ARTICLE IN PRESS

International Journal of Nursing Studies 43 (2006) 447–456

www.elsevier.com/locate/ijnurstu

Reliability and validity of the Faces Pain Scale

with older adults
Eun Joo Kima,, MaryBeth Tank Buschmannb
a
Department of Nursing, Daejeon University, 96-3, Yongun-dong, Dong-gu, Daejeon 300-716, Korea
b
College of Nursing, University of Illinois at Chicago, 845 S. Damen Ave, Chicago, IL 60612-7350, USA
Received 21 July 2005; received in revised form 3 January 2006; accepted 4 January 2006

Abstract

Background: The Faces Pain Scale (FPS) is effective with older adults in clinical assessment of pain intensity. The 0–10
numerical rating scale (NRS) has universally adapted for assessment of pain intensity. The commonly used versions of
the FPS have six, seven or nine faces.
Objectives: We proposed an 11 face modified version of the McGrath nine face FPS to compare with the 0–10 NRS
without the mathematical translation. The psychometric properties of the proposed version were also investigated in a
sample of Korean older adults.
Design: This study employed methodological research design.
Settings and participants: A sample of 31 older adults was recruited through local senior citizen centers to examine the
construct validity and the test–retest reliability. For the concurrent validity testing, a sample of 85 older adults with
chronic pain was recruited through a general hospital and an oriental medical hospital.
Methods: The construct validity was examined by determining if the subjects perceive the FPS as representing pain and
they agree on the rank of each face. The test–retest reliability was examined at a 2-week interval. The concurrent
validity was examined by using the NRS and the Visual Analogue Scale (VAS).
Results: Subjects perceived the 11 FPS as a pain measure, and the subjects’ agreements in the rank ordering of the faces
were almost perfect (Kendall’s W ¼ :93, po:001). Cohen’s kappa of .61 (po:001) for test–retest reliability was
acceptable in the cognitively intact subjects. Concurrent validity measured by the correlation between the FPS and the
NRS (r ¼ :73, po:001) and the VAS (r ¼ :73, po:001) was supported.
Conclusions: These results supported the appropriateness of the 11 FPS for use with the older adults in clinical practice
to measure pain intensity. Additionally, this study provided cross-cultural evidence to evaluate usefulness of the FPS.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Aged; Pain measurement; Reliability and validity

What is already known about the topic?

Corresponding author. Tel.: +82 42 280 2656;
Previous research indicated that the Faces Pain Scale
fax: +82 42 274 2600. (FPS) is effective with older adults
E-mail addresses: ejkim@dju.ac.kr (E.J. Kim),
The FPS with the six, seven, or eleven faces was
marybeth@uic.edu (M.T. Buschmann). evaluated for use with older adults

0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.01.001
 ARTICLE IN PRESS
448 E.J. Kim, M.T. Buschmann / International Journal of Nursing Studies 43 (2006) 447–456
What this paper adds

We proposed an eleven face modified version of the
McGrath 9 face FPS to compare with the 0–10 NRS
without the mathematical translation

This study investigated the initial psychometric
properties of the 11 face FPS using a Korean older
adult sample

