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Journal for Specialists in Pediatric Nursing

ORIGINAL ARTICLE

Exploring inuencing factors of postoperative pain in school-age

children undergoing elective surgery
Ying Jia Shermin Chieng, Wai Chi Sally Chan, Joanne Li Wee Liam, Piyanee Klainin-Yobas, Wenru Wang,
and Hong-Gu He
Ying Jia Shermin Chieng, BSc (Nursing) (Honours), is a Staff Nurse, Division of Nursing, National University Hospital; Wai Chi Sally Chan, PhD, RN, is a
Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore; Joanne Li Wee Liam, BSc (Nursing), RN,
is a Nurse Clinician, Division of Nursing, KK Womens and Childrens Hospital; Piyanee Klainin-Yobas, PhD, RN, is an Assistant Professor; Wenru Wang, PhD,
RN, is an Assistant Professor; and Hong-Gu He, PhD, RN, MD, is an Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, National University of Singapore, Singapore

Search terms
Anxiety, child, pain, postoperative,
preoperative, surgery.
Author contact
nurhhg@nus.edu.sg, with a copy to the Editor:
roxie.foster@ucdenver.edu
Acknowledgements
We appreciate the former director of nursing,
Ms. Lee Heng Pheng, the nurse managers, and
nurse clinicians of the participating wards, KK
Womens and Childrens Hospital, for their
support to this study. We give our heartfelt
thanks to all children and their parents for their
participation. This study did not receive any
specic grant from any funding agency in the
public, commercial, or not-for-prot sectors.

Abstract
Purpose. The purpose of this study was to examine the influencing factors
of postoperative pain among children undergoing elective surgery.
Design and Methods. A survey was conducted in 2011 with a convenience sample of 66 children, 6 to 14 years old, in a tertiary hospital in
Singapore.
Results. Children experienced moderate preoperative anxiety and postoperative pain. Gender, preoperative anxiety, and negative emotional
behaviors were significant influencing factors for postoperative pain. Boys
reported less postoperative pain than girls.
Practice Implications. Effective strategies for assessing and managing
childrens preoperative anxiety are needed to achieve an optimal postoperative pain management outcome.

Author contributions
Study Design: HHG, CWCS, YJSC;
Data Collection and Analysis: YJSC, HHG, JLLW,
CWCS, PKY, WW;
Manuscript Preparation: HHG, CWCS, YJSC, PKY,
WW, JLLW.
Disclosure: The authors report no actual or
potential conicts of interest.
First Received October 21, 2012; Final revision
received February 27, 2013; Accepted for
publication February 28, 2013.
doi: 10.1111/jspn.12030

Pediatric surgery is a distressing and overwhelming

experience for school-age children (Li, Lopez, &
Lee, 2007b) that may induce numerous negative
responses because they are not cognitively and emotionally fully developed. Out of all negative responses
to hospitalization and operation, preoperative
Journal for Specialists in Pediatric Nursing 18 (2013) 243252
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anxiety is the most prominent (Li & Lopez, 2004a).

Anxiety is a subjective experience that describes
a person as feeling tense and apprehensive
(Spielberger, 1983). These feelings of tension and
apprehension are caused by factors such as fear of
pain (Li & Lopez, 2004b; Pritchard, 2009; Vaughn,
243

Exploring Inuencing Factors of Postoperative Pain in School-Age Children Undergoing Elective Surgery

