OBJECTIVES: Previous studies suggested that parents frequently do not adequately treat postoperative pain that is experienced at home. Reasons for these parental practices have not been extensively studied. Aims of this study were to examine parental postoperative pain assessment and management practices at home as well potential attitudinal barriers to such pain practices.
METHODS: This was a longitudinal study involving 132 parents of children who were aged 2 to 12 years and undergoing elective outpatient surgery. Parental attitudes about pain assessment and management were assessed preoperatively, and children's pain severity and analgesic administration were assessed postoperatively for the first 48 hours after discharge.
RESULTS: Although postoperative parental ratings indicated significant pain, parents provided a median of only 1 dose of analgesics (range: 0–3) during the first 48 hours after surgery. In the attitudinal survey, parents' responses have indicated significant barriers. For example, 52% of parents indicated that analgesics are addictive, and 73% reported worries concerning adverse effects. Also, 37% of parents thought that “the less often children receive analgesics, the better they work.” Regression analysis demonstrated that, overall, more preoperative attitudinal barriers to pain management were significantly associated with provision of fewer doses of analgesics by parents (P < .05).
CONCLUSIONS: Parents detected pain in their children yet provided few doses of analgesics. Parents may benefit from interventions that provide them with information that addresses individual barriers regarding assessing and treating pain.
WHAT'S KNOWN ON THIS SUBJECT:
Previous research demonstrated that after outpatient surgery, many parents do not provide their children with prescribed analgesics. Reasons for undertreating may be related to attitudinal barriers in parents, such as incorrect knowledge and misconceptions regarding pain management for children.
WHAT THIS STUDY ADDS:
This study demonstrated that parents provided few doses of postoperative analgesics. Many parents reported misconceptions regarding the utility and safety of analgesia. Parents who had more misconceptions about analgesia use in children provided fewer doses of analgesics at home.
Currently, ∼84% of all pediatric surgical procedures in the United States are performed on an outpatient basis,1 and health care futurists predict that this number will continue to increase. These outpatient children are typically discharged within 4 to 5 hours after their surgical procedures, and parents are expected to manage children's pain at home.2 Unfortunately, previous research demonstrated that after outpatient surgery, many parents do not provide their children with prescribed analgesics.2,–,7 In fact, in 1 study, 70% of analgesic doses that children received at home were subtherapeutic, and 58.8% of children received less than the recommended daily dose.8 Underlying reasons for undertreating pain are not entirely clear but may be related to attitudinal barriers in parents, such as incorrect knowledge and misconceptions regarding pain management for children2,4,8,–,14; however, few studies have examined the relationship between parental attitudinal barriers to pain assessment and treatment with actual postoperative parental pain management practices at home.4,12
The purpose of this study was to examine parental attitudinal barriers regarding children's pain expression and the use of analgesic medication for children and to connect these variables to the actual practice of assessing and treating children's pain after outpatient surgery. We predicted that parental misconceptions about pain and analgesia in children would affect parental practices of assessing pain and administering analgesic medication. Understanding the reasons for undermedicating children who are in pain can contribute to developing interventions aimed at facilitating appropriate management practices.
The study population included a convenience sample of 132 parents of children who were aged 2 to 12 years and undergoing outpatient elective surgery at a tertiary care hospital. Children underwent surgical procedures including tonsillectomy, bilateral hernia repair, adenoidectomy, reset of fracture, orchiopexy, and urethral repair (Table 1). These particular procedures were chosen on the basis of previous research that demonstrated that at least 50% of children who undergo these types of surgeries can be expected to experience pain at home for the first 24 hours after surgery.2 All children were in the American Society of Anesthesiologists physical class I or II, and none of the children was known to have any diseases that could affect pain expression or pain sensation; none of the children required medication that could impair pain sensation. The institutional review board approved the study, and all parents provided written informed consent.
Parental Attitudinal Barriers
The Parental Pain Expression Perceptions (PPEP)11 was developed by Dr Zisk Rony and examines parental knowledge and attitudes regarding the expression of pain in children. This measure consists of 9 items rated on a 7-point Likert scale, and ratings are summed across items. Higher scores represent misinformation and greater attitudinal barriers. The PPEP has been shown to demonstrate good content and construct validity.11 Cronbach's α internal consistency of the scale is reported to be .7911 and was found to be .78 in this study. To further our understanding of pain-related attitudinal barriers, we asked parents to respond “yes” or “no” to the following 2 questions: “Do you think that untreated pain can cause physical damage?” and, “Do you think that untreated pain can cause psychological damage?”