This research results provided cross-cultural evidence
to evaluate usefulness of the FPS
1. Introduction
Many common physiological and chronic pathologi-
cal changes that occur with aging put the older adult at
risk for pain. In fact, pain is extremely common among
older adults (Ferrell, 1991) and chronic pain is common
due to the high prevalence of osteoarthritis, cancer and
peripheral vascular disease (Egbert, 1991). Crook and
colleagues (1984) reported that the incidence of pain was
twice as great in people over 60 years of age than in
those 60 and under. It is estimated that 25–70% of the
adults over 60 years of age in the community (Ferrell
and Ferrell, 1991; Roy and Thomas, 1987), and 45–80%
of nursing home residents (Ferrell, 1995) in America
suffer from significant pain. Prevalence of pain in
Taiwanese nursing homes was reported as 65.3% (Tsai
et al., 2004). Pain among the elderly is mostly constant
and impacts on everyday lives. This pain interferes with
the victim’s daily life and increases with age (Higgins
et al., 2004; Thomas et al., 2004). All of which is
probably an underestimate since accurate detection and
assessment is a problem (Forrest, 1995). Although pain
is common, as one grows older, it is not normal (Ferrell
and Ferrell, 1990). Therefore, it is the responsibility of
the health care provider to provide relief and comfort. In
fact, the assessment of pain is now the 5th vital sign,
along with temperature, pulse, respirations and blood
pressure (Kirsch et al., 2000).
The assessment of pain is difficult because it is
multifaceted including affective, cognitive, physical,
sensory, behavioral and sociocultural factors (McGuire,
1992), subjective (Ferrell, 1991) and done by self-report
(Acute Pain Management Guideline Panel, 1992; Herr,
2002; McCaffery, 1968). Although pain is multifaceted
in concept, subjective intensity is probably the aspect
most often measured (Herr and Mobily, 1993). Forrest
(1995) investigated four pain intensity assessment tools
with older adults, the visual analogue scale (VAS), the
verbal descriptor scale (VDS), the numerical rating scale
(NRS) and the multidimensional McQuill Question-
naire. She found the VDS to be preferred in her study
(Forrest, 1995). Herr and Mobily (1993) compared the
VDS, NRS, pain thermometer, and Faces Pain Scale
(FPS) in older and young adults and found the VDS and
the NRS to be preferred in the elderly.
Several studies have investigated the psychometric
properties of pain intensity scales for the older adults
(Gagliese and Katz, 2003; Gagliese et al., 2005; Herr
et al., 1998; Herr and Mobily, 1993; Scherder and
Bouma, 2000; Taylor and Herr, 2002, 2003). The VDS
and the NRS have adequate to good reliability and
validity for measuring chronic pain intensity in the older
adults (Gagliese and Melzack, 1997; Herr and Mobily,
1993). Taylor and Herr (2003) determined the reliability
and validity of selected pain intensity scales such as the
FPS, the VDS, the NRS, and the modified VDS.
Concurrent validity of the FPS, the VDS, the NRS,
and the modified VDS for use in the older adults was
reported with Spearman rank correlation coefficients
ranging from .74 to .96. Test–retest reliability at a 2-
week interval was acceptable with Spearman rank
correlation coefficients ranging from .73 to .83 in
cognitively intact older adults.
While the FPS was originally developed for use in
pediatrics (Bieri et al., 1990; Wong and Baker, 1988), it
has been found to be valid and reliable in adults
(Stuppy, 1998) and older adults (Herr et al., 1998;
Taylor and Herr, 2002). Stuppy (1998) found that adults
preferred the FPS or the NRS. The comprehension of
the purpose of the FPS by the non-demented older
adults was reported to be 100% (Scherder and Bouma,
2000). This is important because assessment is further
complicated with cognitively impaired individuals due to
their difficulty in self-report and communication in
general (Ferrell et al., 1995). Anecdotal data appear to
indicate that the FPS is effective with the cognitively
impaired and end-of-life non-verbal individuals because
it does not require reading, writing or energy for
extensive expression (Fink and Gates, 2001; Herr,
