POST SURGICAL CARE

Postoperative pain management experiences among school-aged

children: a qualitative study
Qian Wen Sng, Beverley Taylor, Joanne LW Liam, Piyanee Klainin-Yobas, Wenru Wang and
Hong-Gu He

Aims and objectives. To explore postoperative pain management experiences among school-aged children.
Background. Ineffective postoperative pain management among children has been commonly reported. School-aged children
are able to evaluate how their pain is managed and what their preferred strategies are. Most studies in pain management
have adopted quantitative methods and have overlooked childrens pain management experiences.
Design. This is a qualitative study using face-to-face interviews.
Methods. Data were collected from 15 school-aged children admitted to a tertiary hospital in Singapore by in-depth inter-
views conducted between November 2010 and January 2011. Data were analysed by thematic analysis.
Results. Five themes were identified: childrens self-directed actions to relieve their postoperative pain (e.g. using cognitive-
behavioural methods of distraction and imagery, physical method of positioning, sleeping and drinking, seeking other peo-
ples help by informing parents and crying and using pain medications); childrens perceptions of actions parents take for
their postoperative pain relief (assessing pain, administering pain medications, using various cognitive-behavioural, physical
methods and emotional support strategies, assisting in activities and alerting health professionals); childrens perception of
actions nurses take for their postoperative pain relief (administering medication, using cognitive-behavioural methods, emo-
tional support strategies and helping with activities of daily living) and suggestions for parents (using distraction and pres-
ence) and nurses (administering medications, distraction and positioning) for their postoperative pain relief improvement.
Conclusions. This study contributed to the existing knowledge about childrens postoperative pain management based on
their own experiences. Children, their parents and nurses used various strategies, including pain medication and non-
pharmacological methods, especially distraction, for childrens postoperative pain relief.
Relevance to clinical practice. This study provides evidence for health care professionals to consider using more pain relief
strategies when caring for children postoperatively and provide guidance for children to practice these strategies.

Key words: children, experience, interview, management, nursing, pain, postoperative, qualitative, school-aged, Singapore

Accepted for publication: 21 August 2012

Authors: Qian Wen Sng, BSc, RN, Staff Nurse, Division of Nurs-
ing, KK Womens and Childrens Hospital, Singapore; Beverley
Taylor, PhD, RN, Professor, School of Nursing and Midwifery,
Monash University, Gippsland, Victoria, Australia; Joanne LW
Liam, BSc, RN, Nurse Clinician, Division of Nursing, KK
Womens and Childrens Hospital, Singapore; Piyanee Klainin-
Yobas, PhD, RN, Assistant Professor, Alice Lee Centre for Nursing
Studies, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore; Wenru Wang, PhD, RN, Assistant Professor,
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, National University of Singapore, Singapore; Hong-Gu
He, PhD, MD, RN, Assistant Professor, Alice Lee Centre for Nurs-
ing Studies, Yong Loo Lin School of Medicine, National University
of Singapore, Singapore
Correspondence: Hong-Gu He, Assistant Professor, Alice Lee Cen-
tre for Nursing Studies, Yong Loo Lin School of Medicine,
National University of Singapore, Level 2, Clinical Research Cen-
tre, Block MD11, 10 Medical Drive, Singapore. Telephone:
+65 65167448.
E-mail: nurhhg@nus.edu.sg

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958 Journal of Clinical Nursing, 22, 958968, doi: 10.1111/jocn.12052
Post surgical care Childrens experiences in postoperative pain

