Research for Evidence Based Practice

Journal of Pediatric Nursing 55 (2020) 141–146

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Journal of Pediatric Nursing

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The Predictors of Postoperative Pain Among Children Based on the Theory of Unpleasant Symptoms: A Descriptive-Correlational Study

Sara Gholami, MSc a, Leila Khanali Mojen, PhDb,⁎, Maryam Rassouli, PhD c, Bagher Pahlavanzade, PhDd, Azam Shirinabadi Farahani, PhD c

a Student Research Committee, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Iran b Department of Medical Surgical Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Iran c Department of Pediatric Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Iran d Departments of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Iran

⁎ Corresponding author. E-mail address: [email protected] (L.K. Mojen).

https://doi.org/10.1016/j.pedn.2020.08.006 0882-5963/© 2020 Published by Elsevier Inc.

a b s t r a c t

a r t i c l e i n f o

Article history: Received 9 February 2020 Revised 6 August 2020 Accepted 7 August 2020

Keywords: Pain Postoperative pain Predictor Children Theory of unpleasant symptoms

Purpose: Postoperative pain (POP) is a common outcome of surgical interventions among children. Identifying POP contributing factors can help identify children who are at risk for POP and facilitate POP management. The aim of the study was to determine the predictors of POP based on the Theory of Unpleasant Symptoms. Design and methods: This descriptive-correlational study was conducted in 2018–2019 on 153 children purpo- sively recruited. Data were collected using a personal characteristics questionnaire, the Coping Strategies Ques- tionnaire, the Child Pain Anxiety Symptoms Scale, and a Visual Analogue Scale for Pain. The SPSS software (v. 21.0) was used for data analysis. Results: Twelve participants were excluded and final data analysis was done on the data obtained from 141 par- ticipants. Most of participants were male (65.2%), underwent abdominal surgery (53.2%), and experienced POP (86.5%). Their age mean was 8.58±2.23. Linear regression analysis revealed that the physiological factors of heart rate, preoperative pain, and surgery duration as well as the psychological factors of anxiety and coping strategies were significant predictors of POP among children. All these factors collectively explained 34% of the total variance of POP. Situational factors (such as age, gender, and ethnicity) had no significant effects on POP. Conclusions: Heart rate, preoperative pain, surgery duration, anxiety and coping as predictive factors of POP can be considered when designing effective POP management strategies. Practice implications: The findings provide a better understanding about the predictors of POP and can be used to develop pain management among children.

© 2020 Published by Elsevier Inc.

Introduction

Postoperative pain (POP) is a common problem among children and has turned into a major healthcare challenge (Rabbitts et al., 2017; Rabbitts, Cornelius, Gabrielle, & Tonya, 2015). Currently, surgeries are one of the most important causes of pain in pediatric hospitals (April & Wyatt, 2014; Habich et al., 2012; Stevens et al., 2014). Each year, five million children in the United States undergo surgery, 40–60% of whom complain of moderate to severe POP (Braz, 2012; Harrison, 2014; Michelle, 2009; Ocay, Li, Ingelmo, Ouellet, & Pag'e, & Ferland, 2020; Walker, 2015). Different studies reported that 40%–93% of chil- dren who undergo surgery experience POP (Berghmans et al., 2018; Braz, 2012; Harrison, 2014; Huth & Broome, 2007; Shomaker, Dutton, & Mark, 2015; Walker, 2015). POP is also among the most prevalent

postoperative outcomes in Iran (Cheraghi, Almasi, Roshanaei, Behnoud, & Hasan, 2014).

POP is associated with different adverse outcomes for both children and their families (Cheraghi et al., 2014; Dehnavian, 2014; Gimbler, 2008). For instance, it may cause infection, delay recovery, prolong hos- pital stay, increase the risk of rehospitalization, and thereby, increase healthcare costs and lead to patient dissatisfaction (Campbell, 2014; Kanyali, 2017). Moreover, it is associated with sleep problems, anxiety, and ineffective coping among children, low quality of life among chil- dren and family members (Campbell, 2014; Cheraghi et al., 2014; Dehnavian, 2014), and psychological strain, anger, fear, stress, and anx- iety among family members (Cheraghi et al., 2014). Some studies re- ported that acute POP lasts for weeks after hospital discharge and may turn into refractory chronic pain (Michelle, Fortiera, & Zeev, 2015; Walker, 2015). Chronic pain in turn can affect children's growth and de- velopment and result in behavioral disturbances (Christine, 2013; Lovich-Sapola, Smith, & Brandt, 2015).

