Pediatric Pain Management in Post Anesthesia Care Units - an Intervention Study
Phase: NA
Conditions: Postoperative Pain, Pediatric ALL
Sponsor: Oslo University Hospital

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
 
Pediatric Pain Management Practices in  
Postoperative Units – an Intervention Study 
 
Research Group  
- 
Anja Hetland Smeland, Pediatric Nurse, MSc, PhD student, Children's Surgical 
Department, Oslo University Hospital  
- 
Tone Rustøen, RN, PhD, Researcher, Division of Emergencies and Critical Care, 
Department of Research and Development, Oslo University Hospital and Professor II, 
Department of Nursing Science, University of Oslo (supervisor) 
- 
Alison Twycross, PhD, DMS, CertEd(HE), RGN, RMN, RSCN, Editor in Evidence 
Based Nursing and Reader in Children’s Pain Management, Head of Department for 
Children’s Nursing, Department of Children’s Nursing Faculty of Health and Social 
Care, London South Bank University (co- supervisor) 
- 
Stefan Lundeberg MD, PhD, Senior Consultant, Pain Treatment Service, Astrid 
Lindgren Children's Hospital, Stockholm (Intervention study) 
- 
Hanne Reinertsen, Associate Professor, Oslo and Akershus University college of 
applied Sciences (Intervention study) 
- 
Lill Nybro, MSc student, Intensive Care Nurse, Oslo University Hospital (interview 
with children) 
- 
Torgun Næss, MSc student, Pediatric Nurse, Oslo University Hospital (interview with 
children) 
- 
Eva Carlsen, Pediatric Nurse, Children's Surgical Department, Oslo University 
Hospital  (facilitator Intervention study) 
 
Summary 
Despite available research on pediatric pain management, pain is still underestimated and 
undertreated. According to research, nurses’ attitudes and lack of knowledge are some possible 
causes. This study will explore nurses’ pediatric postoperative pain management practices. The 
aim is to evaluate if a tailored educational intervention with nurses working in postoperative 
units improve their knowledge and attitudes of pain management and pain management 
practices. This is a tailored educational intervention study with a pre-post design and a 
comparison group (baseline T-1, one month after intervention T-2, and six months after 
intervention T-3), including a sample of nurses working in six postoperative units. The units 
are the largest pediatric postoperative units of each of the six university hospitals, covering all 
health regions in Norway. Three different approches will be used (survey with questionnaire of 
the nurses, observations of clinical practice, and interviews with children) to collect data about 
pediatric pain management practices in this study. 
 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
Background 
Pain in children and adolescents is underestimated and undertreated even if a lot of research is 
done in the area (1, 2). Research suggests that lack of knowledge about pain and pain 
management in children are one of the reasons for the undertreatment (3-14).  
As late as in the 1970's and 80's premature and newborn children went through surgery 
without pain medication (15) because it was claimed that the children could not feel pain since 
the nervous system was not fully developed. More recent studies show that preterm infants are 
hypersensitive to pain (16), and that surgery in the neonatal period can lead to prolonged pain 
and hypersensitivity in the damaged area (17, 18). 
Untreated pain can cause unnecessary suffering, increased risk of complications, 
increased risk of morbidity and mortality, as well as lead to longer hospital stays and increased 
cost (19). Long-term consequences of inadequate relief of acute pain can be chronic pain for 
10-50% of the patients, of which 2-10% of them will experience severe chronic pain (19). 
Nurses who work at postoperative units have a considerable responsibility to ensure 
optimal pain management. Research shows that the use of guidelines and pain assessment 
tools improve the pain treatment of children through systematic assessment and evaluation (20, 
11). However, more than half of European hospitals are reported to lack written guidelines for 
pain treatment and more than half of the patients experience severe pain (21, 22). 
Pain assessment in children is largely based on patients' self-reports and nurses’ 
assessment and the use of observational pain assessment tools (23, 24). There are many types 
of pain assessment tools for children (behavior form, face form, numerical scales) (11, 25-29), 
but no pain assessment tools are suitable for all children as it must be selected on the basis of 
the child's age, developmental level and context (27).  
Few studies have examined the effectiveness of educational interventions on pediatric 
nurses' pain management (7, 30-33). The studies showed improved perception of pain 
assessment and management (30), improved knowledge of pain management (7, 31,32) and 
increased use of non-pharmacological interventions (31). Johnston et al. (31) & Le May et al. 
(32) studied if there where any change in nurses’ analgesic administration and found that there 
were no significant change. Vincent et al. (33) conducted a pilot intervention study which 
showed significant improvement in nurses’ beliefs and pain management practices. All studies 
have small samples, except Ellis et al. (30), and only Johnston et al. (31) had a comparison 
group. None of these studies have measured if tailored educational intervention improve 
nurses’ pediatric pain management practice by observing the nurses or examined the children’s 
experience of pain and pain management. There is a need to explore this further. 
 