2002). In fact, the FPS was preferred in both cognitively
impaired and the cognitively intact older adults (Taylor
and Herr, 2003) as well as by clinical staff for its ease of
use. However, additional work is needed to establish its
reliability and validity.
There are several versions of the FPS, some with six
(Wong and Baker, 1988), seven (Bieri et al., 1990) or nine
faces (McGrath’s study as cited in Patt, 1993). None of the
scales has 11 faces to compare with the 0–10 NRS without
the mathematical translation. Since Dalton and McNaull
(1998) recommend the universal adoption for the 0–10
NRS for clinical assessment of pain intensity and since its
use is so common (American Pain Society (APS) Clinical
Practice Guideline, 2002; McCaffery and Pasero, 1999), it
has become the gold standard in clinical practice. There-
fore, it would be useful to have a 0–10 FPS (11 faces in
FPS as there are 11 numbers in NRS) that correlated with
the 0–10 NRS. The present study investigated the validity
and reliability of an 11 face (Fig. 1) modified version of the
McGrath nine face FPS.
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E.J. Kim, M.T. Buschmann / International Journal of Nursing Studies 43 (2006) 447–456
Fig. 1. The 11 faces of the FPS.
One of the issues considered in this study is
investigating the conceptual and psychometric charac-
teristics of the 11 face FPS. Some researchers suggested
that there are difficulties with the FPS distinguishing
pain from other constructs, such as distress and anxiety
(Hunter et al., 2000). Previous studies examined this
issue of the FPS with children (Bieri et al., 1990) and
with older adults (Taylor and Herr, 2002) and claimed
appropriateness of the FPS for measuring pain intensity.
Regarding this issue, the construct validity of the 11 face
FPS was examined in the present study.
For validity assessment of magnitude estimation
scaling like the FPS, Waltz et al. (1991) suggested a
method known as cross-modality matching. Cross-
modality matching and related techniques may be the
ideal methodology for psychometric evaluation of pain
measures (Hicks et al., 2001; McGrath, 1987). The
procedure includes the comparisons between the use of
numerical estimates of magnitude and other response
modalities (Waltz et al., 1991). In the present study,
cross-modality matching was utilized to assess the
construct validity of the FPS by having the subjects to
match the pain intensity represented by a face in the FPS
to a number. For testing the concurrent validity subjects
also matched their ratings of pain using the FPS, the
VAS, and the NRS, respectively.
Testing reliability of the magnitude estimation scaling
is generally accomplished using the test–retest procedure
(Waltz et al., 1991). Possible problems with test–retest
reliability were considered. First, unless the variable of
the measure remains at the same level of intensity during
the test and retest, the stability of the scale would not be
assessed independently Waltz et al., 1991). Thus, in the
449
present study, the authors asked the subjects to recall
and to rate the most severe pain ever felt in their lives,
rather than asking them to rate the pain felt at the test
period and retest period. Another problem is a memory-
bias effect because scoring may be based on memory of
the face they responded to the prior FPS test. In this
study, two weeks were chosen as the interval of
test–retest to reduce the bias.
The specific aims of this study were to examine:
(a) the construct validity measured by determining if the
subjects perceive FPS as representing pain more
than other constructs;
(b) the construct validity measured by determining the
subject agreement on the rank of each face;
(c) the test–retest reliability of responses on the FPS to
rating a vividly remembered pain in their life;
(d) the concurrent validity of the FPS with the older
adults experiencing chronic pain.
2. Methodology
2.1. Construct validity and test–retest reliability testing in
a community setting
2.1.1. Sample
A total of 31 subjects were recruited through local
senior citizen centers in Korea. The number of subjects
was based on the sample size used in the previous