S. Gholami, L.K. Mojen, M. Rassouli et al. Journal of Pediatric Nursing 55 (2020) 141–146

According to the Theory of Unpleasant Symptoms (TUS), many dif- ferent factors can affect POP (Gimbler, 2008). TUS, developed by Lenz et al., has widely been used to describe unpleasant symptoms and their relationships (Kless, 2010; Kontkanen & Kariniemi, 2008; Yeon & Youn, 2014). The three main components of this theory are symptoms, their contributing factors, and their consequences (Gomes et al., 2019; Lee, Vincent, & Finnegan, 2017). This theory holds that factors contribut- ing to unpleasant symptoms include physiological, situational, and psy- chological factors. Physiological factors are symptoms which can help establish diagnosis and are related to the experience of the intended symptoms (Eckhardt, DeVon, Piano, Ryan, & Zerwic, 2014; Gomes et al., 2019). Situational factors include the social aspects and the phys- ical environment that can affect the experience and reporting of symp- toms, while psychological factors include mental state, affective reaction to the illness, and knowledge about symptoms and theirmean- ing (Gomes et al., 2019; hauglum Sh., 2015; Kinjo, Sands, Lim, Paul, & Leung, 2012). TUS can be used to determine the contributing factors of symptoms and develop effective interventions for their prevention and management (Amy & Samina, 2011; Júniora, Bomfi, Nascimentoc, Silvac, & Aparecida, 2015; Kanyali, 2017; Lee et al., 2017; Lenz, 1997).

Some studies used TUS to determine the predictors of symptoms (Gomes et al., 2019; Huth & Broome, 2007) and reported that POP can be predicted before surgery based on its potential contributing factors (Campbell, 2014; hauglum Sh., 2015). For instance, a TUS-based de- scriptive study reported that the physiological factors of preoperative pain and heart rate had significant direct correlations with first-day POP and the situational factors of age, gender, and race had significant correlations with POP severity; however, psychological factors such as anxiety and depression had no significant correlations with POP (hauglum Sh., 2015). Another TUS-based study found that the physio- logical factor of surgery type and the psychological factor of child's anx- iety had significant effects on POP, while situational factors had no significant effects on it (Huth & Broome, 2007). Similarly, a study into the effects of situational factors (including age and gender) and physio- logical factors (including preoperative pain, surgery type, surgery dura- tion, and length of surgical incision) showed age as the only factor affecting POP (Kless, 2010).

Despite the wealth of studies into the factors affecting POP among adults, there are limited data about the factors affecting POP among chil- dren.Moreover, there are limited studies into the contributing factors of POP among Iranian children (Mohebi & Azimzadeh, 2014). Therefore, the present study was conducted to address these gaps. The aim of the study was to determine the predictors of POP based on TUS.

Methods

Design

This descriptive-correlational study was conducted from February 2018 to February 2019.

Setting

Study setting was pediatric hospital, Tehran, Iran. Pediatric hospital is a subspecialty referral pediatric care center with different wards and units. The present study was conducted in two surgical care units of the hospital with 61 beds.

Sample

Participants were 153 children who were purposively recruited based on the following criteria: age of 6–12 years, ability to speak Per- sian, hospitalization in surgical care wards, and no affliction by serious physical and mental health problems (based on participants' medical records and their parents' report). The surgeon and the pain manage- ment protocol for all participants were the same. Sample size was

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calculated based on the results of a previous study, using the Chi- square statistic, and with a moderate effect size of 0.3. Twelve partici- pants withdrew from the study.

Procedures

Study variables POP is a multidimensional phenomenon affected by many different

factors. Therefore, it was variable of the study and its contributing fac- tors were studied. These factors were determined based on TUS and were assessed in three main dimensions, namely physiological, situa- tional, and psychological factors. Physiological factors were history of preoperative pain, type of surgery, duration of surgery, baseline heart rate, and baseline blood pressure (hauglum Sh., 2015; Vidya et al., 2014). Psychological factors were anxiety and coping strategies (Mandac & Battsta, 2014; Page et al., 2011) and situational factors were age, gender and ethnicity (Kless, 2010; Welkon, 2009).