Objectives 
The main objective of the present study is to improve pediatric postoperative pain 
management. This will be achieved by first exploring the pediatric postoperative pain 
management practice using different approaches (study 1). Then, an intervention will be 
developed based on the results from the first study and available research in the area (study 2). 
After that, we will investigate if the tailored interventions with nurses at postoperative units 
improve the nurses’ knowledge of pediatric pain management and pediatric pain management 
practice (study 3). The different studies are presented in Table 1: 
 
Table 1: The studies  
 
Studies 
Activity 
Study 1 
Explore nurses’ pediatric 
postoperative pain practices 
Data collection (baseline T-1) using : 
• 
Questionnaire PNKAS-N 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
• 
Observational study of clinical practice 
• 
Interview with children  
Study 2 
Develope a tailored educational 
intervention  
Develope tailored educational intervention based on: 
• 
Available research 
• 
Results from baseline 
• 
Feedback from the head of the relevant units 
• 
Staff views about the facilitators and barriers to 
optimized pediatric pain management 
Study 3 
Implementation and evaluation 
of the intervention  
Implementation of the intervention 
• 
Seminar (lecture and workshop) 
• 
Clinical supervision  
• 
Reminders  
Data collection (T-2 and T-3, one and six mounths after 
the intervention) 
• 
Questionnaire PNKAS-N  
• 
Observational study of clinical practice 
• 
Interview with children 
 
 
Study 1 Exploring Nurses’ Pediatric Postoperative Pain Practices 
 
Research questions 
What kind of knowledge and attitudes do nurses working in postoperative units have about  
pediatric pain management? 
How do nurses manage the pediatric pain practices in postoperative units? 
What is the children’s experience of pain and pain management after surgery? 
 
Three different approches will be used (questionnaire, observation and interview) to collect 
data about pediatric pain management practices in this study. 
 
a) Survey with Questionnaires 
Sample/Setting 
The study will be conducted by nurses at six postoperative units, which have children and 
adolescents after surgery. The units are the largest pediatric postoperative units of each of the 
six university hospitals, covering all health regions in Norway. All nurses (259 nurses) 
working with patients in these units will be asked to participate in this study.  
 
Data Collection 
Data from the nurses regarding knowledge and attitudes toward pain management will be 
collected using “The Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain 
Questionnaire - Norwegian version” (PNKAS-N). The PNKAS was developed by Manworren 
(9) and translated into Norwegian tested and validated according to Norwegian conditions by 
Hovde el al. (5). 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 (9, 10). The PNKAS-N 
consist of 40 questions about general pain management, pain assessment, and use of 
pharmacological and non-pharmacological treatment of pain in children. Several items are 
related to areas in pediatric pain management where lack of knowledge has been reported. An 
appendix of the questionnaire register the nurses’ age, education level, work experience and 
full-time equivalent. An additional section has been added to the questionnaire in order to get 
the staff views about the facilitators and barriers to optimized pain management. The PNKAS-

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
N will be distrubuted to the nurses three times, at baseline (before the intervention), and one 
and six months after the intervention.  
 