The Medication Attitude Questionnaire (MAQ)9,12 examines parents' attitudes about using analgesic medication for treating children's pain. Parents were instructed to consider their views on the specific analgesic(s) prescribed or recommended for a specific event (eg, their child's surgery) or over-the-counter analgesia any time. Higher scores indicate incorrect knowledge and greater attitudinal barriers toward providing children with analgesia. The MAQ demonstrates good content,9 predictive,9 and construct validity.9,11 The internal consistency for the scale is reported to range from .68 to .739,12 and was calculated to be .77 in this study.
The Parent Postoperative Pain Measure (PPPM)12,13 is a 15-item observational checklist in which parents rate behavioral changes that correspond to pain severity. For each item, parents respond “yes” or “no” as to whether the child demonstrates pain-related changes in behaviors. The PPPM has been validated for children aged 2 to 12 years.12,15 Using a cutoff score of 6, the PPPM has excellent specificity and sensitivity in identifying children who are in significant pain.16 The sensitivity of the PPPM instrument in detecting a child's pain was previously reported to be 88%, and the specificity was reported to be 80% on postoperative day 1. The internal consistency for the instrument is reported to be 0.88 on postoperative day 116 and was found to be 0.88 in this study.
Each time the parents completed the pain diary, they were asked to indicate whether they perceived their child to be in pain by using a yes/no rating as well as whether their child verbally reported pain to the parent without being asked (yes/no).
Child report was assessed by using the structured faces17 or numeric scale, which was provided by hospital staff to parents before discharge.
Parents were asked to document all analgesics that the child received at home (time, medication, and dose) by using a pain diary. The use of pain diaries provides real-time assessment of pain and pain management practices that minimizes recall bias and improves validity of pain ratings.2 To assess children's verbal expression of pain after treatment, we also asked parents to document the following: “After trying to help your child's pain, did your child tell you (without you asking) that he/she had ‘no pain,’ ‘less pain,’ ‘same pain,’ ‘more pain,’ or ‘did not say anything.’”
Parents were approached and recruited on the day of surgery in the preoperative holding area. After providing informed consent, parents completed a demographic questionnaire as well as the instruments that examined barriers to pain assessment (PPEP) and pain management (MAQ). Children were discharged from the hospital with standardized instructions to manage pain using acetaminophen (30%), ibuprofen (3%), or acetaminophen with codeine (67%) every 4 to 6 hours on the basis of the type of surgery and the surgeon's preference. After discharge, parents were instructed in completing the pain assessment and management diary for the first 48 hours at home. Parents were asked to complete the pain diary every time they detected that their child was in pain or at least twice a day when no pain was detected (morning and evening). We chose to use the follow-up data for the first full day at home, also known as postoperative day 1, because of the variation in data on the basis of time of surgery, time of discharge, and the distance that the family needed to travel home. Data from pain diaries were retrieved through daily telephone calls.
Power analysis demonstrated that a sample size of 120 patients would result in 80% power to detect a correlation of 0.25 between attitudinal barriers and pain assessment and management practices. To account for a 10% attrition rate, we increased the sample to 132 participants.
We hypothesized that parents who endorse more extreme attitudinal barriers regarding pain assessment and medication would be the most likely to administer fewer medication doses to their children and that these extreme attitudes would be most likely to affect pain assessment. Consequently, for the purposes of analyses, parental attitudinal barriers to pain assessment and management were coded into quartiles and indicator variables were used to estimate differences in pain assessment and management practices. Normally distributed data are presented as mean and SD, and skewed data are presented as median and range (25%–75%). All regression analyses were adjusted for child age and gender. Similar to previous research using the PPPM, we calculated the daily mean score for the purpose of analysis.12P < .05 was considered statistically significant.
A total of 114 parents completed pain diaries and as such were included in the analyses. Demographic characteristics for the entire recruited sample (n = 132), as well as the sample used in additional analyses, are presented in Table 1.
