International Journal of Nursing Studies 40 (2003) 33–44

Hospitalized children’s descriptions of their experiences with

postsurgical pain relieving methods
Tarja Polkki*,
. Anna-Maija Pietil.a, Katri Vehvil.ainen-Julkunen
Department of Nursing Science, University of Kuopio, P.O. Box 1627, 70211 Kuopio, Finland
Received 22 October 2001; received in revised form 1 February 2002; accepted 29 April 2002

Abstract

The purpose of this study was to describe children’s (aged 8–12 yr) experiences with postsurgical pain relieving
methods, and their suggestions to nurses and parents concerning the implementation of pain relief measures in the
hospital.
The data were collected by interviewing children (N ¼ 52) who were inpatients on a pediatric surgical ward in the
university hospital of Finland. Content analysis was used to analyze the data. The children rated the intensity of pain on
a visual analogue scale.
The results indicated that all of the children used at least one self-initiated pain relieving method (e.g. distraction,
resting/sleeping), in addition to receiving assistance in pain relief from nurses (e.g. giving pain killers, helping with daily
activities) and parents (e.g. distraction, presence). The children also provided suggestions, especially as it relates to
nurses (e.g. creating a more comfortable environment), regarding the implementation of effective surgical pain relief.
However, some cognitive-behavioral and physical methods were identified that should be implemented more frequently
in clinical practice. Furthermore, most children reported their worst pain to be severe or moderate, which indicates that
pain management in hospitalized children should be more aggressive.
r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Pain relieving methods; Child; Experience; Surgical pain

1. Introduction and Kristjanson, 1996a; Rheiner et al., 1998). Further-

The experience of pain is common among children
undergoing surgery (Gauthier et al., 1998; Palermo et al.,
1998; Tesler et al., 1998). Several studies have dealt with
the methods of relieving children’s pain during acute,
short-term painful procedures (Broome et al., 1994;
French et al., 1994; Vessey et al., 1994; Sclare and
Waring, 1995; Ebner, 1996) and described the nurses’
viewpoints in children’s pain relief regimen (Caty et al.,
1995; Broome et al., 1996; Coffman et al., 1997; Salanter.a
et al., 1999). However, the topic of postoperative pain
management has not attracted similar interest (Woodgate
*Corresponding author. Kallioputaankatu 9, 95420 Tornio,
Finland. Tel.: +358-16-431-496..
E-mail address: tarja.polkki@nic.fi (T. Polkki).
. conjunction with pain medication.
more, children’s self-reports would be the most reliable
source on how their pain is assessed and managed, due to
the individualized nature of the pain experience.
It is well documented that children are able to
describe their pain and preferred methods of pain relief
(Savedra et al., 1982; Ely, 1992; Harbeck and Pederson,
1992; Bossert et al., 1996; Polkki
. et al., 1999; Pederson
et al., 2000), although the ability to do this is affected by
the developmental level of the child. For example,
according to Vessey and Carlson (1996) some pain relief
strategies, such as hypnosis and imagery, require a
certain level of cognitive maturity that is achieved
during the school-aged period. This means that at this
age it would be appropriate to implement a much
broader array of non-pharmacological methods in