Wichowski, & Bosworth, 2007); this is especially true

in children because their sense of self-esteem is not
yet fully developed (Justus et al., 2006). When left
alone and placed in an unfamiliar environment, children are easily overwhelmed and develop high levels
of anxiety. Factors contributing to anxiety in children
undergoing surgery include unfamiliar environment, faces, and routines; hospital food and clothing;
medical jargon; and witnessing parental anxiety
(Squires, 1995). In addition, studies have shown that
childrens postoperative pain is often undermanaged
(He, Plkki, Pietil, & Vehvilinen-Julkunen, 2005,
2006; He, Vehvilinen-Julkunen, Plkki, & Pietil,
2007; Kankkunen et al., 2009; Twycross, 2007),
which compromises the quality of postoperative care
for children.
Preoperative anxiety and postoperative pain are
two significant problems faced by children undergoing surgery that require nurses attention. These two
problems have been associated with suboptimal
postoperative outcomes, such as lowered immunity,
delayed healing process, and psychological symptoms such as inability to concentrate (Vaughn et al.,
2007). Effective management of these problems is
essential (Kain, Mayes, Caldwell-Andrews, Karas, &
McClain, 2006) because several studies have demonstrated that preoperative anxiety and postoperative pain are positively correlated and influence each
other (Klassen, Liang, Tjosvold, Klassen, & Hartling,
2008; Vaughn et al., 2007).
As much as 50% of the 5 million children undergoing surgery each year in the United States experience preoperative anxiety (Kain et al., 2006).
Excessive preoperative anxiety is unfavorable to
childrens physical and psychological health (Li &
Lopez, 2005b). Physically, preoperative anxiety may
alter childrens rest and sleep patterns as well as
appetite, which can result in fatigue, thus exerting a
physical strain on their bodies (Li, Lopez, & Lee,
2007a). Psychologically, preoperative anxiety may
make children feel upset, thus placing them at risk
of developing maladaptive behavioral changes.
For example, children may exhibit uncooperative
behavior such as excessive crying and wailing,
throwing tantrums, protesting or even having withdrawal reactions to treatment (Kain et al., 2006).
Some factors that may influence preoperative
anxiety in children include not having a clear understanding of the procedures that they are undergoing
(Pritchard, 2009; Vaughn et al., 2007), fear of
pain, and not being in command of their own emotions and behaviors (Li & Lopez, 2004b); being
unaware of the consequences following surgery
244

Y. J .S. Chieng et al.

(Lamontagne, Hepworth, & Salisbury, 2001; Vaughn

et al., 2007); quality of previous medical encounters
(Justus et al., 2006); and parents anxiety (Justus
et al., 2006; Li & Lam, 2003). Moreover, children
tend to exhibit negative emotional behaviors when
in stressful situations (Li & Lopez, 2005a).
Postoperative pain has always been a challenge for
children (Hamers & Abu-Saad, 2002; Li & Lam, 2003;
Twycross, 2007). Studies continuously report that
childrens pain is undermanaged, and they often have
to experience postoperative pain that is beyond their
tolerance level (He et al., 2005, 2006; Kankkunen
et al., 2009; Shorten, Carr, Harmon, Puig, & Browne,
2006; Sutters et al., 2007; Twycross, 2007). Even with
analgesics, children still continue to report moderate
to severe pain following their operations. Postoperative pain may interrupt childrens sleep patterns and
affect their appetites, which would eventually result
in fatigue. According to Melzack (1990), this can
result in the reduction of available nutrients to
organs. This could also lead to negative effects on respiratory and gastrointestinal function and suppress
immune function (Melzack, 1990). In addition, postoperative pain may slow down the recovery process
(Huth, 2002). Also, children might perceive that the
pain they are experiencing is a sort of punishment,
and thus, any inappropriately and undermanaged
pain may make children wonder what they did
wrong and give them the impression that they have
not been behaving well (Gaffney & Dunne, 1987).
When pain continues to intensify in children, their
anxiety and fear can continue to worsen their experience of pain and this can result in the emotional distress cycle (Huth, 2002, p. 7; Huth, Broome, & Good,
2004). Previous evidence demonstrated that children
who had higher levels of preoperative anxiety experienced a higher level of postoperative pain (Bringuier
et al., 2009; Crandall, Lammers, Senders, & Braun,
2009; Kain et al., 2006; Palermo & Drotar, 1996;
Pederson, 1995). Other studies revealed that children
with higher levels of postoperative anxiety also experienced higher levels of postoperative pain intensity
(Caumo et al., 2000; Ericsson, Wadsby, & Hultcrantz,
2006; Lamontagne et al., 2001).
Childrens demographics, such as age, gender, and
previous surgical experience, play a role in their
anxiety and pain experience. However, previous
studies show inconsistent findings about the relationship between childrens age and their postoperative pain. For example, Palermo and Drotar (1996)
found that younger children had higher postoperative pain intensity ratings than older children.
However, Crandall and colleagues (2009) found conJournal for Specialists in Pediatric Nursing 18 (2013) 243252
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Y. J .S. Chieng et al.