Data Analysis 
The data will be analyzed using statistical methods (SPSS). Descriptive and correlational 
statistics will be used to describe and summarize data (34, 35). Means, standard deviations, 
medians, and interquartile ranges will be calculated for continuous data. Frequency counts and 
proportions will be calculated for categorical data.  
 
b) Observational Study 
The aim of this part is to obtain more knowledge about how nurses actually manage post-
operative pain in children and whether pain management practices adhere to current best 
practice guidelines. 
 
Sample 
Non-participant observational studies will be conducted at all six units at baseline.  
Each unit have 40-60 nurses working with patients and 10-15 children undergoing surgery 
every day, 50-75 children/week in total.  
 
Data Collection 
During each data collection period, observations will be carried out for four-hour periods (day 
and evening), two weeks per unit (40 hours per unit per occasion, 240 hours in total). The 
observational study will focus on observing the nurses general pain management practice, pain 
assessment (use of pain assessment tools), use of pharmacological and non-pharmacological 
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 (36). 
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, type of surgery, and days since surgery. The other data that will be recorded is what 
the situation gives, but no data that can identify the patient will be recoded. The checklist will 
be pilot tested based on two different observation situations. 
 
Data Analysis 
Data from each nurse will be collected by using the pain management checklist and 
summarizing each of the nurses’ pain management practices. A content analysis will be carried 
out on data within the field notes (37, 38). Information in the field notes will be examined for 
common themes (35, 39). Using highlighter pens, the researcher will code the data in each of 
the categories. After the data in the field notes are coded, the researcher will identify recurring 
themes and compare this to the data from the pain checklists to provide a picture of current 
pain management practices. The data will be given to another experienced pediatric nurse who 
will code the data without any knowledge of the themes identified by the researcher, to 
minimize researcher bias. After having coded the data the researcher and the second coder will 
discuss and agree upon the final wording of the themes.  
 
c) Interview with Children 
The aim of this part is to obtain more knowledge about what are the children’s experiences of 
pain and pain management after surgery. 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
 
Sample 
Twenty children older than six years going through surgery at the time of data collection at 
two of six units (randomly chosen), and their parents, will be asked to participate in this study.  
 
Data Collection 
The draw and write technique (40, 41, 42) will be adapted for use with children aged 6-9 years 
allowing them to draw and tell, draw and write or write their story about how well their pain 
has been managed in hospital. Older children will be offered the option of individual 
interviews. The semi-structured interview schedule will reflect the questions used by Polkki et 
al. (43) and the Royal College of Nursing (44) and include questions related to:  
 
• Have you had any pain while you were in hospital? 
• Were you asked if you had any pain? 
• Who asked you about your pain? 
• How did the nurses help you when you were in pain? 
• Do you think nurses can help children in pain in a better way? 
• What is tolerable pain to you?  
• Do you have pain at rest and when you move?  
• Does the pain limit your daily activities?  
 
All children will be asked to rate the worst pain experienced during the first 48–72 hours 
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. All children taking part 
in the study will also be asked to rate the worst pain experienced during the post-operative 
period as well as their current level of pain. These interviews will take place before the child is 
discharged from hospital, and all interviews will be tape recorded. The interview guide will be 
pilottested in two different interviews. 
 
Data Analysis 
Children’s responses to the interview questions will be transcribed verbatim. Content analysis 
will be used to analyse the transcripts using a five-step approach (45): 
1 Creating and organising files for data 
2 Reading through the text and forming initial codes 
3 Describing the social setting, people involved and events 
4 Analysing data for identifying emerging themes 
5 Interpreting and making sense of the findings  
 
 
Study 2 Develop the Tailored Educational Intervention 
The intervention will be developed based on available research, results from baseline in the 
present study and staff views about the facilitators and barriers to optimized pediatric pain 
management of the included units.  
The intervention will be a one day seminar for nurses working at the units, with 
lectures and workshops with main focus on the subjects showing the lowest pediatric pain 
management competence. In addition, there will be clinical supervision in pediatric 
postoperative pain management (two or three days per unit). The intervention will be 
conducted by two experts (nurse and physician) in pediatric postoperative pain management. 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
After the intervention there will be different reminders every week for the first month, and 
then every month (in different forms) about pediatric pain management during six months of 
time. 
 