0020-7489/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 3 0 - 5
34 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44
The purpose of this study is to describe children’s
(aged 8–12 yr) experiences with postsurgical pain reliev-
ing methods utilized in the hospital setting. The study
describes both the children’s self-initiated pain relieving
strategies, as well as the strategies utilized by the nurses
and the parents that were deemed to be helpful from the
children’s perspective. Furthermore, the purpose is to
describe the children’s suggestions to nurses and parents
concerning the implementation of effective pain relief
measures. The obtained information about children’s
self-reports enables better understanding of what helps
the children achieve more effective pain management in
a hospital setting.
2. Literature review
Children’s pain experiences may be reduced by a
variety of means. Pharmacological treatment is an
obvious source of pain relief, although many studies
have indicated that children are frequently under
medicated and endure unacceptable levels of pain during
hospitalization (Cummings et al., 1996). For example,
Gauthier et al. (1998) found that 46% of the children
(N ¼ 48) reported having severe pain after surgery and
half of the children (51%) were under medicated for
postoperative pain. This is similar to the prior research
(e.g. Alex and Ritchie, 1992; Johnston et al., 1992;
Palermo et al., 1998) which indicated that the majority
of children reported experiencing high intensity of pain
after surgery, even while receiving analgesics.
A variety of non-pharmacological pain relieving
methods may be used independently or in conjunction
with medication administration (Caty et al., 1995).
Several studies have identified the efficacy of non-
pharmacological methods of pain relief in hospitalized
pediatric patients, such as hypnosis, imagery and
distraction (Broome et al., 1994; French et al., 1994;
Lambert, 1996; Steggles et al., 1997), as well as cold
application (Ebner, 1996) and parental presence (Ross
and Ross, 1984; Wolfram and Turner, 1996). Many of
the non-drug methods may be administered by the
children themselves, but effective relief often requires the
assistance of a nurse or parent (Cummings et al., 1996;
Vessey and Carlson, 1996).
Many studies have examined children’s perceptions
regarding what interventions help alleviate pain (Save-
dra et al., 1982; Ross and Ross, 1984) with a primary
focus on children’s self-initiated pain relief strategies
(Woodgate and Kristjanson, 1995; Bossert et al., 1996;
Campbell and McGrath, 1999; Pederson et al., 2000) or
coping strategies to deal with the pain (Ross and Ross,
1984; Ryan, 1989: Alex and Ritchie, 1992; Ryan-
Wenger, 1992; Olson et al., 1993; Sharrer and Ryan-
Wenger, 1994; Rudolph et al., 1995; LaMontagne et al.,
1997; Reid et al., 1997). According to Hester (1993), the
most consistently reported strategies preferred by
children have been determined to be medication and
parental presence, but unfortunately these strategies
often are not under the child’s control.
The studies concerning children’s self-initiated strate-
gies indicate that children are able to describe the
methods that they themselves use to relieve their pain.
For example, Bossert et al. (1996) demonstrated that all
of the children with cancer examined in a study (ages 4–
16) were able to describe what interventions helped them
manage their pain. This study determined that the most
common pain management strategies reported by the
children (semistructure interview, N ¼ 20) and parents
were rest/sleep, analgesics, rubbing, distraction, social
support and application of heat. Campbell and
McGrath (1999) discovered that 98% of the adolescents
aged 14–21 yr (questionnaire, N ¼ 289) reported using
at least one non-pharmacological method (e.g. rest, heat,
exercise, rubbing/massage, distraction) to manage men-
strual discomfort. Methods perceived as being more
than 50% effective in relieving pain were more
physically oriented than psychologically oriented meth-
ods, but the mean perceived effectiveness of most of
these methods was reported to be below 40%. Further-
more, Pederson et al. (2000) demonstrated that several
children aged 5–17 undergoing bone marrow transplant
(interview, N ¼ 20Þ used non-pharmacological pain
relieving techniques such as distraction, play, relaxation
tapes, breathing exercises, massage and music.
Only a few studies have focused on inquiring about
children’s perceptions regarding receiving assistance for
pain relief from others (Alex and Ritchie, 1992; Bossert
et al., 1996; Cummings et al., 1996; Woodgate and
Kristjanson, 1996b; Pederson et al., 2000) or recom-
mendations by children to health care providers
concerning pediatric pain relief in the hospital setting
(Alex and Ritchie, 1992). However, compiling knowl-
edge especially concerning children’s experiences in
receiving assistance for alleviation of pain would be
important in order to be able to improve pain manage-
ment in the pediatric population.
The studies concerning children’s perspectives regard-
ing receiving pain interventions provided by others
indicate that the most commonly reported nursing
action involves administration of analgesia, whereas
the parents’ role is usually more psychological in nature.
For example, in the study conducted by Woodgate and
Kristjanson (1996b), children aged 21/2–61/2 yr (parti-
cipant observation, interviews, N ¼ 11) were asked
questions concerning the type and intensity of pain they
had experienced, and what others could do to help stop
the pain. ‘‘Taking good care’’ was the most important
thing that hospital staff or parents could do for children,
and four subcategories of good care were identified as
‘‘Mum and dad be with me’’ (i.e. sitting beside the child,
touching, embracing the child) and ‘‘Doing things that
 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44
help’’ (i.e. giving the medicine, applying heat and cold).
Cummings et al. (1996) also indicated that mothers and
nurses were frequently identified as sources of help for
pain relief in hospitalized children. In this study parent
interviews were used for children o5 yr of age
(N ¼ 102), and child interviews were used for children
aged 5 yr and older (N ¼ 98). The subjects identified
medications and non-pharmacological methods (i.e.
talking, repositioning, touch, distraction, food/sleep,
healing) as helpful in managing pain; however, the
results indicated that pain prevention and management
should be more aggressive.
In summary, despite this recent surge in research
interest, knowledge regarding pain relieving methods
from the children’s perspective is limited (cf. Alex and
Ritchie, 1992; Cummings et al., 1996). This means that
more qualitative research is needed, especially concern-
ing children’s experiences on the help received from
nurses and parents during hospitalization, because as
Pederson et al. (2000) have identified, children’s self-
reports of pain often conflict with assessments of their
pain as determined by others. The methods that are
perceived by children to be helpful may provide health
care workers with further insight and additional
strategies to recommend in the relief of surgical pain
in pediatric patients.
3. Research questions
The following research questions were addressed from