Exploring Inuencing Factors of Postoperative Pain in School-Age Children Undergoing Elective Surgery

tradictory findings, whereas Logan and Rose (2005)

found no correlation between age and pain intensity.
Studies examining the relationship between childrens gender and preoperative anxiety and postoperative pain also reported conflicting findings. Logan
and Rose (2004) reported that girls demonstrated significantly higher levels of preoperative state anxiety
and rated postoperative pain among girls higher than
boys. Other studies (Caumo et al., 2000; Ericsson
et al., 2006) found no significant association between
gender and postoperative anxiety. With regard to the
relationship between childrens past surgical experiences and their preoperative anxiety and postoperative pain, Crandall and colleagues (2009) reported
that children without past surgical experience
reported higher postoperative pain scores than other
children with past surgical experiences. Ericsson and
colleagues (2006) found no significant relationship in
the preoperative anxiety levels between children
with and without past surgical experience.
A review of the literature shows that the majority
of studies in this research area were conducted in
Western countries, with limited studies in Hong Kong
and none in Singapore. Culture plays an important
role in individual pain experiences (Davidhizar &
Giger, 2004); therefore, this study intends to fill the
knowledge gap by obtaining information about preoperative anxiety and postoperative pain among children from Singapore, a multicultural Asian country.
The purpose of this study was to examine the
factors influencing postoperative pain among children undergoing elective surgery. Our research
questions were:
1. What are the preoperative anxiety levels, emotional behaviors, and postoperative pain intensity
levels among children undergoing elective
surgery?
2. What are the differences between/among childrens demographic subgroups and childrens
preoperative anxiety, emotional manifestation,
and postoperative pain?
3. What are the relationships among childrens preoperative anxiety, emotional manifestation, and
postoperative pain?
4. What are the influencing factors for childrens
postoperative pain?

specializing in health care for women and children

was chosen as the study site. The pediatric operating
theaters and three pediatric surgical inpatient units
were selected for data collection from October 2010
to January 2011. This study used convenience sampling to obtain a large number of participants within
a short time. The advantages of using this sampling
method were that it allowed for easy, economical,
and rapid organization of participants (Polit &
Hungler, 2001). Inclusion criteria were children
who were: (a) 614 years old; (b) scheduled for an
elective inpatient surgery requiring at least a 24-hr
stay in the hospital; (c) able to demonstrate their
ability to communicate, write, and read in either
English or Mandarin; (d) able to give assent to participate in the study; (e) accompanied by a parent;
and (f) supported and permitted to participate in the
study by the parent. Exclusion criteria were children
who: (a) had a chronic illness and/or chronic pain or
(b) had a history of cognitive and learning disabilities
and/or mental health problems as identified by the
medical records.
Sample size for this study was determined
through a power analysis for a correlation coefficient
test (Cohen, 1988). We obtained an effect size of .53
using findings from a descriptive study that examined factors influencing childrens postoperative
pain after tonsillectomy (Crandall et al., 2009). With
the effect size of .53, power of 80%, and the 5% level
of significance (two-sided), a minimum sample size
of 20 was required (Cohen, 1988).
Of the 83 children who were approached during
the 4-month data collection period, 68 (82%) provided assent to participate in this study. Written
consent was also obtained from their parents. The
main reasons for refusal to participate in the study
included inconvenience, lack of time, and/or fear
that it would increase childrens preoperative level
of anxiety through participation. Of these 68 children who had given assent and whose parents had
given written consent, one childs surgery was cancelled due to unforeseen circumstances and another
was discharged earlier than expected; therefore,
postoperative pain assessment was not obtained for
them. The final sample size was 66 children.
Instruments

METHODS
Design and sample

This is a cross-sectional, descriptive correlational

study. The largest local public hospital in Singapore
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2013, Wiley Periodicals, Inc.