Introduction has been pivotal in reducing childrens pain in different

procedures (Schechter et al. 2007). However, patients suffer-
Accumulating empirical evidence affirms that children
ing from severe pain may not benefit from distraction, as
still suffer from moderate-to-severe postoperative pain
their pain may hinder them from concentrating enough on
(Kortesluoma et al. 2008a), and poorly treated pain can
complicated physical or mental tasks (Smeltzer et al. 2009).
inflict on childrens biological systems and pain responses
Studies have shown that the combination of distraction,
(Coderre et al. 1993) such as nausea and vomiting (Korpela
relaxation, hypnosis and imagery is an effective strategy and
et al. 1999), thus resulting in a longer recovery period and
they support the use of such non-pharmacological methods
hospital stay, and increased medical costs (Roykulcharoen
in the paediatric clinical setting (Uman et al. 2006, Polkki
& Good 2004). Health care professionals are ethically obli-
et al. 2008). Several studies have examined the potential of
gated to prevent unnecessary suffering and pain in patients
physical methods (Ebner 1996, Kahler 2003) to reduce pain
and especially children (McGrath & Unruh 2006); this
experienced by children. Other studies have shown childrens
includes active involvement of the children and their par-
desire for massages and rubbing of their wound sites to alle-
ents in the process.
viate pain (Fongkaeo 2002, He et al. 2007). Parental pres-
Most studies in pain management have adopted quantita-
ence has been seen as a valuable source of emotional support
tive methods and have overlooked childrens pain manage-
and comfort for children, which allayed anxieties during
ment experiences, their perceptions and suggestions in their
their hospitalisation (McCaffery & Wong 2003, Kolcaba &
own pain management. A few studies that focused on chil-
DiMarco 2005). During the postoperative period, children
drens experiences and perceptions have been conducted in
are highly dependent on their parents and nurses to aid them
Finland (Polkki et al. 2003, Kortesluoma & Nikkonen 2004,
in their activities of daily living due to their pain and weak-
Kortesluoma 2006, Kortesluoma et al. 2008a), USA (Sutters
ness, and having these activities taken over from them helped
et al. 2007), Thailand (Fongkaeo 2002) and China (He et al.
to lessen their pain (Polkki et al. 2002, 2003, He et al.
2007). No such study has been conducted in Singapore,
2006). Children also preferred a comfortable environment
where 514-year-old children include 67
9% Chinese,
with good lighting and familiar personal belongings, as it
17
7% Malay, 10
6% Indian and 3
87% of other races
exerted a positive influence on their postoperative experience
(Department of Statistics 2010, p. 43). This cultural diversity
in the hospital (Fongkaeo 2002, Polkki et al. 2003).
provides a useful backdrop for this study, as cultural influ-
ences can affect peoples pain expressions, and are especially
significant in moderating the amplitude of pain behaviours Aim
(Finley et al. 2009). In-depth interviews focusing on pain
The aim of this study was to explore postoperative pain
experiences of school-aged children in the Asian context have
experiences among school-aged children in Singapore.
been very limited.

Background
While pain medication remains the cornerstone of pain
relief, a variety of non-pharmacological pain management
methods could be used for mild pain or in conjunction with
pain medication for moderate-to-severe pain among children
(Caty et al. 1995). Emerging evidence regarding the benefits
and effectiveness of non-pharmacological pain relief strate-
gies has helped to increase their use in the paediatric clinical
setting (DeMore & Cohen 2005). Five categories of non-
pharmacological methods, namely, cognitive-behavioural
methods, physical methods, emotional support strategies,
helping with daily activities and creating a comfortable envi-
ronment, have been identified by Polkki et al. (2001).
Cognitive-behavioural methods encompass interventions
aimed to alter emotions, behaviours and cognitions (Cham-
bers et al. 2009). Among the various strategies, distraction
Methods
Study design
This was a descriptive qualitative study situated within the
interpretive paradigm.
Participants and recruitment
The participants were recruited from two paediatric surgi-
cal wards in a public hospital in Singapore. Purposive sam-
pling was used and data collection proceeded until data
saturation. Eventually, a total of 15 children were inter-
viewed. The inclusion criteria for the participants were chil-
dren who: (1) were 612 years old; (2) were able to
communicate verbally in either English or Mandarin; (3)
had undergone surgery in the participating wards; (4) had a
minimum of more than 24-hour postoperative stay at the