the children’s perspective:
1. Which self-initiated pain relieving methods do the
children use to manage pain after surgery?
2. Which pain relieving methods described by the
children as being effective do nurses and parents
use to alleviate the child’s pain after surgery?
3. What suggestions do the children have to nurses and
parents concerning the implementation of surgical
pain relief measures in the hospital?
4. Method
4.1. Subjects
The subjects consisted of 52 school-aged children who
were inpatients in one of the two pediatric surgical
wards in the university hospital of Finland. The selected
children met the following criteria: (1) they were 8–12 yr
old, (2) they were undergoing a surgery under anaes-
thesia, (3) they were all Finnish speaking, and (4) they
had the cognitive ability to respond to the interview
questions, which meant that the children in general were
able to attend school age appropriately.
35
Sixty-two percent (N ¼ 32) of the children were male
and 38% (N ¼ 20) were female. Their ages ranged from
8 to 12 yr old (M ¼ 10:2; SD=1.3 yr). Most of the
children (56%) had previous experiences with hospita-
lization. Over half of the children (61%) had been
admitted on an emergency basis, and the remainder
(39%) for elective surgery. The mean length of
hospitalization post surgery was 3 days, ranging from
1 to 22 days. Three-fourths of the children (75%)
reported experiencing fear regarding their hospitaliza-
tion. Orthopedic/traumatologic surgeries were the
most common surgical procedures among the children
(Table 1).
The children assessed their worst pain subsequent to
the surgical procedure and the present pain during the
interview by making a vertical mark on a 10 cm Visual
Analogue Scale (VAS). The scale was a single horizontal
line with right angle stops at each end, and included the
anchors ‘‘no pain’’ and ‘‘worst possible pain’’. The VAS
has been identified as a valid and reliable tool in
measuring perceptions of pain intensity by school-aged
children (Abu-Saad and Holzemer, 1981; Abu-Saad,
1984). The children’s assessments of their pain intensity
were defined as no pain (0 cm), mild (0.5–3 cm),
moderate (3.5–6.5 cm) and severe (7–10 cm) pain (Alex
and Ritchie, 1992). Most of the children reported to
have their worst pain during the operative day (57%) or
the first day after the operation (39%). The mean worst
postoperative pain was 5.5 cm (SD=2.5 cm) and the
mean present pain was 1.1 cm (SD=1.3 cm). Fig. 1
indicates that most of the children reported their worst
pain to be severe (33%) or moderate (48%) after
surgery.
4.2. Data collection
The researcher personally interviewed all of the
children during their hospitalization on the day of
discharge (80%) or the day prior to discharge (20%).
The data collection lasted 4 months on average
beginning in August 1999, and concluding in December
1999. The researcher met the child and his/her parents
before the day of the interview and introduced herself.
At the beginning of the interview the researcher talked
Table 1
Hospitalized children’s surgical procedures (N ¼ 52)
Classification of surgical procedures N %
Orthopedic/traumatology 30 58
Gastroenterology 14 27
Urology 6 11
Plastic surgery 1 2
Thoracic surgery 1 2
36 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44
70
60
50
Percent
40
30
20
10
0
Worst pain
Fig. 1. Children’s assessment of their worst pain and present pain using a 10 cm VAS (N ¼ 52).
about generalities with the child, and clarified the role
the child was expected to play during the interview. The
child was told that he/she was expected to discuss issues
with the researcher that have helped him/her to
experience less pain after the surgery, and that there
were no right or wrong answers. The interviews took
place in the child’s own room or in the ward’s admission
room, and they lasted approximately 30–40 min. All
interviews were audio recorded and coded so that the
participant’s name could not be associated with the
information contained on the audiotapes. The children
were told that the purpose for taping was that the
researcher could recall the children’s experiences without
taking notes (Cf. Coyne, 1998; Docherty and Sande-
lowski, 1999). The parents were not present during the
interviews.
Each interview began with general demographic
questions including the child’s age, sex, surgical proce-
dure, the length of post surgery, the manner of
admission to the hospital, possible fears regarding the
hospitalization, previous hospitalizations, and the
child’s assessment of his/her pain intensity using a
10 cm VAS. This information was filled into the
demographic data schedule in which the researcher also
marked the field notes of each interview. The interview
questions consisted of three themes: (1) children’s self-
initiated use of pain relieving methods, (2) nurses and
parents’ use of pain relieving methods as described by
the children, and (3) children’s suggestions to nurses and
parents concerning the implementation of surgical pain
relief measures in the hospital. The use of open-ended
questions and then more direct questions as needed
enabled the researcher to obtain information on
children’s subjective experiences (cf. Docherty and
Sandelowski, 1999). For example, the researcher initially
asked the child the following: ‘‘What has helped you
when you have had pain after the surgical procedure?’’
no pain
mild pain
moderate pain
severe pain
Present pain
After this she focused on the themes of the interview
such as ‘‘How have nurses helped you when you have
had pain after the surgical procedure?’’ This sentence
was clarified as needed by more direct questions such as,
‘‘What have the nurses done with you or for you when
you have had pain after the surgical procedure?’’ The
face-to-face interview allowed clarification and reword-
ing of questions that the children did not understand.
The study was pilot tested with five hospitalized
children who met the aforementioned study participa-
tion criteria. These interviews helped the researcher to
clarify the content of the questions by determining more
appropriate words and formulating more direct ques-
tions as needed in order to establish the child’s ability to
understand the questions. Only one child refused to take
part in the pilot study: conversely, none of the children
refused to participate in the main study. All of the
children willingly participated in the main study and had
the support of their parents as well when they were
provided with sufficient time to make a decision.
4.3. Ethical aspects
According to the literature the consent of the parent
or guardian is required for all aged children in order to
participate in a study, and the child’s assent should be
sought for all children aged seven and older (Coyne,
1998; Lindeke et al., 2000). In this study, both the
children and their parents were given the consent form
at the beginning of the child’s admission. The consent
form consisted of information about the main points of
the study, while emphasizing the confidentiality and the
voluntary nature of participation. The consent form was
developed considering the children’s cognitive ability to
understand involvement in the study. On the day prior
to the interview the children and their parents had an
opportunity to discuss the study with the researcher
 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44 37