Study 3 Implementation and Evaluation of the Intervention 
 
Research Questions 
Will tailored educational interventions improve nurses’ knowledge and attitude to pediatric 
pain management? 
Will tailored educational intervention improve nurses’ pediatric pain management practice? 
 
After the educational intervention is implemented there will be different reminders. The first 
month there will be reminders every week, and thereafter every month for six months period 
of time. The reminders are based on the general pain management practice, pain assessment, 
pharmacological and non-pharmacological treatment of pain in children with main focus on 
the subjects showing the lowest pediatric pain management competence at baseline. The 
reminders will be in different forms (poster, pamphlet, picture, pocket guide etc.) posted in 
different places at the units (46).  
After the intervention there will be an evaluation of the effectivness of intervention. To 
evaluate the intervention three different approches will be used (questionnaire, observation and 
interview) to collect data about pediatric pain management practices. 
 
Pre-post tailored educational intervention design, with comparison group, measured 
during three periods; T-1 (baseline - before intervention), T-2 (one month after intervention) 
and T-3 (six months after intervention). 
 
Table 2: FLOWCHARTS 
 
 
 
Sample/Settings 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
Three of these six units will be randomized (cluster randomized by units) in an intervention 
group and three in a comparison group. Each unit has about 40-60 nurses, approximately 260 
nurses in total. 
 
Data Collection 
All nurses at all six units are asked to take part in the study by completing the PNKAS-N 
questionnaire at T-2 and T-3. Non-participant observational studies will be conducted at four 
units at T-2.  Futhermore, one unit from the intervention group and one unit from the 
comparison group will be randomly chosen for observational studies at T-3. During each data 
collection period observations will be carried out for four-hour periods, two weeks per unit (40 
hours per unit per occasions, 240 hours in total). Children older than six years who are having 
surgery at the time of data collection at the same two units will be asked to participate in an 
interview (20 children from two units) at T-2. 
 
Data Analysis 
Descriptive and inferential statistics will be used to analyse quantitative data at each data 
collection. Regression analyses that accounts for repeated measurements and cluster 
correlations (within units) will be used for comparisons between data collected at baseline T-1, 
T-2 and T-3. Content analysis will be used to analyse the children’s responses to the interview 
questions. Supplemantary data from the interviews and the observation studies at T-1 and T-2  
will be compared to see if the tailored educational intervention improve nurses’ pediatric pain 
management practice and childrens experience of pain assessment (e.g. use of pain assessment 
tools, use of pharmacological and non-pharmacological treatment of pain). 
 
Ethics: 
Ethical research guidelines will be followed (47-52). An approval from the Norwegian Social 
Science Data Services (NSD) and Regional Committee for Medical Research Ethics  (REK 
South-East) will be obtained. Necessary approval from the hospitals will be obtained. Contact 
will be established with relevant persons at the units and cooperation on the implementation of 
the project. The project will be personally presented by the project manager at the relevant 
departments at baseline. A pilot observational study and two  pilot interviews with children 
will be done before baseline (T-1). 
Participants (nurses, children and their parents) will receive oral and written 
information about the study, and informed consents will be obtained from all the participants. 
The information letter includes information about the study, and explains that it is voluntary to 
participate in the study and the participants’ answers will be treated anonymously (53-57).  
 
The questionnaires will be distributed to the nurses with an information letter and an 
envelope for returning the questionnaires. Informed consents will be obtained from all the 
persons (nurses, children and their parents) who are present during the observational studies. 
The participants who do not approve will be excluded from the study. Informed consents will 
be obtained from both the children (> 12 years) and the parents that are participating in the 
interviews. All data will be recorded on standardized forms. The interviews with children will 
be coded so that no data collected include date of birth or other sensitive information that can 
identify the child. Data will be stored securely and deleted at the end of the study (58-61) . 
 
