Pediatric Postoperative Pain Management in Surgical Wards - an Intervention Study
Phase: NA
Conditions: Postoperative Pain
Sponsor: Oslo University Hospital

Unique Protocol ID: 2019/388 [Regional Committee for Medical Research Ethics Norway] 
 
 
 
                              
 
 
 
Norwegian Version 12.02 2019  
 
 
 
Translated into English 30.04.2019 
 
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Title  
Pediatric postoperative pain management in surgical wards – an intervention study 
Background  
Pain is underestimated and undertreated despite a lot of research on the field (1, 2). 
Undertreated pain after surgery may cause increased risk of complications, increased risk of 
morbidity and mortality, developing chronic postsurgical pain, as well as potentially longer 
hospital stays (3-5). 
Possible causes for the undertreatment of pain in children may be healthcare providers’ 
misconceptions and their lack of knowledge about pediatric pain management (6, 7), 
inconsistent use of pain assessment tools (8, 9), and lack of available guidelines for pediatric 
pain management (9). Healthcare providers working in surgical wards have an important role 
and responsibility to provide postoperative pain management. 
Some studies have explored the effect of educational interventions on pediatric postoperative 
pain management by using questionnaires (10, 11) or combining questionnaires and chart 
reviews (12-14), combining questionnaires, chart reviews and focus group interviews with 
healthcare providers (15), and one study by combining use of questionnaire, observational study 
and interviews with children on recovery units (9). These studies revealed increased knowledge 
about pediatric pain management (10-13), and increased documented use of 
nonpharmacological pain management (12, 13) after intervention. 
None of these studies have explored if an educational intervention improve pediatric 
postoperative pain management on surgical wards by combining use of questionnaires and 
observational study, focus-group interviews with healthcare providers and interviews with 
children. Therefore, we will carry out a pre-post educational intervention study where we 
explore healthcare providers’ knowledge and attitude regarding pediatric postoperative pain 
management, their clinical practice and their experience of barrier and facilitators for effective 
pain management, and children’s’ experiences of pain and postoperative pain management. 
 
Aims  
The overall aim is to improve pediatric postoperative pain management on surgical wards. The 
aim of this study is to explore healthcare providers’ knowledge and clinical practice in pediatric 
postoperative pain management in surgical wards, and to evaluate whether an educational 
intervention would improve postoperative pain management. 
 
Methods  
Design  
This study has a pre-post intervention design, with four measurement points: baseline (T1), 
and one month (T2), six months (T3) and 12 months (T4) after intervention. 
 
Procedure  
This study will be conducted on four surgical wards in one university hospital in Norway. There 
will be used different methodological approaches for data collections (interviews, questionnaire, 
observational study) with four measurement points; baseline (T1), and one month (T2), six 
months (T3) and 12 months (T4) after intervention. 

Unique Protocol ID: 2019/388 [Regional Committee for Medical Research Ethics Norway] 
 
 
 
                              
 
 
 
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To get a broader view of barriers and facilitators for effective pediatric postoperative pain 
management, there will be carried out focus group interviews with healthcare providers. 
Further, data about healthcare providers’ knowledge and attitudes regarding pediatric pain will 
be collected using a questionnaire. Data about nurses’ pediatric postoperative pain management 
will be collected using non-participant observational study and data about children’s experience 
about pain and pain management will be collected using face-to-face interviews with children. 
Tailored educational intervention 
The intervention will be based on previous research and results from baseline (T1). The 
intervention will be a one-day educational day and includes lectures and workshops with main 
focus on the lowest competence in pediatric postoperative pain management. Healthcare 
providers at the included surgical wards will be invited to participate on this educational day.  
As a supplement, there will be provided clinical supervision in pediatric postoperative pain 
management and reminders (such as lectures and posters) over a period of six months after 
educational day. 
 