Instruments

Four instruments were used for data collection.

Demographic questionnaire The first instrument was a personal characteristics questionnaire

with items on parents' age, gender, occupation, monthly income, and educational level and child's age, gender, heart rate, blood pressure, his- tory of surgery, preoperative pain, preoperative pain severity, surgery type, and surgery duration. The questionnaire was designed by the study team.

Coping strategies questionnaire The second instrument was the Coping Strategies Questionnaire

with fifty items for the self-assessment of cognitive and behavioral coping strategies. This questionnaire includes the two main domains of cognitive and behavioral strategies. The cognitive strategies domain consists of six subscales, namely ignoring pain sensations, reinterpreting pain sensations, diverting attention, coping self- statements, catastrophizing, and praying or hoping. The behavioral strategies domain also consists of two subscales, namely increasing ac- tivity level and increasing pain behavior. The questionnaire also in- cludes two items on pain control effectiveness and ability to decrease pain. The items of this questionnaire are scored on a seven-point Likert scale from zero (“Never done”) to 6 (“Always done”), resulting in a pos- sible total score of 0–300 with higher scores showing more effective coping. (Abbott, 2010; Gil, Williams, Thompson, & Kinney, 1991; Schanberg, Keefe, Lefebvre, Kredich, & Gil, 1996).

Child pain anxiety symptoms scale The third instrument of the study was the Child Pain Anxiety Symp-

toms Scale for children aged 6–18 years. This scale has twenty items scored on a six-point Likert scale from zero (“Never”) to 5 (Always”), resulting in a total score of 0–100with higher scores standing for higher anxiety (Page et al., 2010; Page et al., 2011).

Visual analogue scale for pain The fourth study instrument was a Visual Analogue Scale (VAS) for

Pain which was a ten-centimeter ruler numbered from zero (“No pain”) to ten (Severest Pain) (Baeyer, 2006; Bailey, Gravel, & Daoust, 2012).

Initially, instruments were translated into Persian. Accordingly, nec- essary permissions were obtained from the developers of the instru- ments and then, two English-Persian translators independently translated the instruments into Persian. Their translations were com- pared and combined to generate a single version of each instrument. For qualitative content validity assessment, several pediatric nurses commented on the relevance and the simplicity of the instrument

S. Gholami, L.K. Mojen, M. Rassouli et al. Journal of Pediatric Nursing 55 (2020) 141–146

items. All of them confirmed the content validity of the instruments. For face validity assessment, ten children and their parents commented on the simplicity and understandability of the items. All of them reported that the items were simple and understandable and hence, none of the items were changed. Reliability of the items was assessed using the internal consistency and the test-retest stability assessment methods. The Cronbach's alpha and the test-retest intraclass correlation coefficient of the Coping Strategies Questionnaire were 0.95 and 0.92, while the Cronbach's alpha and the test-retest intraclass correlation co- efficient of the Child Pain Anxiety Symptoms Scale were 0.91 and 0.90, respectively. The reliability of the Visual Analogue Scale for Pain was assessed through the inter-rater reliability method, in which two raters simultaneously assessed POP severity among fifteen children. The inter- rater intraclass correlation coefficient was 0.95.

Data collection

Before surgery, participants and their parents were asked to com- plete the study instruments during twenty minutes. Children who could not read and write completed the study instruments with the help of their parents. Moreover, children's hemodynamic parameters were measured and documented. POP was also assessed one, three, and six hours after surgery. To do this, children determined the severity of their pain using VAS. Understandable explanations were provided based on the child's age and cognitive development.

Statistical analysis plan

Data were analyzed using the SPSS 21.0 software. Data description was done using mean, standard deviation, and frequency measures. To determinePOP predictors, correlation analysiswas done and then, inde- pendent variables with significant correlations with POP at a signifi- cance level of less than 0.05 were entered into the linear regression analysis model. As the most severe pain was at the second time-point (i.e. three hours after surgery) and there was no significant difference among the three pain assessment time-points respecting pain severity, the readings of the second time-point were used for data analysis.

Ethic

This studywas approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Participants and their par- ents were provided with information about the study aim and the con- fidential management of their data and then, their informed consents were obtained.