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QW Sng et al.
ward and (5) were in a stable postoperative condition. The
exclusion criteria were children who had physical or mental
disabilities, and/or chronic medical conditions and pain.
Data collection
Semi-structured interviews were used to collect data from
December 2010 to January 2011 using an interview guide
developed based on previous studies (Polkki et al. 2003, He
et al. 2007, Wiggins & Foster 2007). Children who met the
eligibility criteria were identified by the nursing staff, who
knew their patients well. One day after the surgical proce-
dure, the researcher approached the parents and the child by
introducing herself to them and inviting them to participate
in the study. A Participant Information Sheet was provided
and the aim of the study, the requirements, risks and benefits
were explained to them. After that, consent from the parents
and assent from the child were obtained of their expressed
interest in participating in the research. On the scheduled
time of the interview, children who were found to be in pain
and uncomfortable were rescheduled to a later time, but
before discharge. When a child was ready for the interview,
the researcher explained that there were no right or wrong
answers regarding their pain management after surgery
(Ungar et al. 2006). Each interview lasted about 10 minutes.
All interviews were audio recorded. Background information
such as age, gender, ethnicity, the procedure undertaken, the
pain medication used and current pain intensity were col-
lected after the interview. A small notebook was given to
each child after the interview as a token of appreciation,
which is a common practice in the local context.
Ethical considerations
Ethical approval was obtained from the participating hospi-
tal. Written informed consent and assent were obtained
from the parents and children respectively. The researcher
emphasised voluntary participation, and that refusal to par-
ticipate in the study would not have any negative effect on
the care the children received and that the data collected
would be kept confidential. Pseudonyms were used to pro-
tect the identities of the participants.
Data analysis
Thematic analysis was used to analyse the data (Taylor
et al. 2006). All audio-recorded data were transcribed by
the same researcher who conducted the interview. The tran-
scripts and audio-recording data were reviewed by two
other researchers to ensure verbatim accuracy. Colour-
960
coding method was used to identify the distinct concepts
and categories (Braun & Clarke 2006), which were read
through several times to ensure that these concepts and
categories accurately reflected interview responses. The con-
cepts and categories were then regrouped to form the sub-
themes of the study, which were eventually collated
together to form the themes of the study.
Rigour
Lincoln and Guba (1985) enumerated the following criteria
for ensuring the rigour of qualitative studies: credibility,
transferability, dependability and confirmability. To enhance
the credibility of the findings, investigator triangulation was
used to analyse the data (Polit & Beck 2006); critical self-
reflection and bracketing were also used in the process of
data collection and data analysis to reduce bias by being vig-
ilant in avoiding imposing personal viewpoints (Ahern 1999,
Macnee & McCabe 2008). To enhance the transferability,
the researcher included descriptions of the interview settings
and those of her observations of the participants during the
interview (Polit & Beck 2006). To ensure dependability, an
audit trail, consisted of raw data, including all field notes,
audio recordings, products of data analysis and synthesis,
process notes and interview guides, was created to increase
transparency of the research process (Halpern 1983). To
ensure the confirmability, two researchers who were content
and methodology experts re-examined the transcribed inter-
views and validated the findings; and an audit trail concern-
ing decisions of data collection and analysis was kept to
ensure that this study was auditable (Polit & Beck 2006).
Results
Participants background information is shown in Table 1.
All children experienced mildto-severe postoperative pain
with worst pain scores ranging from 210 on the Numeri-
cal Rating Scale (Miro et al. 2009). They had undergone a
variety of elective and emergency surgeries. Children were
mostly given a combination of paracetamol and ibuprofen
for pain relief, followed by opioids, such as oxycodone and
morphine infusions.
Five themes emerged from the analytic process. A sum-
mary of findings is shown in Table 2.
Theme 1: childrens self-directed actions to relieve pain
postoperatively
Four sub-themes emerged relating to childrens self-directed
actions to relieve their pain postoperatively.
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 Post surgical care Childrens experiences in postoperative pain

Sub-theme 1: using cognitive-behavioural methods

Morphine infusion, paracetamol, ibuprofen

Morphine PCA, paracetamol, ibuprofen,

Children used a variety of cognitive-behavioural methods,
including distraction and imagery when they were in pain.