before deciding to sign the consent form. At the

beginning of the interview the researcher clarified the Reading through the interviews
purpose of the interview with the child, and emphasized
the confidentiality of the study, while ensuring that the
data were collected for the researcher and would not be
revealed to the nurses or the child’s parents. Permission Identifying the unit of analysis
to carry out the study was guaranteed by a research
committee in the hospital.

4.4. Data analysis Structuring the content of each interview according to the themes

The data were analyzed using the method of content

analysis (Downe-Wamboldt, 1992; Burns and Grove, Theme 1: Theme 2: Theme 3:
1997; Polit and Hungler, 1999). The first step of this Children’s self-initiated Nurses’ and parents’ Children’s suggestions
use of pain relieving use of pain relieving to nurses and parents
process after reading through the interviews was to methods methods
identify the unit of analysis, which was defined as
complete thought, ranging from one word to several
Nurses’ use Parents’ use Suggestions Suggestions
sentences (Downe-Wamboldt, 1992). Secondly, the of pain relieving of pain relieving to nurses to parents
content of each interview was structured according to methods methods
the themes (e.g. children’s self-initiated use of pain
relieving methods) based on the research questions.
After this the similar descriptions (e.g. reading, watching The similar descriptions were grouped into categories and named through the
TV/videos, playing games, drawing, doing hobby crafts) process of clusteration and abstraction. The following types of categories were
formed under each theme:
were grouped into categories while making comparisons
for similarities and differences between each pair of
concepts under the themes. The categories were named
through the process of abstraction (e.g. distraction) 13 types of 10 types of 14 types of 7 types of 4 types of
self-initiated pain relieving pain relieving suggestions suggestions
(Fig. 2). pain relieving methods methods to nurses to parents
methods utilized by the utilized by the
Finally, the data of content analysis were quantified nurses parents
within categories: the number of the children’s responses
were reported to illustrate how many children responded Fig. 2. The process of data analysis in the study.
to an item in a particular way (Cole, 1988; Polit and
Hungler, 1999). Descriptive statistics were used as well
to summarize the demographic characteristics of the playing I don’t have much time to think about
children. anything else’’. (7)