This study will have different phases (see table 1). 
Table 1 Overview of the different phases in the study 
 
Phase 
Activity  
Preparations Explore nurses’ barriers and 
facilitators for effective 
pediatric postoperative pain 
management on surgical wards 
Data collection using (pre project) 
 
Questionnaire regarding barriers and 
facilitators for nurses 
Phase 1 
Explore healthcare providers’ 
knowledge, clinical practice 
children’s experiences of pain 
and pain management, and 
healthcare providers’ 
experiences of barriers and 
facilitators for effective pain 
management  
Data collection using (baseline – T1) 
 
Questionnaire PNKAS-N 
 
Observation of clinical practice 
 
Face-to-face interviews with children  
 
Focus group interviews with healthcare 
providers (barriers and facilitators) 
Phase 2 
Develop  and implement a 
tailored educational 
intervention 
Develop tailored educational intervention 
based on: 
 
Available research 
 
Results from baseline 
 
Feedback from head of the relevant 
units 
 
Staff views about the facilitators and 
barriers to optimized pediatric pain 
management  
Implementation of the intervention 
 
Seminar (lecture and workshop) 
 
Clinical supervision  

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 
Reminders  
Phase 3 
Evaluation of the intervention Data collection using (T2, T3, T4) 
 
Questionnaire PNKAS-N 
 
Observation of clinical practice 
 
Interviews with children  
Research questions  
How do children experience pain and postoperative pain management? 
Data collection 
At baseline there will be conducted 8-12 face-to-face semi-structured interviews with children 
6-18 years old. Children 6-9 years old will be given opportunity to use write and draw technique 
to tell their story about how they experienced pain management during the hospital stay. Older 
children will be offered to participate in an individual interview. A semi-structured interview 
guide will be developed including questions related to:    
 
Tell about how you were doing after the surgery 
 
Did you have pain after surgery  
 
Were you asked if you had any pain? 
 
When you were in pain, did someone help you? 
 
Do you have any suggestions to the nurses on how they could manage children’s pain in a 
better way? 
 
Do you have any suggestions to the children who are undergoing surgery (on how to 
manage pain)? 
All children will be asked to rate the worst pain experienced postoperatively using a numeric 
rating scale (NRS) from 0 “no pain” to 10 “worst pain imaginable” or a face scale depending on 
their cognitive capabilities. These interviews will take place before the child is discharged from 
hospital, and all interviews will be audio‐recorded. 
Data Analysis 
Children’s responses to the interview questions will be transcribed verbatim and structured 
using NVivo (QRS NVivo Pro for Windows, version 11). Content analysis will be used to the 
transcripts by using a six-step approach (18): 
1. Creating and organizing files for the data 
2. Reading through the text and forming initial codes 
3. Coding the data 
4. Describing the social setting, people involved, and events 
5. Analyzing data for identifying emerging themes 
6. Interpreting and making sense of the findings  
 
Focus group interviews with healthcare providers 
Research questions 
How do healthcare providers experience pediatric postoperative pain management? How do 
healthcare providers experience barriers and facilitators for effective pain management? 

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Data collection 
At baseline there will be conducted two focus group interviews with healthcare providers (two 
to four nurses, two surgeons, and two anesthesiologists in each group). A semi-structured 
interview guide will be developed including questions related to:    
 
How do you experience pediatric postoperative pain management in your department? 
 
How do you experience pain assessment in your department? 
 
Is there a need for improvement in pediatric postoperative pain management in your 
department? 
 
If so, what is possible to do to improve pediatric postoperative pain management? 
 