Pain Attitudinal Barriers
Parent responses to the PPEP are presented in Table 2. Indeed, 36% of parents endorsed the perception that children always express pain by crying or whining, 30% of the parents agreed that children always tell their parents when they are in pain, and 22% of the parents thought that children who are experiencing pain report it immediately. In addition, 11% of the parents were uncertain whether children feel less pain than adults.
In response to the 2 questions regarding the possible effects of untreated pain, some (39%) parents reported that they did not think that untreated pain could cause physical damage. Fewer (14%) parents reported that they did not think that untreated pain could cause psychological damage.
Analgesics Attitudinal Barriers
Table 3 presents data regarding concerns or uncertainty about addiction potential, adverse effects, and the utility of analgesics that were reported by parents on the MAQ. For example, 73% of parents agreed that adverse effects were something to worry about when giving children pain medication. In addition, 52% of parents agreed and 25% were uncertain as to whether the pain medication that was prescribed to their child was addictive. Nearly half (42%) of the parents reported the belief that pain medication should be used as little as possible because of adverse effects.
Postoperative Pain Assessment at Home
In terms of behavioral indicators of children's pain, the majority of parents indicated that children expressed pain through quiet and withdrawn behaviors rather than loud and active behaviors on the PPPM (Table 4). According to the PPPM, 51% of children were rated as experiencing significant pain (score ≥6) on postoperative day 1.
Although hospital staff provided parents with a developmentally appropriate structured pain scale, only 10 (7%) parents reported that they used it to assess children's pain at home. In response to the categorical questions, 60% of parents endorsed the perception that their child was in pain, and 30% of the parents reported that their child verbally expressed pain without being asked.
Postoperative Pain Management at Home
The median number of analgesic doses provided on the first full postoperative day was 1 (range: 0–3), and 26% of parents provided no analgesics. Only 17% of the parents provided ≥4 doses of analgesics on the day after surgery.
Ninety-five percent of parents reported that they received specific instructions regarding analgesics at home. Of these parents, 69% administered the specific prescribed analgesic medication, and 55% administered the prescribed dosage, yet only 35% administered the prescribed number of doses. Of the parents who did not provide the prescribed medication, 20% undermedicated by providing less potent, over-the-counter analgesia (acetaminophen or ibuprofen) instead of the prescribed acetaminophen and codeine. A small proportion (3%) of parents provided stronger-than-prescribed analgesia. In terms of doses provided, 12% of parents administered smaller-than-prescribed analgesic doses, whereas 2% provided larger-than-prescribed doses of the analgesia. The most frequently reported reason for not providing acetaminophen and codeine was that the child refused (44%) because of bad taste. Additional reasons reported were that it hurt to swallow, the child refused to take any medication, and the child refused to swallow anything.
Attitudinal Barriers as Predictors of Pain Assessment and Management Practices
To examine the relationship between parental misconceptions about children's pain expression (PPEP) and parents' report of observed pain behaviors (PPPM), we conducted a multiple linear regression analysis with total PPPM score as the outcome variable and child age, gender, and the top quartile on the PPEP entered as predictor variables. Results indicated that pain attitudinal barriers were not a significant predictor of parental pain assessment at home (F = 0.96, P = .436).
Next, we used a linear regression analysis to examine the relationship between parental attitudes about the use of analgesia in children (MAQ) and doses of analgesics provided to children by parents at home. In this analysis, number of doses provided on day 1 was the dependent variable, and child age and gender, parental report of observed pain behavior (PPPM), and parent attitudes about pain medication (top quartile on MAQ) were entered as predictor variables. We found that decreased pain severity as well as higher MAQ score predicted the provision of fewer doses of analgesics postoperatively (F = 18.27, P < .01; Table 5).