Another method of drawing attention away from pain

5. Results
5.1. Children’s self-initiated use of pain relieving methods
The children reported 13 successful types of self-
initiated pain relieving methods. As shown in Table 2,
most of the children reported using distraction, resting/
sleeping, positioning/immobility and asking for pain
medication or help from nurses when they experienced
pain.
The most common methods of distraction by which
the children tried to focus their attention away from
pain included reading, watching TV/videos and playing
games. For example, a 10-yr-old boy described his
experiences as follows:
‘‘I have read Donald Duck comicsythis helps me to
forget the pain. I can also get my thoughts elsewhere
by playing Nintendo games. When I concentrate on
included the use of imagery in which the children
reported thinking about some pleasant action/happen-
ing (e.g. getting home), important people (e.g. mother/
father, friends) or pets in order to forget the pain. The
method of thought stopping was used by only one child.
A 12-yr-old boy described this method as follows
without utilizing specific replacement thoughts:
‘‘Then I have kept on thinking that I am not hurting,
there is no pain, there is no pain’’. (11)
Children who used positioning typically associated
this method with immobility or restricting movement, as
one 12-yr-old girl described after undergoing an
appendectomy:
‘‘I have attempted to determine the best possible
position to be inyeither on my side or in a crouched
position. I have tried to be without moving so that it
would not hurt more’’. (15)
38 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44
Table 2
Children’s self-initiated use of pain relieving methods after surgery (N ¼ 52)
Pain relieving methods
‘‘How have you tried to manage pain/what have you done to help yourself when you have had pain?’’
Distraction
Resting/sleeping
Positioning/immobility
Asking for pain medications/help from nurses
Imagery
Walking/moving/doing exercises
Just being and trying to tolerate pain
Eating/drinking
Relaxation
Thought-stopping
Breathing technique
Thermal regulation (cold application)
Urinating often
Table 2
Children’s self-initiated use of pain relieving methods after surgery (N ¼ 52)
All children reported using at least one self-initiated
pain relieving method. The majority of them claimed to
use four of these strategies during their hospitalization.
The mean number of strategies identified was 3.8 with a
range from 1 to 8.
5.2. Nurses’ use of pain relieving methods
The children reported ten successful types of pain
relieving methods utilized by the nurses (Table 3). The
children reported that nursing actions involving the
administration of pain medications, helping them with
daily activities, and distraction most often minimized
their pain.
For example, a 9-yr-old boy described the method of
receiving help with daily activities as follows:
‘‘The nurses helped me out of bed in the morning
when it is difficult for me to get up. I am entirely
lacking in strength. They have brought me food and
taken the tray awayythey have brought my urina-
lyand helped with my morning bath’’. (18)
As shown in Table 3 approximately three-fourths of
the children reported that the nurses had given them
instructions regarding what measures they could imple-
ment themselves to alleviate their pain. The most
common strategies were the importance of positioning/
immobility after the surgical procedure, and distraction
in which the child was instructed about meaningful
activities (e.g. playing games, watching TV/videos,
reading) that he/she could engage in during hospitaliza-
tion.
All of the children reported that the nurses used at
least two pain-relieving methods. The children expressed
N %
51 98
42 81
27 52
27 52
16 31
11 21
10 19
6 12
4 8
1 2
1 2
1 2
1 2
that a combination of three methods was most
commonly utilized by the nurses. The mean number of
strategies identified was 3.0 with a range of 2–5.
5.3. Parents’ use of pain relieving methods
The children reported 14 successful types of pain
relieving methods utilized by their parents (Table 4). The
children described that the methods of distraction,
presence, positive reinforcement and helping with daily
activities were the most popular strategies how the
parents helped them in pain.
Positive reinforcement included rewarding the child in
a concrete way during the hospitalization or promising
to do so after discharge. The children related that their
parents had brought them something good to eat (e.g.
sweets, ice cream) or had rewarded them by buying
something pleasant (e.g. books, toys). For example, one
9-yr-old boy described this method in the following way:
‘‘When I lay in bed suffering my parents have
brought me sweets for comfort or something else
like a book or other things’’. (40)
Seven children reported that their mothers served as
advocates by requesting help or pain medications from
nurses on behalf of the child. Some children also related
that their parents had brought them personal belongings
(e.g. bear, magazines) from home in order to create a
more comfortable environment.
As shown in Table 4, two-thirds of the children
expressed that their parents had given them instructions
regarding measures they could implement themselves in
order to alleviate their surgical pain during hospitaliza-
tion. The most commonly utilized strategies included
 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44 39

Table 3
Nurses’ use of pain relieving methods after surgery according to children (N ¼ 52)

Pain relieving methods N %

‘‘How have nurses helped you/what have they done with you or to you when you have had pain?’’