research (Herr et al., 1998). Volunteers aged 65 years of
age or older were initially screened by the research
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450 E.J. Kim, M.T. Buschmann / International Journal of Nursing Studies 43 (2006) 447–456
assistants using the Mini-Mental State Examination,
Korean Version (K-MMSE) to determine the presence
of cognitive impairment. Prior to screening the subjects,
the researcher trained two research assistants who were
registered nurses having experience in working with
dementia patients. If the subjects were unable to follow
simple directions, such as answering questions on the K-
MMSE, they were excluded. However, those with a
score suggesting cognitive impairment were included as
long as they were able to communicate. Other exclusion
criteria included severe hearing or vision impairment.
2.1.2. Instrument
The FPS used for this study is the McGrath nine face
scale modified into an 11 face scale to compare to the
numeric 0–10 rating scale. Based on a previous study
(Herr et al., 1998), the tears on the faces of the original
nine face scale were removed for preventing bias
produced by personal beliefs related to pain expression.
Scores from zero to 10 were assigned to the faces
showing different amounts of pain, with zero implying
‘no pain’ and 10 implying ‘the worst pain possible’.
Subjects pointed to the face indicating their current level
of pain.
The MMSE developed by Folstein et al. (1975) was
used for the subject’s cognitive assessment in a commu-
nity setting and a clinical setting. Reliability and validity
have been reported (Folstein et al., 1975; Tombaugh and
McIntyre, 1992). Kang et al. (1997) reported that
sensitivities of the MMSE translated into the Korean
language (K-MMSE) for dementia ranged from .70 to
.93. Factor analysis on demented subjects revealed two
factors for Alzheimer subjects and one factor for
subjects with vascular dementia. At that time, concur-
rent validity was also established for the K-MMSE. The
11-item internal consistency reliability coefficient of the
K-MMSE was Cronbach’s alpha of .71 (Kim and
Buschmann, 1999). Agreement on items was ‘‘good to
excellent’’ (kappas varying from .64 to 1.00) and overall
inter-rater agreement was .86 (Lee, 1992). The internal
consistency reliability coefficient of K-MMSE in this
study was Cronbach’s alpha of .75 and .72 in the
community setting and clinical setting, respectively. A
score of less than 10 of K-MMSE corresponds to severe
cognitive impairment (Kang et al., 1997). For the
Korean elderly with poor education, three to four
points were added to the obtained scores of K-MMSE
as was highly recommended (Kwon and Park, 1989).
The adjusted score of less than 19 of K-MMSE
corresponds to moderate or definite cognitive impair-
ment (Park and Kwon, 1989) and of X21 corresponds
to no cognitive impairment (Kim et al., 2001). There-
fore, in the present study, the adjusted score of p13
indicated severe cognitive impairment, of 14–20 indi-
cated mild to moderate cognitive impairment, and of
X21 indicated no cognitive impairment.
2.1.3. Procedures
In order to determine construct validity of the FPS,
the subjects were first asked to rate their degree of
agreement between the faces and a given feeling/
emotion. The unlabeled set of 11 faces were presented
to each subject six times (e.g., once for each feeling/
emotion). Each time the subject was asked, ‘‘Do these
faces represent ____?’’ The question was completed each
time using a different feeling/emotion in alphabetical
order (i.e., anger, boredom, pain, sadness, sleepiness and
sourness, respectively). This order of questioning pre-
vented any bias of the data. The subject rated her/his
degree of agreement with a number 1 (agree), a number
2 (do not know) or a number 3 (disagree). Based on the
previous research (Herr et al., 1998; Taylor and Herr,
2002), theses constructs were selected in contrast with
pain. Secondly, to determine the properties of the 11 faces
of the scale, we asked the subject to arrange the 11 face
cards in order. Each face of the FPS was placed on a
4  4 in card. In the rank-ordering task, we observed that
the subjects had difficulty in arranging the 11 face cards