Preoperative anxiety was measured using the short

form of the State Anxiety Scale for Children (SASC), which is a self-report instrument containing 10
statements where each statement is scored as 1, 2, or
3, with the total score of 10 items being 10 to 30 (Li
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Exploring Inuencing Factors of Postoperative Pain in School-Age Children Undergoing Elective Surgery

& Lopez, 2007). This tool, originally developed by

Spielberger (1983) for children between the ages of
9 and 18 years, has been translated by Li and Lopez
(2007) to suit children from 7 to 12 years of age. The
higher the score, the higher the level of preoperative
anxiety. The validity and reliability of SAS-C (short
form; Li & Lopez, 2007) have been documented in
previous studies for children varying in age from 7 to
12 years. The Cronbachs alpha was .88, indicating
high internal consistency reliability. The concurrent
validity of the scale was supported by significant
positive correlation with heart rate (r = .68) and
arterial blood pressure (r = .46; Li & Lopez, 2007).
Preoperative negative emotional behaviors were
measured by the Childrens Emotional Manifestation
Scale (CEMS), through the observation of childrens
emotional behaviors when faced with distressing
medical procedures (Li & Lopez, 2005a, 2006). Five
behaviors, namely, facial expression, vocalization,
activity, interaction, and level of cooperation, are
observed and scored; each behavior is scored from 1
to 5, with a total score of 5 to 25. The higher the scores,
the more negative the emotional manifestations portrayed. The validity and reliability of CEMS have been
demonstrated by Li and Lopez (2005a) for children
who are between 7 and 12 years old. The Cronbachs
alpha was .92, suggesting excellent internal consistency reliability. The validity of CEMS was supported
by significant positive correlation with the State
Anxiety Scale (r = .76), heart rate (r = .61), and arterial
blood pressure (r = .43). There was good content
validity, with a context validity index of 96%.
The intensity of postoperative pain among children was measured by the Numeric Rating Scale
(NRS; He et al., 2006; Williamson & Hoggart, 2005).
Children were instructed to rate their postoperative
pain on a scale from 0 (no pain at all) to 10 (the highest
postoperative pain intensity score). This tool had been
validated with children older than 6 years, who
understood the concept of rank and order (He et al.,
2006). The concurrent validity was supported by the
relationship between the NRS and visual analog
scale (r = .94; Williamson & Hoggart, 2005).
Childrens demographic and clinical data, including gender, age, ethnicity, previous hospitalization
experience, type of surgery, and time of admission
were obtained from childrens medical records.
Ethical considerations

Ethical approval was obtained from the ethics committee of the participating hospital prior to data collection. All children were recruited on a voluntary
246

Y. J .S. Chieng et al.

basis after obtaining written informed consent

(parents) and assent (children). They were assured
confidentiality of the data collected and told that
their refusal to participate in the study would not
affect the care provided to the child.
Data collection

After obtaining the ethical approval, a meeting with

nurse clinicians and nurse managers of the respective pediatric surgical wards and operating theaters
was arranged to explain the study to them. Permission was sought to gain access to childrens medical
records. Participants were screened according to the
inclusion and exclusion criteria from the daily surgical case listings. They were approached and invited
to participate in the study on arrival in the surgical
inpatient unit on the day of admission, either 1 day
before the surgery or on the day of surgery. Participants were briefed regarding the objectives, risks,
and benefits of participating in the study. A participant information sheet was given to the children
and their parents, and they were given an opportunity to raise any questions. Written informed
consent from their parents and written assent from
children were obtained for those who agreed to participate. Preoperatively in the ward, children were
instructed to complete the SAS-C (short form) questionnaires, with help from their parents when
needed. While a child was undergoing an interview
with the anesthetist at the holding area of the operating theater, the researcher who was responsible
for all data collection silently observed the childs
emotional manifestations using CEMS. In the ward,
childrens pain intensity was recorded using the NRS
24 hr postoperatively.
Data analysis

Data were analyzed using the Statistical Package for

the Social Sciences version 20.0 for Windows (SPSS
Inc., Chicago, IL, USA). Descriptive statistics were
used to summarize the demographics of participants
in this study. Frequency analyses were performed to
analyze each individual question from the SAS-C
(short form) and CEMS. Because the majority of the
data were normally distributed, parametric tests were
used. Pearsons productmoment correlation coefficient was used to examine the relationships among
childrens preoperative anxiety, preoperative negative emotional behaviors, and their postoperative
pain. According to Pallant (2001), the correlation
coefficients of .10.29, .30.49, and .501.0 are typiJournal for Specialists in Pediatric Nursing 18 (2013) 243252
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Exploring Inuencing Factors of Postoperative Pain in School-Age Children Undergoing Elective Surgery