Findings

In total, 153 children and their parents were recruited to complete the study instruments. Seven participants were excluded due to incom- plete answering to the study instruments and five participants were ex- cluded due to their voluntary withdrawal from the study. Final data analysis was done on the data obtained from 141 participants.

Participants were 92 males (65.2%) and 49 females (34.8%) with an age mean of 8.58 ± 2.23. Most of them were from Fars ethnicity (51.8%), had previous history of surgery (54.6%), reported preoperative pain (52.1%), and underwent abdominal surgeries (53.2%), and one third of them had the history of chronic pain in the past month (33.5%). Surgery duration was 134.29 min, on average.

Three hours after surgery, themean of POP severitywas 5.10± 3.20. Around 86.5% of participants experienced POP, from whom 41.13% had severe pain, 24.82% had moderate pain, and 20.56% had mild pain.

Correlation analysis revealed that none of the situational factors had significant correlation with POP (P> .05). Among physiological factors, POP had significant positive correlations with heart rate, previous pain experience, and surgery duration (P < .05). Moreover, among

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psychological factors, POP had significant positive correlation with anx- iety and significant negative correlationwith coping strategies (P< .05).

Linear regression analysis using the Stepwise method was done to determine the predictors of POP. Variables with significant correlation with POP in correlation analysis were entered into the regression model. Initially, the preoperative pain anxiety variable was entered and results showed that it significantly explained 12% of the total vari- ance of POP (P < .001). Then, the heart rate variable was entered into the model and results showed that preoperative pain anxiety and heart rate significantly predicted 23% of the POP variance (P< .001). Af- terwards, the surgery duration variablewas entered and results showed that preoperative pain anxiety, heart rate, and surgery duration ex- plained 28% of the POP total variance (P < .001). Thereafter, the preop- erative pain variable was entered and results showed that preoperative pain anxiety, heart rate, surgery duration, and preoperative pain ex- plained 32% of the POP variance (P< .001). Finally, the coping strategies variablewas entered and results showed that thefinal five-factormodel (consisted of preoperative pain anxiety, heart rate, surgery duration, preoperative pain, and coping strategies) significantly explained 34% of the POP total variance (P < .001; Table 2). (See Table 1.)

Discussion

This study aimed to determine the predictors of POP based on TUS. Findings showed that most participants experienced moderate to se- vere POP. Moreover, the physiological factors of heart rate, preoperative pain, and surgery duration aswell as the psychological factors of anxiety and coping strategies were significant predictors of POP among children.

Study findings indicated the high prevalence of moderate to severe POP among participants. Previous studies also reported pain as one of the most common postoperative complications (Beltramini, Milojevic, & Pateron, 2017; Rabbitts et al., 2015; Stevens et al., 2014) with a prev- alence rate of 40%–93% (Berghmans et al., 2018; Braz, 2012; Ocay et al., 2020; Shomaker et al., 2015; Walker, 2015). The most important cause of POP is tissue physiological responses to surgery-related damage and edema. Damaged tissue cells release chemicals which affect nociceptors and cause pain (Felipe, Ribeiro, Waldiceu, Verri, & Isaac, 2017). Con- trarily to our findings, a former study on 154 children who had underwent surgery in eight different hospitals reported that only 8% of them experienced POP (Stevens et al., 2014). This contradiction can be attributed to ineffective POP management in our study setting prob- ably due to healthcare providers' lack of knowledge and skills for POP management (Lak et al., 2014). It is noteworthy that knowledge and skills are the bases for quality care delivery (Dehnavian, 2014; Sadeghi et al., 2017).

Our findings also showed preoperative heart rate as a predictor of POP. Increased heart rate due to sympathetic stimulationmay be caused by different factors such as fear and anxiety. Several studies reported anxiety induced by hospitalization, separation, and unfamiliar environ- ment of the operating room as a predictor of increased preoperative heart rate (Das & Kumar, 2017; hauglum Sh., 2015; Kinjo et al., 2012; Mohebi & Azimzadeh, 2014; Rabbitts, Aaron, et al., 2017). Moreover, sympathetic stimulation results in the release of catecholamines which can lead to POP through increasing the levels of stress hormones and inflammatory markers and stimulating nociceptors (Karami, Gohari, Ebrahimzadeh, Danaei, & karimloo S., 2016). Studies on adults also reported that preoperative heart rate and pain had significant direct relationships with POP (hauglum Sh., 2015; Ip, Abrishami, Wong, & Chung, 2009; Kinjo et al., 2012).