What is difficult to achieve regarding improvement of pediatric postoperative pain 
management? 
The interviews will be audio‐recorded. 
Data analysis  
The interviews will be transcribed verbatim and structured using NVivo (QRS NVivo Pro for 
Windows, version 11). Content analysis will be used to the transcripts by using a six-step 
approach (18): 
1. Creating and organizing files for the data 
2. Reading through the text and forming initial codes 
3. Coding the data 
4. Describing the social setting, people involved, and events 
5. Analyzing data for identifying emerging themes 
6. Interpreting and making sense of the findings  
Questionnaire for healthcare providers (nurses and physicians) 
Research questions 
What kind of knowledge and attitudes do healthcare providers have about pediatric 
postoperative pain management? 
Data Collection 
All nurses at all four wards (160 nurses) and all surgeons (experienced) at the corresponding 
wards (60 surgeons) will be invited to answer the questionnaire “The Pediatric Nurses’ 
Knowledge and Attitudes Survey Regarding Pain Questionnaire - Norwegian version” (PNKAS-
N). The PNKAS was developed by Manworren (16) and translated into Norwegian, tested and 
validated according to Norwegian conditions by Hovde el al. (17). The questionnaire is based 
upon guidelines for acute pain management in infants, children and adolescents, American Pain 
Society, The World Health Organization and the Joint Commission on Accreditation of Healthcare 
Organizations. The PNKAS-N consists of questions about general pain management, pain 
assessment, and use of pharmacological and nonpharmacological treatment of pain in children. 
In addition, healthcare providers’ age, education and work experience will be recorded. The 
PNKAS-N will be distributed to the healthcare providers four times, baseline (T1), and one 
month (T2), six months (T3) and 12 months (T4) after intervention 
Data Analysis 
The data will be analyzed with statistical methods using SPSS version 25 (IBM SPSS Statistics for 
Windows, version 25.0. IBM Corp, Armonk, NY, USA). Descriptive and correlational statistics will 
be used to describe and summarize data. Means, standard deviations, medians, and interquartile 
ranges will be calculated for continuous data. Frequency counts and proportions will be 

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calculated for categorical data. Multiple linear regressions for repetitive measurement will be 
used for analyzing the effect of the intervention. 
Observational study 
Research questions 
How do healthcare providers practice pediatric postoperative pain management? 
Data Collection  
Non-participant observational studies of clinical practice will be carried out for four-hours 
periods, one week per ward, at all four surgical wards at all measurement points. The 
observational study will focus on observing the nurses general pain management practice, pain 
assessment (use of pain assessment tools), use of pharmacological and nonpharmacological 
treatment of pain in children. A checklist and field notes will be used based on the PNKAS-N 
themes and essential areas of pediatric pain management identified in a literature review. Field 
notes will include descriptions of what is occurring during the period of observation and records 
of comments made by nurses related to pediatric pain management. The field notes will be 
recorded partly during the observation and partly after the observation (directly after), 
depending on the situation at the unit. No data about the child will be recorded except age, 
gender and type of surgery. The other data that will be recorded is what the situation gives, but 
no data that can identify the patient will be recorded. Observational studies will be carried out at 
baseline (T1), and one month (T2), six months (T3) and 12 months (T4) after intervention. 
Data Analysis 
The data will be analyzed with statistical methods using SPSS version 25 (IBM SPSS Statistics for 
Windows, version 25.0. IBM Corp, Armonk, NY, USA). Descriptive and correlational statistics will 
be used to describe and summarize data. Means, standard deviations, medians, and interquartile 
ranges will be calculated for continuous data. Frequency counts and proportions will be 
calculated for categorical data 
Ethical considerations 
Approval from the Norwegian Regional Committee for Medical Research Ethics and necessary 
approval from the hospital will be obtained. This study is based on the experience from the 
study Pediatric Pain Management - an Intervention Study where both the interview guides 
for interviews with children and the observational study checklist were pilot tested. The 
information letters to children will be sent to the hospital’s youth council to ensure the 
adolescents feedback before the study start. Further, we would cooperate with the hospital’s 
youth council throughout the whole study period to ensure feedback.  
The participants will receive both verbal and written information about the study explaining 
that it is voluntary to participate in the study and that it will not affect the treatment if they do 
not want to participate. Written informed consent will be obtained from all participants who are 
participating in the survey, the persons (nurses, children and their parents) who are present 
during the observational studies, and both the children (> 12 years) and the parents that are 
participating in the interviews. Verbal informed consent will be obtained from children younger 
then 12 years. The interviews will be transcribed and coded so that no data collected include 
names or other sensitive information that can identify the participants. Data will be stored 
securely, and ethical research guidelines will be followed. 
Research Group  
- 
Morten Carstens Moe, Professor, Surgeon, Division of Head, Neck and Reconstructive 
Surgery, Oslo University Hospital, Norway  