Y. J .S. Chieng et al.

cally interpreted as small, medium, and large coefficients, respectively. The independent samples t-test
and analysis of variance were used to test the differences among preoperative anxiety, CEMS scores, and
postoperative pain among groups. Multiple linear
regression analysis was used to identify the predictors
for postoperative pain from a set of independent variables, including demographic and clinical variables,
preoperative anxiety, and preoperative negative
emotional behaviors. p-values less than .05 were
considered statistically significant. Cronbachs alpha
values were used to determine the internal consistency reliability of the instruments.
FINDINGS
Childrens demographic and clinical information

As shown in Table 1, the study participants ages

ranged from 6 to 14 years (mean [M] = 10.2, standard deviation [SD] = 2.5). Thirty-eight (58%) of the
children were boys. Most were Chinese (n = 40,
61%). About half (n = 36, 55%) had no previous
history of hospitalization. The most common
surgery that the children underwent was otolaryngology surgery (n = 27, 41%). About half of the participants (n = 34, 52%) were admitted 1 day prior to
surgery.
Childrens preoperative anxiety, negative emotional
behaviors, and postoperative pain

In our study, the Cronbachs alpha value of the

SAS-C (short form) and the CEMS were .88 and .68,
Table 1. Demographic Description of Sample (N = 66)
Demographics

Subgroups

Gender

Boy
Girl
Age (years)
68
911
1214
Ethnicity
Chinese
Malay
Indian
Other
Previous hospitalization Yes
No
Type of surgery
Otolaryngologic surgery
Orthopedic surgery
Plastic and reconstructive surgery
Ophthalmologic surgery
Neurosurgery
Other
Time of admission
Day before
Same day

Journal for Specialists in Pediatric Nursing 18 (2013) 243252

2013, Wiley Periodicals, Inc.

respectively. The preoperative anxiety level among

the children varied from 10 to 29 (M = 19.4, SD =
4.9). Childrens preoperative emotional behaviors
measured by observational CEMS scored from 5 to
13 (M = 7.4, SD = 1.8). At the 24-hr postoperative
interval, children were asked to rate their current
pain intensity, which was from 0 to 10 (M = 4.1, SD =
2.6). Table 2 illustrates the details of the SAS-C
scores, CEMS scores, and pain intensity 24 hr postoperatively in different demographic subgroups.
Comparison of childrens SAS-C (short form) scores,
CEMS scores, and postoperative pain intensity
across their subgroups of demographics

As shown in Table 2, there was no significant difference in childrens SAS-C (short form) scores, preoperative CEMS scores, and postoperative pain
intensity comparing demographic groups.
Relationships among preoperative anxiety,
preoperative negative emotional behaviors,
and postoperative pain

Based on the results from the Pearsons product

moment correlation coefficient tests for all measured
variables, there were significant moderate positive relationships between childrens preoperative
anxiety and preoperative negative emotional behaviors (r = .39, p = .001), between childrens preoperative anxiety and their pain 24 hr postoperatively (r =
.32, p = .01), and between childrens preoperative
negative emotional behaviors and their pain 24 hr
postoperatively (r = .40, p < .01).

n (%)
38 (58)
28 (42)
20 (30)
21 (32)
25 (38)
40 (61)
18 (27)
6 (9)
2 (3)
30 (45)
36 (55)
27 (41)
12 (18)
11 (17)
2 (3)
2 (3)
12 (18)
34 (52)
32 (48)

Factors inuencing childrens postoperative pain

Postoperative pain was regressed on demographic

and clinical variables (including gender, age, ethnicity, past hospitalization, type of surgery, and time of
admission), preoperative anxiety, and negative
emotional behavior. Results indicated that all independent variables explained 17% (adjusted R2 =
.170) of variance in postoperative pain (Table 3).
Among all variables, gender, preoperative anxiety,
and preoperative negative emotional behaviors
were significant factors influencing postoperative
pain. Regression coefficients were .28 (p = .03), .26
(p = .03), and .26 (p = .04) for preoperative negative
emotional behaviors (by CEMS), gender, and preoperative anxiety (by SAS-C short form), respectively.
Boys (M = 3.6, SD = 2.6) were more likely to have less
postoperative pain than girls (M = 4.7, SD = 2.5).
247