Morphine, paracetamol suppository

Ibuprofen, paracetamol, oxycodone

Paracetamol, ibuprofen, oxycodone

Paracetamol, ibuprofen, oxycodone

Distraction was the most frequently mentioned technique
Type of pain medication used

for pain relief. It involved the use of electronic gadgets,

such as mobile phones and Play Station portables (PSPs)

Ibuprofen, paracetamol
Paracetamol, ibuprofen
Paracetamol, ibuprofen

Paracetamol, ibuprofen
that provided distractions such as games, music and inter-
net surfing; portable laptops that allowed them to play
postoperatively

games, reading comics and watching videos; reading books

Paracetamol.
Paracetamol

Paracetamol

Paracetamol
oxycodone

and magazines; interacting with their parents and friends or

engaging in fantasy play and conversations when parents
had little time with them. Some children were able to jus-

tify their own use of such techniques to distract themselves
after surgery
Worst pain

during episodes of pain. A child described using imagery by

his own initiative to make himself feel better when he had
pain:
2
8

6
6

5
4
6

2
9

2
10

10

I will play my PSP, then listen to the songs on PSP and sometimes
Hours after

7 days

I will go to Facebook using my Aunties phone. Then snoop on

surgery

other peoples business. (Teresa, age 11)

26
24

54
26

70
20
72

44

26

45

24
26
164
155
Eight plate insertion, medial distal femur and proximal tibia

Sub-theme 2: using physical methods

Incision and drainage (skin and subcutaneous haematoma)
Mandibulectomy, wound debridement, wound inspection

Children used several physical methods for their postopera-

Eyelids, ptosis, correction levator palpebrae superioris
Vulva haematoma evacuation (incision and drainage)

tive pain relief, which included positioning, drinking fluids

and sleeping. Two children indicated that they made adjust-
Excision biopsy (infected cervical sebaceous cyst)

Close reduction elastic nailing (TENS insertion)

ments to their physical positions to relieve their own pain.

Scrotal exploration and bilateral orchidopexy

Skin and subcutaneous tissue large excision

A child was cautious and wary of any movement in the

lower part of his body, as he knew it would cause pain to
Bilateral and lateral rectus recession

his penis:

Sometimes it is prickly when I move about. It hurts here and there,

Laparoscopic appendectomy

Laparoscopic appendectomy

Laparoscopic appendectomy
Repair of septal perforation

very cold, leg muscles ache. After surgery I could not lift my legs
Correction of chordee

up, it was very difficult to move it, and when I moved it my penis
resection (bilateral)
Surgical procedure

hurt again. (Amos, age 9)

Sub-theme 3: seeking other peoples help

When children were in pain, they tried to seek other peo-
ples help, including informing parents and crying to indi-
cate the need for help. For some children experiencing pain
Gender
Table 1 Description of participants (n = 15)

or discomfort postoperatively, the first natural course of

M
M

M
M
M

M
M

M
M

action was to inform their parents for help by alerting them

F
F

of the symptoms. For example, a child said:

(years)
Age

11
12

11
12

12
10
11
11

12
9

9
8

9
8

After I woke up from the sedation, I vomit. I told my mother I was

in pain and she helped me. (John, age 11)
Chinese
Chinese

Chinese
Chinese
Chinese

Chinese

Chinese
Chinese

Chinese
Pilipino
Malay

Malay
Malay
Malay
Indian
Race

Sub-theme 4: using pain medication

A child mentioned using medication to deal with her pain.
of participants
Pseudonyms

She was prescribed patient-controlled analgesia, morphine,

Nurlina

and had been instructed by the nurse to use it when in pain:

Farhan

Suman
Xavier
Teresa
Amos

Elyas

Greg
Rose

Jesse
John
Joan

Safir

Don

Jay

I will press the morphine. (Rose, age 12)

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QW Sng et al.

Table 2 Summary of themes and subthemes

Themes Sub-themes Pain relief strategies

Childrens self-directed actions to relieve pain Using cognitive-behavioural methods Distraction

postoperatively Imagery
Using physical methods Positioning
Drinking fluids
Sleeping
Seeking other peoples help Verbally informing parents
Crying
Using pain medication

Childrens perception of actions parents take Assessing the child

for their postoperative pain relief Giving pain medications
Using cognitive-behavioural methods Distraction
Preparatory information
Positive reinforcement
Using physical methods Massage
Positioning
Using emotional support strategies Presence
Reassuring/comforting
Touch
Empathising
Assisting in activities of daily living
Alerting health professionals

Childrens perceptions of actions nurses take Administering medication

for their postoperative pain relief Using cognitive-behavioural methods Positive reinforcement
Breathing technique
Distraction
Using emotional support strategies Reassurance
Touch
Helping with activities of daily living