in order in the pilot study. This difficulty in ordering 11
face cards without guidance may come from the subjects’
low educational level. Thus, research assistants placed
three cards at the ends and the center, at the sacrifice of
the accuracy in evaluating construct validity. We placed
the first face (face number 0) at the beginning of the row
and explained ‘‘This is a very happy face because there is
no pain at all.’’, then we placed the last face (face number
10) at the end of the row and explained ‘‘This is a very sad
face because it describes the worst pain possible.’’ Finally,
we placed the neutral face (face number 5) in the middle
of the row and explained, ‘‘This is a neutral face which
occurs between ‘no pain’ and ‘the worst pain possible’.’’
Then, we laid all eight cards randomly on the desk and
asked the subject to arrange faces numbers 1, 2, 3, and 4
in rank order of increasing pain between the first and the
6th faces (viz. face #0 and face #5), and to arrange faces
numbers 6, 7, 8, and 9 in rank order of increasing pain
between the 6th and 11th faces (viz. face #5 and face #10).
Thirdly, using the pack of 11 face cards, we showed five
possible random pairs of cards to each subject, one pair at
a time, and asked them to indicate which card of each
pair expressed more pain to test correct discrimination.
Test–retest reliability of the FPS was examined at a 2-
week interval which is considered a memory-bias effect
(Waltz et al., 1991). No matter what pain the subject was
experiencing, the subject was asked to rate the most
severe pain ever felt in his/her life.
2.2. Concurrent validity testing in a clinical setting
2.2.1. Sample
A total of 85 older adults with chronic pain (i.e., a
state of pain X6 months duration and for which the
cause of the pain could not be removed) were recruited
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through a general hospital and an oriental medical
hospital in Korea. The number of subjects was
generated through Cohen’s (1988) power analysis for
multiple correlations. A sample size of 85 would provide
a power of .85 for three variables to be examined in their
relationships at a ¼ :05 and a value of medium effect
size (f ¼ :15) (Cohen, 1988; Volicer, 1984). Inclusion
criteria were hospitalized clients or outpatient clinic
clients aged 65 years of age or older and a signed consent
form from the patient or family member. Exclusion
criteria included severe hearing or vision impairment or
inability to communicate or severe cognitive impairment
based on a score of less than 14 on the K-MMSE. Since
poor education was anticipated prior to collecting the
data, exclusion criteria included a K-MMSE score of
less than 14 points as a cut-off level (Kang et al., 1997;
Kwon and Park, 1989).
2.2.2. Instruments
The NRS consists of a vertical line calibrated with
numbers from 0 as ‘no pain’ to 10 as ‘the worst pain
possible’. Subjects pointed to the number that best
reflected the level of pain, which was currently felt.
The VAS consists of a 10 cm horizontal line anchored
with ‘no pain’ on the left and ‘worst possible pain’ on the
right. Subjects marked on the line indicating the
intensity of pain they felt. A research assistant measured
the length from the left anchor to the marked point with
a 0–10 cm calibrator.
2.2.3. Procedures
The subjects were asked to rate their current level of
pain using the FPS, the NRS and the VAS.
3. Results
3.1. Construct validity and test–retest reliability in a
community setting
In the community setting, the mean age of the subjects
was 77.32 years (SD ¼ 6.40). Sixteen subjects (51.6%)
were female, and 15 subjects (48.4%) were male. Most
subjects (26, 83.8%) had poor school education.
Thirteen (41.9%) subjects attended grade school, and
13 (41.9%) had no school education. The mean score for
the K-MMSE was 24.16 (SD ¼ 5.07) with a range from
11 to 30. Most subjects (24, 77.4%) scored 21 points or
more for the K-MMSE, and six subjects (19.4%) scored
20 points or less (Table 1).
Table 2 shows descriptive data on the degree of
agreement for each construct, which is related to the
subject’s perception of the FPS. Most subjects re-
sponded ‘agreed’ on the construct of pain (n ¼ 21,