Giving pain killers 50 96

Helping with daily activities 46 88
Distraction 27 52
Inquiring about the child’s condition/need for pain medications 16 31
Positioning 9 17
Presence 4 8
Thermal regulation (cold application) 3 6
Touch 1 2
Giving information 1 2
Changing bandages 1 2

‘‘Have nurses given you instructions about what you could do to alleviate your pain?’’

No, they have not given instructions 14 27

Yes, they have given instructions. What instructions were given? 38 73

Distraction 24 46
Positioning/immobility 15 29
Walking/moving/doing exercises 7 13
Resting/sleeping 6 12
Relaxation 3 6
Asking for help from nurses 3 6
Eating/drinking 2 4
Supporting the wound area 2 4
Imagery 1 2
Thought-stopping 1 2
Breathing technique 1 2

Table 3
Nurses’ use of pain relieving methods after surgery according to children (N ¼ 52)
distraction and resting/sleeping, whereby the parents
urged the child to engage in some meaningful activities
(e.g. reading, playing games, watching TV/videos), but
also to rest or sleep adequately in order to promote
recovery after surgery.
All of the children reported that their parents used at
least one method in order to help alleviate the child’s
pain during hospitalization. According to the children’s
descriptions the parents most commonly utilized a
combination of four methods. The mean number of
strategies identified was 3.7 with a range of 1–6.
5.4. Children’s suggestions to nurses and parents
Most of the children had suggestions to the nurses
concerning the implementation of effective pain relief
measures in the hospital, but only a few had suggestions
to the parents (Table 5).
Creating a more comfortable environment in the
hospital was the most common suggestion among the
children This included such suggestions to the nurses as
minimizing noise problems (especially those caused by
crying children), and making the child’s room more
comfortable (decoration, entertainment, equipment,
friends). Many of the children also wished that the
nurses would have arranged more meaningful activities
for them, either by doing something nice with the child
(e.g. playing, doing hobby crafts) or offering the child
some meaningful things to do. Furthermore, the
children wished that the nurses would have given them
more or stronger pain medication without delay,
because many of them experienced pain, even when
receiving pain medication after surgery.
Ten children reported that the nurses should regularly
visit the child’s room or allocate more time to stay with
the child. For example, an 11-year-old boy described his
experiences as follows after orthopedic surgery:
‘‘I guess I would have wanted those pain medications
more often, but I did not always dare to ask for them,
and sometimes I was ashamed to press the call button
since it made such a loud noise and my roommate
was sleeping. I would have liked it if the nurses would
round every hour so that I would not have to suffer
40 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44

Table 4
Parents’ use of pain relieving methods after surgery according to children (N ¼ 52)

Pain relieving methods N %

‘‘How have parents helped you/what have they done with you or to you when you have had pain?’’

Distraction 51 98
Presence 38 73
Positive reinforcement 35 67
Helping with daily activities 32 62
Inquiring about the child’s condition/need for pain medications 7 13
Advocating for the child 7 13
Positioning 5 10
Touch 5 10
Arranging a comfortable environment 6 12
Massage 3 6
Comforting 3 6
Thermal regulation (cold application) 1 2
Asking the child for preferred pain relief method 1 2
Giving information 1 2

‘‘Have parents given you instructions about what you could do to alleviate your pain?’’

No, they have not given instructions 17 33

Yes, they have given instructions. What instructions were given? 35 67

Distraction 18 35
Resting/sleeping 10 19
Walking/moving/doing exercises 7 13
Positioning/immobility 6 12
Imagery 3 6
Thought-stopping 1 2
Informing others when in pain/asking for help from nurses 1 2
Taking pain medication 1 2
Obeying the nurses 1 2