Suggestions for parents for alleviating Using distraction

postoperative pain Being present

Suggestions for nurses for alleviating Administering medications

postoperative pain Using distraction
Using positioning

Sub-theme 2: giving pain medication

Theme 2: childrens perceptions of actions parents take
A child mentioned that his parents gave him analgesics
for their postoperative pain relief
when he was in pain:
Seven sub-themes emerged relating to parents actions to
Give me pain killer, panadol and ask me to sleep or think of good
relieve childrens postoperative pain.
things also. (Jay, age 9)

Sub-theme 1: assessing the child

Children perceived that they were assessed by their parents,
as parents frequently asked questions about their childrens
current conditions. Some of them were ordinary questions
such as Are you okay? whereas others were more specific,
asking children about their pain. For example, a child said:
He ask me whether my neck pain or what, then where pain or
what. (Jay, age 9)
Sub-theme 3: using cognitive-behavioural methods
Parents used cognitive-behavioural methods including dis-
traction, preparatory information and positive reinforce-
ment to help relieve their childrens postoperative pain.
They generally encouraged their children to distract them-
selves by engaging in activities such as watching television
programmes and/or reading. They also brought reading
materials for their children:

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Post surgical care
(They will ask me to) watch TV. Theyll go and buy me magazines
to read. (Teresa, age 11)
Parents frequently advised children to avoid thinking of
their pain. They rationalised to children that the feeling of
pain would worsen if they continued to focus on it; hence,
they should try to ignore the pain by occupying themselves
with other thoughts:
Shell keep telling me that it is not painful and tell me to think that
there is no pain. (Jesse, age 12)
Sub-theme 4: using physical methods
The physical methods used by parents were massage and
positioning. Childrens responses showed that their parents
most regularly massaged them or change their position to
help relieve their pain. Children who had abdominal surgery
were stroked near their surgical wounds on their abdomen,
their heads and legs. These actions were either initiated with
childrens requests or from their parents initiatives:
Ask my father and mother to rub my stomach, massage my head,
hold my hand. (Suman, age 9)
She adjusts my positions and makes me feel more comfortable.
(Nurlina, age 11)
Sub-theme 5: using emotional support strategies
Parents used various emotional support strategies for their
childrens postoperative pain relief. These included their
presence, reassuring/comforting, touching and empathising
with the child. Children acknowledged that their parents
spent time with them during the difficult times in the hospi-
tal when they experienced postoperative pain. Parents com-
pany was well appreciated as the children felt happier in
their presence:
When my mother is here she would make me happier. Ill be hap-
pier also. (Elyas, age 10)
Children were able to recall the reassuring words given
by their parents to comfort and cheer them up. Parents told
their children that even though they may be experiencing
pain at the moment, they would eventually be able to
recover, return home and resume their normal lives. Parents
also reassured their children that they would not be alone
after their surgery:
They say that if I go for surgery then they will wait for me until I
am okay They say they will take care of me whenever (Jay,
age 9)
Touch was mentioned as a method parents used to relieve chil-
drens postoperative pain. Children recalled that their parents held
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Journal of Clinical Nursing, 22, 958968
Childrens experiences in postoperative pain
their hands, patted their bodies, hugged them or gently touched
their wounds. These activities were considered by children as what
parents do when they take care and comfort:
She hugged me. She rubbed me. She pacified me. (Nurlina, age 11)
Sub-theme 6: assisting in activities of daily living
Children frequently mentioned that their parents assisted
them with activities of daily living. For example, helping
them when they needed to pass urine, helping them with
food, drinks and books, especially when they were confined
to bed:
She helps me take the books when my leg is very painful then
I cannot reach the book then she help me take Help me take the
food. (Rose, age 12)
Sub-theme 7: alerting health professionals
When children were experiencing pain, parents informed
nurses or doctors about their childs condition, either
promptly or after attempting to manage the pain on their
own:
She (my mother) just turn my body like that and then later called
the nurse to check. See I am okay or not. (John, age 11)
Theme 3: childrens perceptions of actions nurses take
for their postoperative pain relief
Four sub-themes emerged in relation to nurses actions to
relieve childrens postoperative pain.
Sub-theme 1: administering medication