Exploring Inuencing Factors of Postoperative Pain in School-Age Children Undergoing Elective Surgery

Y. J .S. Chieng et al.

Table 2. Comparison of Childrens SAS-C (Short Form) Scores, CEMS Scores, and Postoperative Pain Intensity Across Their
Subgroups of Demographics (N = 66)
SAS-C
Demographics

Subgroups

M (SD)

Gender

Boy
Girl
68
911
1214
Chinese
Malay
Indian
Other
Singapore citizen
Singapore PR
Other
Primary
Secondary
Yes
No
Otolaryngologic
Orthopedic
Plastic and reconstructive surgery
Ophthalmologic
Neurosurgery
Other surgery
Day before
Same day

38
28
20
21
25
40
18
6
2
58
3
5
54
12
30
36
27
12
11
2
2
12
34
32

19.9 (4.7)
18.7 (5.2)
19.6 (5.2)
20.1 (4.8)
18.6 (5.0)
19.5 (4.7)
19.5 (5.0)
20.2 (6.2)
14.0 (5.7)
19.6 (5.1)
18.0 (1.0)
17.2 (5.0)
19.4 (5.0)
19.4 (5.1)
20.1 (4.7)
18.9 (5.1)
18.9 (4.8)
18.2 (5.0)
21.0 (5.8)
20.0 (2.8)
21.0 (1.4)
20.8 (4.6)
18.9 (5.6)
19.8 (4.1)

Age (years)

Ethnicity

Nationality

Educational level
Previous hospitalization
Type of surgery

Time of admission

CEMS
t/F
(p)
t = .94
(.35)
F = .54
(.58)
F = .84
(.48)

F = .68
(.51)
t = -.03
(1.00)
t = 1.03
(.31)
F = .82
(.54)

t = -.74
(.46)

M (SD)
7.6 (1.9)
7.2 (1.6)
7.9 (2.4)
7.4 (1.5)
7.1 (1.4)
7.4 (1.8)
7.9 (1.9)
7.0 (.9)
5.5 (.7)
7.5 (1.8)
7.0 (1.7)
6.8 (2.2)
7.6 (1.8)
6.9 (1.6)
7.8 (1.5)
7.1 (1.9)
6.8 (1.2)
7.6 (1.8)
7.2 (1.5)
8.0 (1.4)
5.5 (.7)
8.3 (2.2)
7.1 (1.6)
7.8 (1.9)

Pain (24 hr)

t/F
(p)
t = .88
(.39)
F = .92
(.40)
F = 1.43
(.24)

F = .46
(.64)
t = 1.12
(.27)
t = 1.65
(.10)
F = 1.60
(.17)

t = -1.81
(.08)

M (SD)
3.6 (2.6)
4.7 (2.5)
3.8 (3.0)
4.6 (2.3)
3.8 (2.5)
3.7 (2.6)
5.2 (2.6)
3.5 (2.3)
2.5 (.7)
4.1 (2.7)
4.0 (1.0)
3.0 (2.2)
4.2 (2.7)
3.5 (2.3)
4.4 (2.7)
3.8 (2.5)
3.9 (2.8)
4.1 (2.9)
4.7 (2.6)
4.5 (.7)
2.0 (2.8)
3.8 (2.1)
4.2 (2.8)
3.8 (2.5)

t/F
(p)
t = -1.7
(.09)
F = .74
(.48)
F = 1.89
(.14)

F = .43
(.65)
t = .80
(.43)
t = .91
(.36)
F = .43
(.83)

t = .61
(.55)

Note: CEMS, Childrens Emotional Manifestation Scale; M, mean; SAS-C, State Anxiety Scale for Children; SD, standard deviation; Singapore PR,
Singapore permanent resident.

such as tonsillectomies with or without adenoidectomy were the most frequently performed pediatric
surgical procedures in the participating hospital,
which is similar to international studies (Crandall
et al., 2009; Huth et al., 2004; Kain et al., 2006). The
majority of children admitted to the study site for
surgery were 614 years old.
Our study results found that children reported a
moderate level of preoperative anxiety. This result

