions of analgesic efficacy, and experiences with
nonpharmacologic pain management strategies at home
following tonsillectomy. Journal for Specialists in Pediatric
Nursing, 12(3), 139148. doi:10.1111/j.1744-6155.
2007.00107.x
Twycross, A. (2007). Childrens nurses post-operative pain
management practices: An observational study.
International Journal of Nursing Studies, 44(6), 869881.
doi:10.1016/j.ijnurstu.2006.03.010
Wang, H. L., & Keck, J. F. (2004). Foot and hand massage
as an intervention for postoperative pain. Pain
Management Nursing, 5(2), 5965. doi:10.1016/
j.pmn.2004.01.002
Wennstrm, B., Hallberg, L. R., & Bergh, I. (2008). Use of
perioperative dialogues with children undergoing day
surgery. Journal of Advanced Nursing, 62(1), 96106.
doi:10.1111/j.1365-2648.2007.04581.x
Wiroonpanich, W., & Strickland, J. C. (2004). Normalizing:
Postoperative acute abdominal surgical pain in Thai
children. Journal of Pediatric Nursing, 19(2), 104112.
doi:10.1016/S0882-5963(03)00145-3

Journal for Specialists in Pediatric Nursing 16 (2011) 2738 2010, Wiley Periodicals, Inc.

Copyright of Journal for Specialists in Pediatric Nursing is the property of Wiley-Blackwell and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.