Children widely recognised the administration of medica-
tions as nurses main effort to help them reduce their pain;
some children thought it was the only thing nurses did for
their pain. These medications that children mentioned were
not limited to oral analgesics; they included morphine infu-
sions, antibiotics and eye drops. A child also mentioned
that she was reminded to use the patient-controlled analge-
sia whenever she experienced pain:
Yes, medicine. They put up the *beep beep beep* (morphine) also,
it has been removed already. (Amos, age 9)
Sub-theme 2: using cognitive-behaviorial methods
The cognitive-behavioural methods mentioned included
positive reinforcement by praising the children, teaching
them breathing techniques and distraction. Nurses some-
times tried to cheer these children up and also praised
them. A child mentioned that the nurse asked her to
breathe when she was in pain. Nurses distracted childrens
963
QW Sng et al.
attention from pain by chatting with them and allowing
them to watch television:
Talking. Like they all ask about my CCA (co-curriculum activities)
and all that. (John, age 11)
Sub-theme 3: using emotional support strategies
Nurses used emotional support strategies such as reassur-
ance and using touch. They sometimes provided words of
reassurance to children. Children remembered that the
nurses told them to relax, be calm and endure with the
pain. Some children encountered nurses who used touch
when they were experiencing pain:
Usually they just talk to you, and hold your hand. (Teresa, age 11)
Sub-theme 4: helping with activities of daily living
Children recognised that nurses helped them to a great
extent in their routine daily activities and felt that the
nurses treated them well. The activities included eating,
drinking, brushing teeth and using the toilet.
Theme 4: suggestions for parents for alleviating
postoperative pain
Two sub-themes emerged in relation to childrens sugges-
tions for parents to alleviate their postoperative pain.
Sub-theme 1: using distraction
The most common suggestion children had for their
parents related to the provision of materials and
equipment to distract their attention. They wanted their
parents to bring in videos, hand phones, homework, mag-
azines, books, toys, games and food. For example, a child
said:
Im recently reading some books so I hope that she can bring more
books here so that I can read and I wont feel so pain. As for the
games I hope that she can bring more batteries so I can play the
whole day. (Xavier, age 12)
Sub-theme 2: being present
Many children brought up wanting their parents to accom-
pany them for longer periods of time in the hospital:
I want her to be with me all the time. (Nurlina, age 11)
Theme 5: suggestions for nurses to alleviate
postoperative pain
Three sub-themes emerged about childrens suggestions for
nurses for their postoperative pain relief.
964
Sub-theme 1: administering medications
Some children explained that they wanted medication for their
constipation and topical applications at their wound sites:
Put some oil, medicine on my scrotum. (Farhan, age 12)
Sub-theme 2: using distraction
Some children wanted nurses to allow them to play to dis-
tract them from pain:
The best thing is they would let me go up to the play center, at
level 8. That is the best thing that would make me happy. (Elyas,
age 10)
Sub-theme 3: using positioning
Children hoped that nurses would be more aware of their
sensations, especially during nursing activities. These
included positioning them properly to avoid inducing
more pain and being neat with tubes and wires connected
to the child and positioning the children to maximise
comfort:
They can properly position me, not leave the tubes and wires messy
and tugging, so that it will not be painful here and there. Position
me properly and make me comfortable, not shift me here and there
haphazardly. (Amos, age 9)
Discussion
This study explored childrens experiences in their postop-
erative pain management using semi-structured in-depth
interviews, which fill in the knowledge gap of the topic
from childrens point of view in the Asian context. The
findings show that children used a variety of strategies to
cope with their postoperative pain. These strategies con-
sisted of cognitive-behavioural methods, physical methods,
seeking help from others and using pain medications. The
results suggest that school-aged children are able to use
pain relief strategies such as cognitive-behavioural methods
and physical methods, a finding that is consistent with the
results of earlier studies (Polkki et al. 2003, He et al. 2007,
Kortesluoma et al. 2008a). These methods were popular
among children as they were simple to use and gave
children a sense of control over their pain sensation and
pain behaviour (Kortesluoma et al. 2008a).
Among all cognitive-behavioural methods, distraction
was most frequently used by children to cope with their
pain (Fongkaeo 2002, Polkki et al. 2003, He et al. 2007).
In our study, children had a wide range of entertainment
options to choose from, such as playing games using their
mobile phones, PSPs and laptops. Imagery was less