Other variables including age, ethnicity, previous

hospitalization, type of surgery, and time of admission did not significantly predict postoperative pain
within 24 hr.
DISCUSSION

Most of the participants (41%) underwent otolaryngology surgery. Otolaryngology surgical procedures,

Table 3. Multiple Regression Analysis for the Predictors Associated With Postoperative Pain (N = 66)
95% CI
Predictor variables

Lower bound

Upper bound

Gender
Agea
Ethnicity
Previous hospitalization
Type of surgerya
Time of admission
Preoperative anxietya
Preoperative negative emotional behaviorsa

.26
-.03
-.12
.04
-.05
.16
.26
.28

2.23
-.22
-1.03
.34
-.38
1.33
2.04
2.14

.03*
.82
.30
.73
.70
.19
.04*
.03*

.14
-.28
-1.89
-1.03
-.57
-.42
.003
.03

2.59
.23
.60
1.45
.38
2.08
.27
.80

Note: *p < .05. aVariables were treated as continuous variables. b = standardized beta coefficient, t = t-test statistics, p = significance value, 95% CI =
95% confidence interval for b; Gender: 1 = Girls, 0 = Boys; Ethnicity: 1 = Chinese, 0 = other ethnicity; Previous hospitalization: 1 = Yes, 0 = No; Time
of admission: 1 = day before admission, 0 = same-day admission.

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Y. J .S. Chieng et al.

Exploring Inuencing Factors of Postoperative Pain in School-Age Children Undergoing Elective Surgery

was consistent with previous findings (Li & Lam,

2003; Pederson, 1995), which indicated the need to
assess and manage childrens preoperative anxiety.
However, children in our study exhibited greater
cooperation and less negative emotional behavior
preoperatively, with a mean CEMS score of 7.4 (SD =
1.8) as compared with those in Li and colleagues
(2007b) study , where childrens mean CEMS scores
for the therapeutic play intervention group and
control group were 10.46 and 13.63, respectively.
The most possible reason for the difference was that,
in our study, childrens negative emotional behaviors
were assessed at the holding area before the children
entered the operating theater due to the constraints
set by the participating hospital, whereas in Li and
colleagues study, the CEMS was used in the operating theater when the children were undergoing anesthesia induction. The unfamiliar environment and
medical equipment in the operating theater in Li
and colleagues study might have affected childrens
expression of negative emotional behaviors. Children reported a moderate mean pain intensity score of
4.1 in the 24-hr postoperative period, a finding that is
similar to previous studies (Crandall et al., 2009; Sng
et al., 2013; Twycross, 2007). This finding implies
that childrens postoperative pain remains a challenge for health professionals.
A moderate positive relationship was found
between preoperative anxiety and preoperative
negative emotional behaviors (Li et al., 2007a).
Strategies such as therapeutic play intervention (Li
et al., 2007a) could be used to reduce childrens preoperative anxiety, which would subsequently lead
them to exhibit less negative emotional manifestations right before their operations (Vagnoli, Caprilli,
Robiglio, & Messeri, 2005) and ensure greater
cooperation during anesthesia induction.
Our findings also showed moderate positive relationships between childrens preoperative anxiety
and postoperative pain as well as childrens negative
emotional behaviors and postoperative pain. That is,
children who had a higher level of preoperative
anxiety and exhibited more negative emotional
behaviors experienced a higher postoperative pain
intensity 24 hr postoperatively, which supports the
findings by other researchers (Bringuier et al., 2009;
Crandall et al., 2009; Kain et al., 2006; Palermo &
Drotar, 1996). This phenomenon may be explained
by the physiological mechanism of pain and anxiety
(Walding, 1991). According to Walding (1991),
when human beings face stressors, the fight or flight
response is activated, which affects the bodys
mental system, making one more alert to his/her
Journal for Specialists in Pediatric Nursing 18 (2013) 243252
2013, Wiley Periodicals, Inc.