Preoperative pain was another physiological predictor of POP in the present study. Several former studies also reported positive relationship between preoperative pain and POP (Connelly, Fulmer, Prohaska, Anson, & Dryer, 2014; Ip et al., 2009; Ocay et al., 2020; Rabbitts, Fisher, Rosenbloom, & Palermo, 2017; Tsirline, Belyansky, Zemlyak, Amy, & Heniford, 2013; Verghese & Hannallah, 2010). Similarly, studies

Table 1 Participants' demographic characteristics.

Characteristics N (%) or Mean ± SD

Child's age 8.58 ± 2.233 Child's gender

Female Male

49 (34.8) 92 (65.2)

Ethnicity Fars Kurdish Turkish Other

73 (51.8) 23 (16.3) 31 (22) 14 (9.9)

Surgery type Abdominal Genitourinary Other

75 (53.2) 42 (29.8) 24 (17)

Positive previous history of surgery 77 (54.6) Positive history of chronic pain in the past month 33 (33.5) Preoperative pain severity

Mild Moderate Severe

57 (59.6) 31 (22) 26 (18.4)

Time passed from the last surgery (Months) 12.29 ± 20.77 Surgery duration (Minutes) 134.29 ± 68.58 Baseline heart rate (Beats per minute) 100.26 ± 16.118 Baseline blood pressure (mm Hg) 99.50 ± 8.507 Pain anxiety 53.66 ± 21.284 Coping strategies 138.35 ± 46.300

S. Gholami, L.K. Mojen, M. Rassouli et al. Journal of Pediatric Nursing 55 (2020) 141–146

on adults revealed preoperative pain as a significant predictor of POP (hauglum Sh., 2015; Ip et al., 2009). Previous pain experience is a signif- icant factor for pain perception in new conditions and may even in- crease pain perception (Janssen et al., 2008). Preoperative pain may make children irritable and more responsive to stimuli and thereby, cause them to more closely focus on painful stimuli, have greater fear over experiencing pain, and thereby, experience pain even in case of

Table 2 The results of the linear regression analysis to determine POP predictors.a

Model Unstandardized Coefficients

Stand Coeffi

B Std. Error

Beta

1 (Constant) 8.535 0.294 Pain anxiety 0.010 0.002 0.360

2 (Constant) 4.193 1.014 Pain anxiety 0.010 0.002 0.336 Heart rate 0.043 0.010 0.331

3 (Constant) 3.489 1.014 Pain anxiety 0.009 0.002 0.311 Heart rate 0.040 0.009 0.311 Surgery duration

0.006 0.002 0.218

4 (Constant) 3.085 1.004 Pain anxiety 0.011 0.002 0.376 Heart rate 0.041 0.009 0.317 Surgery duration

0.005 0.002 0.200

Preoperative pain

0.202 0.076 0.199

5 (Constant) 7.325 2.265 Pain anxiety 0.011 0.002 0.393 Heart rate 0.040 0.009 0.311 Surgery duration

0.005 0.002 0.194

Preoperative pain

0.197 0.075 0.194

Coping strategies

−0.047 0.023 −0.1

a . Dependent variable: POP three hours after surgery

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non-painful stimuli. Therefore, previous pain history may be associated with higher levels of POP (Ferland et al., 2016).

Surgery durationwas the other physiological predictor of POP in the present study. A former study also reported surgery duration as a POP predictor. Like our study, the most common type of surgery in that study was abdominal surgery (Avian, Messerer, & Wunsch, 2016). Sur- gery duration largely depends on surgery type and extensiveness. More extensive surgeries, such as orthopedic and abdominal surgeries (Ip et al., 2009), last for longer periods of time, are usually associated with larger tissue damage, and hence, cause higher levels of POP. In contra- dictionwith ourfindings, a former study showed no significant relation- ship between surgery duration and POP (Kless, 2010). This contradiction may be related to the differences in the operating room management systems in different settings (Kless, 2010) as well as the difference between the studies in terms of surgery type and surgery du- ration measurement protocols.