Table 1
Demographic characteristics

Variables Community sample (n ¼ 31) Clinical sample (n ¼ 85)

a
N (%) Mean (SD) N (%) Mean (SD)a
Range Range

Age (years)
65–69 4 (12.9) 34(40.0)
70–74 6 (19.4) 77.32 (6.40) 26(30.6) 72.85 (5.42)
75–79 8 (25.8) 65–88 17(20.0) 65–86
80–84 11 (35.5) 7 (8.2)
X85 2 (6.5) 1 (1.2)
Gender
Female 16 (51.6) 44 (51.8)
Male 15 (48.4) 41 (48.2)
Educationb
No school education 13 (41.9) 25 (29.4)
Attend grade or 6th grade 13 (41.9) 41 (48.2)
9th grade 3 (9.7) 6 (7.1)
High school 1 (3.2) 7 (8.2)
Some college 1 (3.2) 5 (5.9)
K-MMSE scoreb 24.16 (5.07) 22.00 (4.57)
0–20 6 (19.4) 11-30 34 (40) 14–30
21–30 24 (77.4) 24, 22-29c 51 (60) 22, 18–26c
a
Raw data were used for calculation of mean and standard deviation.
b
Excluding missing data.
c
Median, interquartile range.
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Table 2
Descriptive data for the subject’s perception of the FPS

Construct Agreed (1) N (%) Neutral (2) N (%) Disagreed (3) N (%) Mean SD

Pain 21 (67.7) 9 (29.0) 1 (3.2) 1.35 .55

Sourness 7 (22.6) 8 (25.8) 16 (51.6) 2.29 .83
Sleepiness 6 (19.4) 8 (25.8) 17 (54.8) 2.35 .79
Sadness 13 (41.9) 8 (25.8) 10 (32.3) 1.90 .87
Anger 17 (54.8) 8 (25.8) 6 (19.4) 1.64 .79
Boredom 8 (25.8) 14 (45.2) 9 (29.0) 2.03 .75

100
93.5
subjects produced would not simply have occurred by
90 90.3
83.9 chance.
80 77.4 80.6
Percent Accuracy