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Journal of Clinical Nursing, 22, 958968
Post surgical care
frequently mentioned by Singaporean children as compared
with distraction. Smeltzer et al. (2009) suggested that chil-
dren who suffer moderate-to-severe pain may lack mental
and cognitive resources at that point to perform tasks for
distraction. Childrens lack of relevant knowledge may
also be one of the reasons for their lack of use of other
cognitive-behavioural methods (Polkki et al. 2003, He
et al. 2007). Our results show that children also favoured
sleeping, resting, lying down to try to escape from their
pain, which corresponds to results from a previous study
(Franck et al. 2008). However, children were sometimes
unable to carry out these strategies due to severe pain or
cold environment. This suggests that improvements can
be made to the ward environment to facilitate childrens
rest.
When faced with pain, children frequently sought help
from others, especially parents, by informing them of their
symptoms. Childrens responses implied their trust in their
parents to make decisions or take actions to help them.
Interestingly, children did not mention informing nurses
about their pain or other needs; they seemed to regard
their parents as their only immediate sources of help. This
finding is consistent with previous findings (Polkki et al.
2003, He et al. 2007, Lim et al. 2012). For example, par-
ents of school-aged children mentioned that their children
preferred parents to be their advocates (Lim et al. 2012).
Previous studies have found that children depended
greatly on their parents for their everyday and acute
needs, and this was especially so in the hospital settings
(Runeson et al. 2002, He et al. 2006, Kortesluoma et al.
2008b).
Children perceived that their parents played an important
role in their postoperative period (He et al. 2006, Lim et al.
2012). Consistent with the Singaporean study on parents
(Lim et al. 2012), children reported that their parents
frequently assessed them for their well-being, provided pain
relief by administering medications to them, used some
cognitive-behavioural methods such as distraction and pro-
vided preparatory information for them, where distraction
was the most commonly used method (Kankkunen et al.
2003, He et al. 2006, Lim et al. 2012). Some children men-
tioned that their parents provided preparatory information
to them, which is consistent with the findings of Lim et al.
(2012), based on parents reports. However, this was not
mentioned in similar studies (Fongkaeo 2002, Polkki et al.
2003). Cheng et al. (2003) found that some parents were
apprehensive about telling the truth as they did not want
children to react emotionally or perceive more pain. This
tendency to avoid truth telling is based on a misconception,
as children have shown lower distress levels when they
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Journal of Clinical Nursing, 22, 958968
Childrens experiences in postoperative pain
were equipped with preparatory information (Kolk et al.
2000, Jaaniste et al. 2007). This suggests that it may be
beneficial to build an understanding with parents and dispel
misconceptions to facilitate the provision of information to
children.
This study shows that different emotional support strate-
gies were commonly practised by parents according to the
children. Interviews with Singaporean parents revealed
similar results (Lim et al. 2012). Children voiced apprecia-
tion of their parents emotional support during their hospi-
tal stay. In the participating hospital, parents are
encouraged to stay overnight with their child, with one
foldable bed provided. There is no strict enforcement of
visiting hours. Parental presence should continue to be
encouraged and facilitated, as parents can increase chil-
drens comfort and allay their anxieties (McCaffery &
Wong 2003). This in turn could reduce childrens postoper-
ative pain, as previous studies have shown that childrens
perioperative anxiety level is positively related to their
postoperative pain (Ericsson et al. 2006, Crandall et al.
2009).
Children unanimously agreed that nurses helped to allevi-
ate their pain by administering medications, using some
cognitive-behavioural methods and helping with their daily
activities. Administration of medications was the first
response of most children in this study (Alex & Ritchie
1992, Fongkaeo 2002). It is noteworthy that children did
not mention pain assessment performed by nurses, and
some children thought that administering medication was
the only thing nurses did for their pain. The findings indi-
cate that the use of non-pharmacological methods by nurses
was uncommon or not well planned, which is contrary to
the high positive responses by nurses regarding their own
use of methods such as cognitive-behavioural methods
(He et al. 2010, 2011). This may be attributed to the possi-
bility that nurses could have responded in a way to present
themselves positively (Dihle et al. 2006) and warrants fur-
ther study to explore the actual practice through observa-
tion. Previous studies have addressed reasons such as heavy