Under the conditions of this study, we found that a significant number of parents exhibited multiple attitudinal barriers to postoperative pain assessment and pain management of children. We also found that the vast majority of parents undertreated their child's pain both in terms of the dosage of analgesics and the frequency at which analgesics were given. Previous studies that examined parental pain assessment and management reported similar findings.2,–,7,18 Moreover, endorsement of attitudinal barriers was found to be a significant predictor of the actual behaviors involved in children's pain management. That is, when parents had more misconceptions about analgesia use in children, they provided children with fewer doses of analgesics at home. To date, few studies have identified specific preoperative parental attitudes as barriers to parental postoperative pain assessment and management at home. On the basis of the answers to the categorical questions, 60% of the parents reported that they thought that their child was in pain, yet only 30% of children verbally reported pain without being asked. The notion that children do not always express pain verbally without being asked is further supported by findings of previous research.19,20
The discrepancy between parent ratings of children's pain severity and parental pain management practices was very evident in this study. For example, although the median pain score on the PPPM was 6, which indicates clinically significant pain, the median number of analgesics actually given to children was 1. Indeed, in this study, extreme attitudinal barriers were a strong predictor of the number of analgesic doses given by parents. Many parents reported uncertainty and misconceptions regarding the utility and safety of analgesia as well as fear of adverse effects and addiction potential of pain medication for children. These attitudinal findings are congruent with previous studies that documented parental fear of adverse effects,2,4,8,9,11 addiction potential,2,4,9,11 the belief that analgesics should be used only as a last resort,2,9,11 and perception that acetaminophen works best when provided only for severe pain9,11; however, this study extends previous research that illustrated that parents who endorse these attitudinal barriers more strongly may be the most likely to undermedicate their children at home, thereby presenting an opportunity to improve postoperative pain management for children at home. That is, tailored education to change parental attitudes may improve actual administration of analgesics. Unfortunately, previous research suggested that although providing parents of children who were undergoing surgery with generic written information improved parental attitudes, pain management practices by parents were not influenced.12,13 Thus, it is likely that additional behavior change interventions will be required, such as scheduled reminders or interventions that are tailored to parent and child personality characteristics, including beliefs about analgesic medications and the type of analgesia prescribed to the child. In addition, parents who hold more extreme misconceptions about analgesia are the most important to target through intervention.
Other surprising findings were that although only 3% of the parents agreed that children feel less pain than adults, it was disturbing that 11% reported uncertainty when faced with this questionnaire item. These findings are unexpected, especially in light of the fact that this misconception had been refuted >20 years ago.21 In addition, our findings suggest that there has been little change in terms of parental knowledge and perceptions of pain medication for children and actual pain management practices in the past 10 years. These results illustrate that despite the significant change in practice in medical settings and efforts to increase public awareness of the need to manage children's pain, there has been little success in translation of this knowledge to home management of children's pain.
Several methodologic limitations related to this study should be noted. First, the study examined a convenience sample that consisted of mostly white, married parents of boys and as such limits the external validity of the findings. Future research involving more diverse patient populations is needed. Second, because parents received instructions regarding pain assessment at home, they may have been alerted to behaviors that they may have not identified otherwise. In addition, more research is needed regarding parental knowledge and attitudes of the use of analgesics in children. Specifically, the MAQ does not distinguish between differences in parental perceptions regarding the use of narcotic medications (eg, codeine) and over-the-counter medication (eg, acetaminophen, ibuprofen).
Our results have significant implications for both clinical care and research. Specifically, the findings of this study support the need to develop tailored interventions to provide parents with improved knowledge regarding the safety and utility of analgesia for use in children after surgery and studies that check the effect of real-time information that addresses parental concerns as they are managing their children's pain at home. Given the large numbers of children who experience acute pain after surgery and that the majority of postoperative pain is handled by parents, efforts to arm parents with adequate strategies to treat pain are vital.
Dr Zisk Rony was supported by University of Wisconsin, Department of Family Medicine grant T32PH10010 and by Yale School of Nursing grant T32NR008346.
We thank Dr Ward, Dr Wald, Dr Serlin, Ms M. Krause, Ms M. Ezenwa, Ms F. Naab from University of Wisconsin for their insightful comments and ongoing support, Dr M. Mundt and Dr T. Becker for the statistical consultation and assistance and Dr M. Gray from Yale School of Nursing for her guidance and support during study design and data collection.
- Accepted February 9, 2010.
- Address correspondence to Rachel Yaffa Zisk Rony, PhD, RN, MPH, Henrietta Szold School of Nursing, Hadassah-Hebrew University, PO Box 12000, Jerusalem 91120, Israel. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- PPEP =
- Parental Pain Expression Perceptions •
- MAQ =
- Medication Attitude Questionnaire •
- PPPM =
- Parent Postoperative Pain Measure
- 1.↵Centers for Disease Control and Prevention. National Survey of Ambulatory Surgery. Available at: www.cdc.gov/nchs/nsas.htm. Accessed January 15, 2009
- Fortier MA,
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- Copyright © 2010 by the American Academy of Pediatrics