Related to psychological factors, our findings indicated that preoper- ative pain anxiety was a significant predictor of POP. In line with this finding, several earlier studies reported preoperative anxiety as a signif- icant factor contributing to acute POP (Bandeira, Gomes, Bezerra, & Duarte, 2017; Connor et al., 2019; Dehghan, Jalali, & Bashiri, 2019; He et al., 2015; Michelle et al., 2015; Mimic et al., 2018; Prisca, Seetharaman, & Deryk, 2016; Rabbitts et al., 2015; Williamsa, Howarda, & Liossi, 2017) and chronic POP (Connelly et al., 2014; Gabrielle, Jennifer, Fiona, Lisa, & Joel, 2012; Rabbitts, Fisher, et al., 2017). Around 60%–65% of children experience preoperative anxiety due to many factors such as their parents' anxiety, preoperative pain, unfamiliar hospital environment, uncertainty over surgery outcomes, separation from parents, fear over the unknown, and previous unpleas- ant experiences of hospitalization (Connelly et al., 2014). Preoperative pain anxiety lowers pain threshold (Ip et al., 2009) and thereby, in- creases pain sensitivity and POP severity (Das & Kumar, 2017; Dehghan et al., 2019; He et al., 2015; Rosenberg et al., 2017). Studies on adult patients based on TUS also reported anxiety as a psychological

ardized cients

t Sig. F R2

29.052 0.000 4.544 0.000 20.645 0.12 4.136 0.000 21.619 0.23 4.513 0.000 4.450 0.000 3.442 0.001 18.215 0.28 4.271 0.000 4.271 0.000 2.987 0.003

3.073 0.003 16.025 0.32 4.989 0.000 4.455 0.000 2.787 0.006

2.654 0.009

3.233 0.002 14.001 0.34 5.242 0.000 4.422 0.000 2.733 0.007

2.617 0.010

47 −2.082 0.039

S. Gholami, L.K. Mojen, M. Rassouli et al. Journal of Pediatric Nursing 55 (2020) 141–146

predictor of POP (hauglum Sh., 2015; Ip et al., 2009). Contrary to our findings, some studies reported no significant relationship between anxiety and POP among children and attributed it to factors such as small sample size and inappropriate time for POP measurement (Ferland et al., 2016).

Finally, study findings showed coping strategies as the other psycho- logical predictor of POP among children. Similarly, several earlier stud- ies reported coping as a significant factor which directly and indirectly affects pain perception among children (Welkon, 2009). A study showed coping as a ineffective predictor of POP so that children with higher levels of coping had lower levels of pain (Connelly et al., 2014; Gil et al., 1991). Other studies on children also reported that pain had significant relationship with coping (Schmitz, Vierhaus, & Lohaus, 2013). Improving children coping skills through counseling or educa- tional services can reduce their preoperative pain and POP (Ocay et al., 2020; Tomaszeka, Cepuchb, & Fenikowskia, 2019). .

Practice implications

Although POP is a common problem among children, POP manage- ment is still a major care-related challenge in Iran and most healthcare providers have limited knowledge about it. The findings of the present study provide a better understanding about the predictors of POP among children and can be used by nurses and other healthcare pro- viders for determining children at risk for POP and taking appropriate measures for its management. Effective POP management among chil- dren produces positive outcomes for children, families, and healthcare systems.

Conclusion

This study concludes that heart rate, preoperative pain, surgery du- ration, anxiety and coping as predictive factors of POP can be considered when designing effective POP management strategies. These findings can be used to develop pain management interventions to manage POP among children and thereby improve their satisfaction. Moreover, study findings can be used to improve healthcare providers' POP- related knowledge.

Strengths and weaknesses

Although, this hospital is a referral center for children all over the country, but there is a geographical, social and ethnic diversity in Iran. So, study sample might have not been representative of all children in Iran and in theworld. Hence, findingsmay have limited generalizability. Further studies on larger samples of children are recommended. Using the Coping Strategies Questionnaire was another limitation of this study. It was used in different populations (adult, children). It is recom- mended to conduct studies with specific children coping tools.

Acknowledgment

This article came from a Master's thesis in pediatric nursing ap- proved by the Institutional Review Board of Shahid Beheshti University ofMedical Sciences, Tehran, Iran.Wewould like to thank all peoplewho helped us conduct this study, particularly the managers and the staff of Mofid pediatric hospital as well as children and parents who partici- pated in the study.

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