workload and lack of skills, knowledge and support from
the organisation for limited use of non-pharmacological
pain-relieving strategies among nurses (Polkki et al. 2003,
He et al. 2005, 2010, 2011); this warrants attention from
hospital administrators.
Some children suggested that their parents bring different
things for their distraction and be present when they were
in pain (Fongkaeo 2002, Polkki et al. 2003, He et al.
2007). A few children suggested that nurses administer
medications, and needed nurses to facilitate meaningful
activities for their distraction, such as allowing them to go
965
QW Sng et al.
to the play centre of the hospital (Polkki et al. 2003, He
et al. 2007), make them comfortable by positioning and
pausing during wound dressings when the pain became too
intense. A similar suggestion was given in Alex and Rit-
chies (1992) study, which found children wanting nurses
to pay more attention to their distress cues.
Limitations of the study and recommendations for
further research
A few limitations of this study need to be addressed. First,
the participants were children from 612 years old. The
behaviour of a child of 6 years old and a child of 12 years
old might be different. It could be interesting to observe the
differences in postoperative experiences between age groups
in the future studies. Second, the participants underwent
various surgical procedures and various amount/types of
pain medication were used for pain relief across informants,
which might have affected childrens experience of pain
and pain management given. Third, childrens natural wari-
ness of strangers may have compromised the quality of
some of the interviews, resulting in short durations. None-
theless, the researcher attempted to build rapport with each
child at the beginning of each interview session, by chatting
about issues of interest with children. Also, data collection
proceeded until data saturation was reached to ensure the
richness of information collected. Future studies should
consider strategies to enhance the clarity and depth of data
by using data and methodological triangulation (Speziale
et al. 2010, p. 351).
Conclusion
This study contributed to the existing knowledge about
childrens postoperative pain management based on their
own experiences. Children themselves, their parents and
nurses used different strategies to relieve childrens postop-
erative pain. Although using pain medication was the
most commonly mentioned strategy, various non-pharma-
cological pain relief methods were also used by children
themselves, their parents and nurses. Children made sev-
eral suggestions to their parents and nurses in terms of
better management of their postoperative pain. These
included distraction and presence of parents, and using
medications and methods like distraction and positioning
for nurses. This study provides evidence for health care
professionals to consider the use of more pain relief strat-
egies when caring for children postoperatively and guide
966
their practice to achieve optimal pain management out-
comes in children.
Relevance to clinical practice
Our findings indicate that it is important for health care
professionals to value childrens roles in their own postop-
erative pain management. They need to be encouraged to
use the non-pharmacological pain-relieving strategies. Par-
ents and nurses could try to facilitate such strategies by
providing materials or devices for childrens distraction.
Instructions on the use of cognitive-behavioural methods
can be provided to children preoperatively. More informa-
tion and guidance on pain-relieving strategies need to be
provided to parents so that they become more competent
and in turn, instruct and guide their child on the use of
such strategies. In view of childrens reliance, inherent trust
and honesty with their parents, nurses can check with par-
ents regarding their childs pain levels when the child
appears to be concealing pain. However, assessing pain via
a proxy is less desirable compared with childrens self-
report. Therefore, nurses should strive to build better rap-
port with children so that they trust nurses enough to
report their pain truthfully. Nurses need to enhance their
pain assessment practice by using appropriate tools. Chil-
dren would benefit if nurses become less task oriented, and
are more tuned in to childrens needs. Organisational
efforts to change the culture and promote the use of such
strategies are needed.
Acknowledgements
We would like to thank the Director of Nursing Ms. Lee
Heng Pheng, the Nurse Managers and Nurse Clinicians of
the participating wards, KK Womens and Childrens Hos-
pital, for their support and cooperation to allow access to
the pediatric patients and their parents. We appreciate all
participants for their great support.
Contributions
Study design: HHG; data collection and analysis: SQW,
HHG, JLWL, BT and manuscript preparation: HHG,
SQW, BT, PKY, WW, JLWL.
Conflict of interest
We declare that there is no conflict of interest.
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 958968
Post surgical care
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