70 71 In order to test the subject’s discrimination in paired

60 61.3 61.3
50
40
30
20
10
0
1 2 3 4 6 7
Faces
Fig. 2. The accuracy of ordering of faces.
67.7%). The mean rating was 1.35 (SD ¼ .55) of pain,
followed by 1.64 (SD ¼ .79) of anger, and 1.90
(SD ¼ .87) of sadness. Repeated measures ANOVA
showed that significant differences exist among the
means of all constructs (F(5, 150) ¼ 8.62, po:001).
Simple contrast test yielded that the mean rating of pain
is significantly different from the mean of sourness (F(1,
30) ¼ 27.25, po:001), the mean of sleepiness (F(1,
30) ¼ 31, po:001), sadness (F(1, 30) ¼ 7.83, p ¼ :009),
and boredom (F(1, 30) ¼ 13.87, p ¼ :001) and has
marginally significant difference from anger (F(1,
30) ¼ 3.21, p ¼ :083). This means that the subjects
perceived the FPS as representing pain rather than
other constructs.
Fig. 2 shows the accuracy of placing faces #1, 2, 3, 4
and 6, 7, 8, 9 in rank of increasing pain. Face #9 was
placed with the highest accuracy of 93.5% and face #4
was placed with 90.3% accuracy. Faces #6 and #7 were
placed with the lowest accuracy of 61.3%. Mean
numbers of nominated rank positions of face were 1.35
of face #1, 2.03 of face #2, 2.77 of face #3, 3.84 of face
#4, 5.45 of face #6, 5.90 of face #7, 6.74 of face #8, and
7.90 of face #9. Kendall’s coefficient of concordance (W)
and its significant test were utilized to determine the
degree of agreement on a rank order among the subjects
and to determine whether the ordering the faces
correctly was occurred by chance (Herr et al., 1998;
Seigel and Castellan, 1988). Kendall’s W was .93
(po:001), indicating that agreement on a rank order
among subjects is near perfect, and the rank order the
comparisons for all possible random pairs of face cards,
a total of 155 trials were performed. Each combination
had 3–4 trials. The pair of faces #4 and #5 and the pair
of faces #6 and #7 resulted in the lowest correct rate of
71.4%. All pairs including face # 0, #1, and #2 were
8 9 100% correctly judged by subjects. The pair of face # 8
and #9 and the pair of face #9 and #10 resulted 87.5%
and 75% of correct discrimination, respectively.
In order to evaluate the test–retest reliability of the
FPS, data collected at 2-week intervals were analyzed
using Cohen’s kappa and the Spearman’s rank order
correlation. The mean of subject’s pain score at the
initial testing was 8.40 (SD ¼ 1.27), at the retesting was
8.47 (SD ¼ 1.50). Cohen’s kappa for the whole test–ret-
est data could not be calculated due to lack of filling of
the cells in the 2  2 matrix. Since subject’s cognitive
impairment might impact his/her recalling the experi-
enced pain, we analyzed test–retest data of subjects with
K-MMSE score of 21 points or more, assuming their
cognition intact. Cohen’s kappa in cognitively intact
subjects was .61 (po:001), indicating that this propor-
tion of subjects consistently rated the same face on both
the initial and the second ratings of pain intensity. The
Spearman’s rank order correlation coefficient for the
test–retest was .60 (p ¼ :004) in all subjects and .74
(p ¼ :003) in the cognitively intact subjects, indicating
acceptable test–retest reliability.
3.2. Concurrent validity of the FPS with the older adults
with chronic pain in a clinical setting
In the clinical setting, the mean age of the subjects was
72.85 years (SD ¼ 5.42). Forty-four subjects (51.8%)
were female, and 41 subjects (48.2%) were male.
Twenty-five (29.4%) subjects had no school education,
and 41 (48.2%) attended grade school. The mean score
on the K-MMSE for subjects was 22 (SD ¼ 4.57) (Table
1), with a range from 14 to 30. Fifty-one subjects
(60.0%) scored 21 points or more for the K-MMSE, and
34 subjects (40.0%) scored 20 points or less (Table 1).
The locations of pain complaints and the etiology of
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primary pain complaint were obtained from the medical
records. Forty-five percent of the subjects reported more
than one location for pain. The most common location
of pain was back (30, 35.3%) followed by legs (24,
28.2%) and knee (14, 16.5%). Stroke was the most
common etiology (24, 29.3%) of data obtained from 45
subjects from the oriental medical hospital. This reflects
that Korean older adults with stroke are common, and
these subjects prefer the oriental medical treatment.
Cancer (12, 14.6%) is the second common etiology
identified for the primary pain followed by arthritis (9,
11.2%), old fractures (6, 7.1%), spinal stenosis (5,
5.9%), muscle spasm (5, 5.9%), and osteoporosis (5,
5.9%).
The mean of the subject’s pain intensity was 7.32
(SD ¼ 2.11) as measured by the FPS, 7.22 (SD ¼ 2.47)
as measured by the NRS, and 6.96 (SD ¼ 2.72) as
measured by the VAS. To determine if intensity
estimates generated from three different tools were
significantly different, we compared the means of pain
intensity by using repeated measures ANOVA. Results
indicate that pain intensities by the FPS, the NRS and
the VAS were not significantly different (F(1.00,
68.00) ¼ 2.93, p ¼ .09); likewise the tools were not
different in reporting the intensity of patient’s pain
(Table 3). Table 4 shows the bivariate correlation
coefficients between pain intensities measured by the
FPS, the NRS and the VAS. The FPS had moderately
strong correlation with the NRS (r ¼ :73, po:001) and
the VAS (r ¼ :73, po:001). To evaluate the effects of the
cognition impairment in using the FPS with the older
adults, the subjects were assigned to one of two groups
according to their K-MMSE score. For the Korean
elderly with poor education, adjusted score of p20 was
used as a criterion to split elderly into two groups (Kim
et al., 2001; Kwon and Park, 1989). Therefore, scores of
p20 comprised a cognitively impaired group and scores
of X21 comprised a cognitively intact group.
We assigned 34 subjects with K-MMSE score of 20
points or less to Group 1, assuming their cognition was
mildly impaired. Fifty-one subjects with K-MMSE score
of 21 points or more were assigned to Group 2,
assuming their cognition intact. While correlation
between the VAS and the NRS of the cognitively
impaired group (r ¼ .88, Po:001) was weaker than the
correlation of the cognitively intact group (r ¼ .92,
Po:001), correlation between the FPS and the NRS of
the cognitively impaired group (r ¼ .75, Po:001) was
slightly stronger than correlation of the cognitively
intact group (r ¼ .70, Po:001). These results suggest
that the FPS is valid, and the validity in measuring pain
intensity is maintained even in older adults with
cognitive impairment.