surroundings and constantly shifting attention and

focus on the immediate surroundings. Therefore, a
reduction in childrens preoperative anxiety before
surgery may be beneficial for their postoperative
pain relief.
While previous studies have demonstrated that
children with a history of hospitalization tended to
have lower preoperative anxiety levels and pain due
to the conditioned learning model (Crandall et al.,
2009; Huth, 2002), our findings showed otherwise.
Children with a history of previous hospitalization
reported higher anxiety and pain intensity than
those without this experience. This could be due to
the suboptimal quality of their previous medical
experiences, which shaped their perception of hospitalization and surgery. However, this difference
had no statistical significance. This may have been
due to factors such as postoperative analgesics that
we were not able to capture. This finding warrants
further investigation.
The multiple regression results showed that
gender, preoperative anxiety, and preoperative
negative emotional behaviors were significant
factors influencing childrens pain intensity 24 hr
postoperatively. Boys in our study reported lower
postoperative pain intensity 24 hr postoperatively
than girls. One possible explanation is that girls
tended to use a technique called emotional support
seeking when dealing with pain more frequently
than boys and, therefore, girls generally reported
more pain (Logan & Rose, 2004). The results also
implied that childrens preoperative anxiety needs
to be better managed in order to reduce their negative emotional behaviors and postoperative pain.
Limitations of the study

Postoperative pain medications were not recorded

and therefore not included in the data analysis. The
type, scheduling, and dose of analgesics might have
influenced the postoperative pain intensity. The
CEMS was developed to assess childrens negative
emotional behaviors when undergoing invasive
procedures. Due to the restrictions of the hospital
protocol, the researchers were not allowed to enter
the operating theater; therefore, childrens emotional behaviors were assessed in the waiting room
while children were waiting for their turn to enter
the operating theater instead of during anesthesia
induction. This arrangement might have influenced
the outcomes of the study. Moreover, the CEMS
developed by Li and Lopez (2005a) was validated for
children 7 to 12 years old; however, in our study, we
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Exploring Inuencing Factors of Postoperative Pain in School-Age Children Undergoing Elective Surgery

included children 6 to 14 years old, which might

have affected the result. In addition, childrens
characteristics can influence their anxiety level
(Spielberger, 1983), but this study did not measure
trait anxiety.

How might this information affect

nursing practice?

This study helps to fill in the knowledge gap by

demonstrating the positive relationships among
childrens preoperative anxiety, preoperative
negative emotional behaviors, and postoperative
pain in the Singapore context. This understanding
is crucial to the management of childrens pain
over the course of recovery from surgery. This
study will hopefully enable healthcare professionals to better understand the effect of preoperative
anxiety on childrens postoperative pain and help
nurses to plan and implement interventions so as
to reduce anxiety and pain for children during the
perioperative period.
Several implications for practice are generated
from our findings. The present evidence supports
that children with higher preoperative anxiety
exhibited more negative emotional behaviors and
experienced higher pain intensity, which are consistent with previous findings reported by studies
conducted in Western countries and Hong Kong;
this may indicate that those children have similar
concerns despite their culture. These results highlight the need to reduce childrens anxiety before
the surgery so as to increase their cooperation
during analgesia induction and optimize postoperative pain relief. As such, we recommend that
childrens preoperative level of anxiety be routinely assessed in clinical settings prior to their elective surgical procedures. Due to the good internal
consistency of the SAS-C (short form), which is
easy to use and takes only a few minutes to complete, the SAS-C (short form) can be considered an
option. Should high anxiety be detected from children, healthcare providers could intervene in a
timely manner using appropriate strategies, such as
therapeutic play (Li et al., 2007a). A clinical
evidence-based guideline regarding childrens pain
management, including contents such as the relationship between anxiety and pain, could also be
developed. This may make the postoperative
period less troublesome and the hospitalization
experience a more satisfying one for children.

250

Y. J .S. Chieng et al.

Several recommendations for future research

are derived from our findings. Because analgesics
affect childrens pain intensity, future research
should take the postoperative pain medication
intoconsideration so as to provide a more accurate
reflection of the pain scores. This study only
measured the preoperative anxiety level among
children. Future studies could assess postoperative
anxiety level and its relationship with postoperative pain. Moreover, future studies are needed to
develop and examine different interventions, such
as therapeutic intervention, for reducing childrens
perioperative anxiety and postoperative pain when
undergoing elective surgery.

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