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- 
Anja Hetland Smeland, Pediatric Nurse, MSc, PhD student, Children's Surgical 
Department, Division of Head, Neck and Reconstructive Surgery, Oslo University 
Hospital, Norway 
- 
Ann-Hallfrid Sørensen, nurse educator, KAB 1, Children's Surgical Department, Division 
of Head, Neck and Reconstructive Surgery, Oslo University Hospital, Norway 
- 
Espen Helvig, Pediatric Nurse, MSc, Nurse Educator, KAB 2, Children's Surgical 
Department, Division of Head, Neck and Reconstructive Surgery, Oslo University 
Hospital, Norway 
- 
Helle Eide, Pediatric Nurse, Nurse Educator, KAB 1, Children's Surgical Department, 
Division of Head, Neck and Reconstructive Surgery, Oslo University Hospital, Norway 
- 
Guro Reyes Simonsen, Pediatric Nurse, MSc, Nurse Educator, KAB 3, Children's Surgical 
Department, Division of Head, Neck and Reconstructive Surgery, Oslo University 
Hospital, Norway 
- 
Anne-Lise Seipajærvi, Pediatric Nurse, Nurse Educator, KAB 4, Children's Surgical 
Department, Division of Head, Neck and Reconstructive Surgery, Oslo University 
Hospital, Norway 
- 
Birgitte Larsen, nurse specialist, Nurse Educator, Division of Emergencies and Critical 
Care, Oslo University Hospital, Norway 
- 
Torgun Næss, Pediatric Nurse, MSc, Nurse Educator, Division of Head, Neck and 
Reconstructive Surgery, Oslo University Hospital, Norway  
- 
Hilde Silkoset, Pediatric Nurse, MSc, Division of Emergencies and Critical Care, Oslo 
University Hospital, Norway 
- 
Kristian Kolstad Kjærnes, Pediatric Nurse, MSc, Nurse Educator, Division of Pediatric, 
Oslo University Hospital, Norway 
- 
Stefan Lundeberg, PhD, MD, Pain Treatment Service, Astrid Lindgren Children's Hospital, 
Sweden 
- 
Kari Sørensen, Intensive Care Nurse, MSc, PhD student, Division of Emergencies and 
Critical Care, Oslo University Hospital, Norway 
- 
Tor Thomas Vatsgar, MD, Division of Emergencies and Critical Care, Oslo University 
Hospital, Norway 
- 
Solveig Slåtto Gjems, MD, Division of Pediatric, Oslo University Hospital, Norway 
- 
Pernille Lindholm, Surgeon, Division of Head, Neck and Reconstructive Surgery, Oslo 
University Hospital, Norway 
- 
Kjersti Langmoen, Intensive Care Nurse, MSc, Children's Surgical Department, Division of 
Head, Neck and Reconstructive Surgery, Oslo University Hospital, Norway 
 
Schedule 2019-2026 
Preparation 
 
May 2018 – February 2019 
Data collection 
T1 
April – May 2019 
 
PNKAS-N 
 
Observational study 
 
Interviews with children 
 
Focus group interviews with healthcare 
providers 
 
Intervention 
 
September – January 2020 
 
T2 
October 2019 
 
PNKAS-N 
 
Observational study 

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T3 
February 2020 
 
PNKAS-N 
 
Observational study 
 
T4 
September 2020 
 
PNKAS-N 
 
Observational study 
Data analysis 
 
June 2019 – December 2020 
 
Publications 
Paper 1 
September – December 2019 
 
PNKAS-N (baseline) 
 
Paper 2 
September – December 2019 
 
Observational study (baseline) 
 
Paper 3 
September – December 2019 
 
Interviews with children (baseline) 
 
Paper 4 
January – December 2020 
 
Effect of intervention  
 
 
 

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