Table 4
Parents’ use of pain relieving methods after surgery according to children (N ¼ 52)
from the pain because I didn’t dare to use the call
button. I could have told my father, but it was
already eleven o’clock and he wasn’t with me
anymore’’. (31)
Only a few children had suggestions to the parents
concerning surgical pain relief measures in the hospital
(Table 5). The most common suggestion among the
children was simply the following: ‘‘Mum and dad, please
stay with me more’’.
6. Discussion
6.1. Relevance of the results to nursing practice
This interview study indicated that hospitalized
children, aged 8–12 yr old, are capable of describing
the methods for relieving their pain. The results are
consistent with earlier studies conducted among pedia-
tric patients (Savedra et al., 1982; Polkki
. et al., 1999;
Pederson et al., 2000). In order to achieve the children’s
own perspective, however, the children should be asked
about the methods that could potentially alleviate their
pain, as well as their suggestions regarding the
implementation of pain relief measures. Due to their
tendency to be independent, school-aged children may
conceal their pain and be reluctant to request help from
others (cf. Lutz, 1986; Woodgate and Kristjanson,
1995). This phenomenon in the children requires specific
attention, despite the fact that a certain level of cognitive
maturity is achieved during the school-aged period, and
a much broader array of non-pharmacological methods
are appropriate to use at this age (Vessey and Carlson,
1996).
The children in this study reported using at least one
self-initiated pain relieving method. Almost all of them
admitted to using distraction and resting/sleeping, which
are also commonly used strategies identified in other
studies involving children (Bossert et al., 1996; Campbell
 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44 41

Table 5
Children’s suggestions to nurses (N ¼ 41) and parents (N ¼ 13) concerning the implementation of surgical pain relief measures

Suggestions N %

‘‘What suggestions do you have to nurses/how could they alleviate your pain better?’’

Creating a more comfortable environment 16 31

Arranging more meaningful activities 15 29
Giving more/stronger pain medication without delay 13 25
Visiting regularly/staying with the child more 10 19
Familiar, friendly nurses, who offer good treatment 8 15
‘‘Getting home’’ 7 13
Better food services 6 12

‘‘What suggestions do you have to parents/how could they alleviate your pain better?’’

Staying with the child more 11 92

Arranging meaningful activities 1 8
Helping the child according to his/her wishes 1 8
Having an opportunity to give pain medications 1 8

Table 5
Children’s suggestions to nurses (N ¼ 41) and parents (N ¼ 13) concerning the implementation of surgical pain relief
and McGrath, 1999; Pederson et al., 2000). Watching
TV/videos, reading, and playing games were the most
popular ways of focusing the child’s attention away
from the pain according to the children’s descriptions.
The nurses and parents also most often provided
instruction to the children regarding the use of distrac-
tion. Only some children reported using cognitive-
behavioral methods such as imagery, relaxation and
breathing techniques, as well as some physical methods
such as cold application, even though many of these
methods have been tested to be effective in children’s
pain relief (Broome et al., 1994; Ebner, 1996; Lambert,
1996; Pederson, 1996; Peretz and Gluck, 1999). It is
interesting to note that the parents and nurses instructed
the children less often or not at all about the use of the
above techniques despite their efficacy, which may
explain the minimal use of these strategies among the
children. The reasons for the nurses’ and parents’ lack of
providing instructions to the children on certain
evidence-based non-pharmacological techniques could
potentially be due to the following: the lack of knowl-
edge regarding how to use the techniques in children’s
pain relief, or lack of time or resources to teach these
techniques to the children especially concerning the use
of imagery, relaxation and breathing techniques (cf.
Woodgate and Kristjanson, 1996a; Rheiner et al., 1998;
Polkki
. et al., 2001). In any case, the results of this study a few to the parents concerning the implementation of
indicate that health care providers should give more
guidance about the use of various pain relieving
methods to hospitalized children, thereby providing
the children with options for the most effective pain
relieving methods for their individual needs.
All of the children reported that the nurses had used
at least two pain-relieving methods and that parents
used at least one method. Almost all of the children
related that administering pain medication and helping
with daily activities were the methods most frequently
used by nurses to relieve their pain. Conversely, the
methods of distraction, presence, positive reinforcement
and helping with daily activities were the most popular
methods used by the parents according to the children’s
descriptions. While 38 children reported that the
presence of their mother/father helped them to feel less
pain, only four children reported that this strategy was
implemented by nurses. This may be explained by the
nurses’ lack of time to sit beside the child, but also by
different roles between the nurses and the parents in a
child’s care. On the whole the parents seemed to provide
more emotional support to their hospitalized children
than the nurses. According to the study by Woodgate
and Kristjanson (1996a), nurses primarily provided
technical care for hospitalized young children experien-
cing pain from surgical interventions, whereas care
provided by parents included comfort measures and
vigilant monitoring of the children’s pain. In this study
the children also reported that the parents used some
pain relieving methods (e.g. positive reinforcement,
creating a comfortable environment and massage) that
the nurses did not use to promote the child’ pain relief.
Many children had suggestions to the nurses, but only
surgical pain relief measures. This may indicate that the
children expect the nurses to know how to care for them
and relieve their pain (cf. Alex and Ritchie, 1992),
whereas the children do not have specific expectations of
their parents other than simply to ‘‘stay with me more’’.
In order to improve nursing care for children with
postoperative pain the recommendations provided by
42 T. Polkki
. et al. / International Journal of Nursing Studies 40 (2003) 33–44