Table 3
Pain intensity as measured by three pain scales
4. Discussion
Tool Mean (SD) dfa MS F P
In this study, we attempted to determine the psycho-
FPS 7.32 (2.11) metric properties of an 11 face FPS and additionally to
VAS 6.96 (2.72) 1.00, 68.00 8.40 2.93 .09 evaluate the scale’s usefulness with the older adults
NRS 7.22 (2.47) experiencing chronic pain. The FPS has been inter-
changeably used with various pain intensity scales in the
An adjusted degree of freedom based on lower-bound epsilon
was used. clinical field. The 0–10 NRS or the VAS are commonly
a
The sphericity test was rejected (Mauchly’s W ¼ :28, used, but researchers suggested that the FPS is appro-
po:001). priate for use with older adult patients. Recent research
gave support for reliability and validity of the FPS with
Table 4 six or seven faces for measuring pain intensity in
Correlations between pain intensity rating scales African-American or Caucasian older adult cohorts
(Herr et al., 1998; Taylor and Herr, 2002; Stuppy, 1998;
FPS VAS Wynne et al., 2000). However, some researchers raised
Total a
Group1 b
Group2 c
Totala Group1b Group2c questions about the appropriateness of the interchan-
ging of the six or seven face with the 0–10 NRS or the
FPS — VAS without the mathematical transformation (Free-
VAS .73 .76 .68 — man et al., 2001). Using the 0–10 FPS with psychometric
NRS .73 .75 .70 .91 .88 .92 properties that are correlated with the NRS would
provide better understanding and communication for
Note: Numbers represent Spearman rho correlation coefficients.
older adult’s pain interventions.
Po:001 for all values.
a
n ¼ 85. The subjects participating in this study provided
b
Group 1 was composed of 34 subjects with MMSE-K score additional cross-cultural evidence to evaluate usefulness
of 14–20. of the FPS because Korean older adults dwelling in the
c
Group 2 was composed of 51 subjects with MMSE-K score community and experiencing chronic pain were included
of 21–30. in this study. Although this study was conducted in a
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454 E.J. Kim, M.T. Buschmann / International Journal of Nursing Studies 43 (2006) 447–456
different culture than that in which the original tool was
developed, the findings of the present study are similar
to (not much different from) the results of testing the
various FPSs with the American elderly population
(Stuppy, 1998). Previous research evaluated the con-
struct validity of Bieri et al’s (1990) seven face FPS with
older adults and reported that many subjects agreed that
the faces represented pain, as well as representing other
constructs, depending on how the subjects were cued
(Herr et al., 1998; Taylor and Herr, 2002). Similar
responses appeared in this study, since subjects re-
sponded with some agreements that the FPS could also
represent other constructs according to the cue they
received. This indicated that our FPS could also serve as
a pain measure including affective components. How-
ever, we found a significant difference between the
construct of pain and all other constructs (i.e., sourness,
sleepiness, sadness, and boredom) with the exception of
anger. Theses findings are in contrast to Herr et al.’ s
(1998) who used the seven face FPS with Caucasian
older adults and found that only the construct of anger
was significantly different from all other constructs (e.g.,
pain, sourness, sleepiness, sadness, and boredom). On
the other hand, Taylor and Herr (2002) applied the same
seven face FPS to African-American older adults and
reported that the construct of pain was significantly
different from the constructs of sour, sleep and
boredom, but not different from sadness and anger.
Since we applied the 11 face FPS to Korean older adults,
this particular finding may result from cultural differ-
ences, as well as instrumental differences.
The subjects’ agreements in the rank ordering of the
faces were near perfect. Faces #6 and #7 were the faces
that caused most confusion in the ordering test and the
paired comparison test. Some amendments of face #6
and face #7 through further study would improve its
psychometric property.
Cohen’s kappa for test–retest reliability at a 2-week
interval was .61 (po:001) in the cognitively intact
subjects. As a general guide, Cohen’s kappa ranging
from .40 to .80 is acceptable, interpreting mild to
moderate consistency (Lewis, 1999). These results
provide support that the 11 face FPS is stable and
reproducible for using over time. The Spearman’s rank
order correlation coefficients for the test–retest ranged
from .60 to .74. The higher value of the correlation
coefficient resulted only when analyzing cognitively
intact subjects. This is to be expected, considering the
impact of memory deficits with cognitively impairment
subjects. These findings are similar to the previous study
with the seven face FPS (Taylor and Herr, 2003), in
which the Spearman’s rank order correlation coefficients
at a 2-week interval were .79 and .81 in the cognitively
impaired and the cognitively intact African-American
older adults, respectively. The sample size used in the
present study is small but justified by a power analysis
(see 2.2.1 Sample). Replication studies with larger
samples would confirm its test–retest reliability of the
11 face FPS for cognitively impaired population.
The concurrent validity of the FPS with the older
adults experiencing current pain was strongly supported.
This result also provided the appropriateness of the FPS
in use with the older adult in clinical practice to measure
his/her pain intensity. Using only the data composed of
cognitively impaired subjects, we found the relationship
of the VAS and the NRS was weaker, whereas the
relationship of the FPS and the NRS became stronger.
These results support the potential use of the facial scale
with the cognitively impaired older adults postulated by
some researchers (Herr et al., 1998; Taylor and Herr,
2002; Wynne et al., 2000).
It is the first study that has been done in justifying the
FPS in older adults with respect to reliability and
validity against a gold standard of the NRS. Perhaps
future work could add to this knowledge.
5. Conclusion
This study reveals the initial psychometric properties
of the 11 face FPS using a Korean older adult sample.
The FPS is appropriate for use to assess the pain
intensity of older adults, even when their cognition is
mildly or moderately impaired. The concurrent validity,
especially, the correlation between the FPS and the NRS
was strongly supported. In clinical practice, the 11 face
FPS may be interchangeably used with the universally
adopted NRS without the mathematical translation. The
FPS is ordinal in nature, indicating that the interval of
the 0–10 scale is not artificially implying equal incre-
ments. Further study evaluating linear increment and
the intervals among the faces will provide further
psychometric soundness of the 11 face FPS.
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