Benefit/Risk: 
Participating in the study will involve some extra work in filling in the questionnaire and to 
participate in the intervention. Furthermore, the participants may feel uncomfortable being 
observed during the observational study. They will be informed that no data about any nurses 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
or others will be avalaiable for others. It will also be voluntary to participate. Furthermore, the 
questionnaires are anonymous. Studying the nurses’ knowledge and attitudes to pain in 
children and adolescents in Norway may lead to increased focus, awareness and attention on 
the topic among nurses. This means that while taking part in the study will not be of direct 
benefit to the children participating it may result in improved care for children in the future, 
The study will summarize Norwegian nurses' knowledge and attitudes to pain in children and 
adolescents. Further, the study will summarize nurses' use of pain assessment tools and if there 
are guidelines for pain assessment and treatment of the various units in the all health regions in 
Norway. The evaluation of the intervention can contribute to development of a national 
educational program for nurses in relation to post-operative pain and pain management in 
children and adolescents. 
 
Declaration of Conflicting Interests:  
There are no conflicts of interest. 
 
 
Schedule 2014-2019 
Preparation 
 
November 2013 - June 2014 
 
Data collection 
T-1 
September -  November 2014 
PNKAS-N 
Observation 
Interview with children 
 
intervention 
January – February 2015 
 
 
T-2 
March - April 2015 
PNKAS-N 
Observation 
Interview with children 
 
T-3 
September- October 2015 
PNKAS-N 
Observastion 
Data analysis 
 
September 2015 - March 2017 
 
Papers 
paper 1 
December 2015 – March 2017 
 
 
paper 2 
April 2016 - March 2017 
 
 
paper 3 
October 2016 - November 2017 
 
 
paper 4 
October 2016 - November 2017 
 
 
Publication Plan: 
2016 
Nurses knowledge about pediatric postoperative pain management  
Data from baseline, PNKAS, observasjon (short summari in table) baseline 
Journal: Pain Management Nursing 
http://www.painmanagementnursing.org/content/authorinfo  
(Nurses’ pediatric pain management practices in postoperative units in Norway 
- data will be from the questionnaires at baseline and the observation studies. ) 
2016 
Pain in children after surgery- an interview study  
Data from T1 
Journal: Journal of Clinical Nursing 
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-2702/homepage/ForAuthors.html  
2017 
The development of a tailored intervention about pediatric pain management after surgery  
(Data from baseline interview, baseline observation, PNKAS) 
Theoretical framework 
Journal: Scandinavian Journal of Caring Sciences 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1471-6712/homepage/ForAuthors.html  
(A tailored educational intervention with nurses in pediatric pain management 
- the content of the intervention will be published were all the details will be given. ) 
2017 
Implementation and evaluation of an intervention about pediatric pain management after 
surgery 
Data: Endring fra T1, T2, T3- PNKAS, interview 
Journal: Pain 
http://edmgr.ovid.com/pain/accounts/ifauth.htm  
(Evaluation of a tailored educational intervention with nurses pediatric pain management 
- the main paper will describe the effect of the intervention. Data from all measurement points will be 
presented, and data from the interviews and observations will be given as well.) 
Even if only three publications will be included in the doctoral thesis, the reseach group will write the fourth one.  
 
 
The results from the study will be presented at national as well as international conferences. 
  
Dissemination of the results: 
 
Presentation 
Oral 
January 2017 
National conference Norway 
NOSF, Oslo 
http://www.norsksmerteforening.no/kurs 
Presentation 
Oral 
March 2017 
National conference Norway 
Norsk Barnesmerteforenings vårseminar, Oslo 
http://www.norskbarnesmerteforening.no/arrangementer 
Presentation 
Oral 
April 2017 
National conference Norway 
BSF Vårseminar, Bergen 
http://www.reiseogkonferanseservice.com/Barnesykepleie
rforbundet/Varseminar2017/program.cfm 
Presentation 
Poster 
July 2017 
International Conference 
11th International Symposium on Pediatric Pain (ISPP) 
Kuala Lumpur, Malaysia 
http://www.ispp2017.org/abstract 
 

 
 
Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
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Date: 14.12 2017  
Unique Protocol ID: 2014/7951 
Secondary Ids: 2014/878 [Regional Committee for Medical Research Ethics Norway] 
 
 
  
2011 Jul;11(4):250-5. doi: 10.1016/j.nepr.2010.11.016. Epub 2010 Dec 24. 
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