children to the nurses, such as creating a more
comfortable environment (especially minimizing noise
problems), giving more or stronger pain medication
without delay, as well as visiting regularly or staying
with the child more, should be taken seriously into
account in nursing practice.
6.2. Reliability and validity
Use of the interview as a data collection method
allowed the children to express their own perspectives
regarding the methods of relieving their pain in the
hospital; however, there were some defects that may
potentially prevent the attainment of this purpose. First,
some children may have tried to provide favorable
answers during the interview even though the researcher
reminded them that there were no right or wrong
answers. Secondly, there were practical problems that
may have disturbed some children’s ability to concen-
trate on relating their experiences. For example,
practical issues independent of the researcher included
conducting the interviews just prior to the child’s
discharge, and use of the unfamiliar hospital room as
the place for conducting the interviews. An interesting
question is whether the results would have been different
if the children had been asked open-ended questions as
opposed to forced-choice questions regarding the
methods of pain relief (cf. Branson et al., 1990). The
use of triangulation, such as observing the children
during their hospitalization, may have increased the
validity of the results. Talking with the children after the
data had been analyzed may also have increased the
validity of the results (face-validity) (Downe-Wamboldt,
1992; Polit and Hungler, 1999). However, the children
were asked during the interview to clarify unclear
responses by questioning such as ‘‘What do you mean
by this’’ or ‘‘Could you tell me more about this’’. The
researcher also often summarized or paraphrased the
responses to the children at the end of each theme in
order to make valid interpretations of the data.
In order to improve the validity and reliability of the
study the researcher attempted to establish a confiden-
tial relationship with the child and minimized noise
problems during the interview. The researcher person-
ally collected and analyzed the data, and coded the
formed categories three times at 1-month intervals
(intrarater reliability). The discrepancies in the cate-
gories were resolved through discussion with two
independent researchers (panel of experts). The data
were quantified, which is justified in the use of content
analysis, in order to give the reader a tangible basis for
assessing what the analyst claims are the important
patterns in the data and improve on impressionistic
judgements of the frequencies of categories (Morgan,
1993). The validity of the formed categories in this study
was supported by previous relevant research in the area
of pain relieving methods in pediatric patients (Downe-
Wamboldt, 1992).
6.3. Challenges for future research
This study provided new information regarding the
implementation of pain relieving methods from the
children’s perspective in a hospital setting; however,
more research is required in this area in order to validate
and expand on the discoveries of this study. More
research is required on the children’s experiences
regarding help received from nurses and parents for
relieving pain. Also, it would be interesting to investigate
the roles of the other family members and friends in the
child’s pain relief. One of the challenges for future
research is to test effective interventions for surgical pain
relief in pediatric patients, which should not be restricted
only to the non-pharmacological methods implemented
by nurses in the hospital.
7. Conclusions
This study indicated that hospitalized children, aged
8–12 yr old, are capable of describing the methods for
relieving their pain, as well as providing recommenda-
tions regarding the implementation of effective surgical
pain relief measures. This means that the children should
be actively involved with the planning and implementa-
tion of their pain management regimen in the hospital.
Furthermore, children, parents and nurses should more
frequently utilize some cognitive-behavioral pain reliev-
ing methods, such as imagery, relaxation and breathing
techniques, as well as some physical methods, such as
cold-application and massage. Most children reported
their worst pain to be severe or moderate, which
indicates that pain management in hospitalized children
should be more aggressive.
Acknowledgements
The authors would like to thank the Emil Aaltonen
Foundation for providing funding for this research, and
the nursing staff of the university hospital in Finland for
their assistance in data collection. Special appreciation is
extended to the children who willingly participated in
the study, and the parents who supported their children
in this decision.
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