Running head: RESEARCH ARTICLE CRITIQUE 1

Research Article Critique

Ashley King

University of Saint Mary

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Introduction

Title

In the article, “Use of Specific Methods for Assessment of Pain in Children with Severe

Multiple Disabilities”, the title lays out the research aspects of the study by giving the population

of interest, which is pain in children with multiple disabilities, and also what is being studied

which is the assessment of that populations pain. This title sets up a broad expectation of the

study but leaves a question mark when it comes to the actual tools being used to assess pain. The

authors of this article are Jana Chromá and Lucie Sikorova. There are no credentials after either

of the authors names but below it is stated that they are associated with department of nursing in

midwifery and faculty of medicine. The credentials are not specific enough to know each authors

level of education or role in the healthcare field which leaves the reader unclear if the research is

reliable. Overall, even though the specific role of each author is unclear the role in nursing

midwifery and faculty of medicine makes these authors qualified to research this subject.

Abstract

The abstract includes an aim, design of the study, the methodology used, the results of the

study, and conclusion. The aim introduces the reader to the purpose of the study that draws them

to keep reading by getting to the point of the study in a simple one sentence statement. The

results section of the abstract is on the lengthy side and could be condensed to keep the reader’s

attention. The authors completed this concise and to the point abstract in 229 words. This word

count is in between 100 to 250 words which is recommended by Grove, Gray, & Burns (p.51).

This abstract grabs the reader’s attention and keeps it right up to the conclusion. It is a proper

summary of the study and gives the reader enough information to draw them in but not too much

that would confuse them.

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Problem

The problem statement is stated in the last sentence of the introduction on page 246, “In

the Czech Republic, no specific method for pain assessment in children with severe disabilities

has been developed yet.” This statement clearly introduces the problem of the study with

indication of the need of research by stating no pain assessment has been developed yet in the

Czech Republic. The population of children with severe disabilities narrows the scope, but not to

the point of one certain disability, which would limit the study drastically. Categorization of the

certain disabilities are later explained in the article. The problem is significant because the

research could potentially result in improved assessment of pain in disabled children, which

positively impacts their level of care and comfort which is most nurses main goal.

Purpose

The purpose is stated under the aim section on page 246, “The study aimed at comparing

the intensity of pain in children with severe multiple disabilities assessed with three specific

scales and analyzing selected pain scoring systems that may be used in children with severe

multiple disabilities, namely the Paediatric Pain Profile, the revised Face, Legs, Activity, Cry,

Consolability scale and the Non-Communicating Children’s Pain Checklist – Revised.” The

purpose correlates with the problem statement in this article, because the aim of the study is

researching which pain scale will better assess pain in children with disabilities. This purpose is

very feasible with parents’ consent for their child’s pain to be assessed with these different scales

while in the hospital. These scales do not cost the hospital any extra money, but can require some

continuing education course for their staff to understand the scoring system of each different

scale, and how to use them correctly when assessing these children’s pain.
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Literature Review

The study as a whole referenced forty-seven articles with publication dates ranging from

1994-2013. Eleven of the articles were published within five years of the article’s publication

date which was in 2014. The literature review referenced thirteen articles with publication dates

ranging from 1997-2011. Only five of the articles published in the literature review, were

published within five years of the article’s publication. Also, fifteen of the forty-seven sources

were in Czech or Slovakia. With these numbers it is safe to say this topic needs more recent

research conducted, and all of it needs to be conducted in the same language so the research is

easier to assess. Without the ability to read Czech or Slovakia, determining primary and

secondary sources was condensed to the 32 references in English. Of those 32 references, 26

were primary and six were secondary.

All of the references in English include key words such as pain, children, and

disabilities. These key words give reason to believe they are very representative of this study.

These articles examined all types of disabilities from cognitive, physical, and developmental

delays. With 81% of the resources being primary, this means most of the research was conducted

and interpreted by the researcher, which is beneficial compared to the 19% of secondary sources

that is an interpretation of another person’s research that could be falsified to fit that certain

study. Primary sources reduce false results and bias. There are positive sides to these references

but also some negatives which include the language barrier and the publication dates mostly

being in the early 2000’s.

Theoretical Framework

The authors of this article did not utilize a theoretical framework. I believe the article

would of benefited from having one present to serve as a basis to refer back to in this study and a
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generalized theme. Theoretical framework helps to describe, explain and predict in research. The

framework I believe would be appropriate for this research topic would be the “Comfort Theory”

that was developed in the 1990s by Katharine Kolcaba. The comfort theory in nursing is

described as the process of assessing the patient’s comfort needs, developing and implementing

appropriate nursing interventions, and evaluating patient comfort following nursing interventions

(“Current Nursing” 2013). That theory as a whole explains the main goal of nursing, which is to

make your patient as comfortable as possible by trial and error of interventions. This research

study goal is also to bring comfort to children that are in pain but cannot express it in the same

way as other children.

Evaluation of the Research Methods

Research Design Elements

This research article is a correlational research design based on the fact that it is

examining the relationship between variables. The research variables in this study are intensity of

pain and the three pain assessment tools; Paedeatric Pain Profile, the revised Face, Legs,

Activity, Cry, Consolability scale and the Non-Communicating Children’s Pain Checklist-

revised. There was no clear hypothesis stated but the implied hypothesis states; the use of three

standardized pain scales in children with severe disabilities has made assessing their pain level

more efficient. I believe, if this article stated a hypothesis it would have made for an easier

understanding as to what these scales purpose was in the disabled child’s pain assessment.

Data Collection and Instruments

The data for this study was collected between March 2013 till November 2013 in

hospitals and institutional care facilities in the Czech Republic that remain anonymous. I believe

a hospital is the most appropriate place to assess pain, but when it comes to assessing pain in
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children with disabilities it is hard to know when exactly these children are in pain. The most

appropriate way to figure out what stimulates their pain would be to assess their pain level over a

long period of time in an environment that is comfortable to them. For most of these children a

hospital or care facility will seem more normal to them than a child without a disability due to

more frequent hospitalizations. So, I believe this setting reflects the real world in most of these

children’s lives.

These authors used three different standardized pain scale tools as mentioned above. The

Paediatric Pain Profile (PPP) assessment tool was specifically developed for use in children with

severe disabilities, specifically the children who have difficulty verbalizing their pain and are

dependent on a caregiver. The authors state, the PPP is a reliable and valid tool to be used in both

clinical and interventional research (p. 246). It’s internal consistency (Cronbach’s alpha) is 0.75-

0.89 and reliability is 0.74-0.89 (interclass correlation). The next pain assessment tool used in

this study is the Non-Communicating Children’s Pain Checklist- Revised (NCCPC-R). This tool

is used in children unable to communicate verbally due to their cognitive impairment. The

authors state, this tool showed very good reliability and validity, with a Cronbach’s alpha of 0.93

(p. 247). The final pain assessment tool used in this study is the Revised Face, Legs, Activity,

Cry, Consolability (rFLACC). This scale is reliable and valid for pain assessment in children

with cognitive impairment. The internal consistency of the rFLACC may be considered

excellent, with a Cronbach’s alpha of 0.86 for all the items (p. 247). With the information

provided concerning these tools validity and reliability, I believe they are very appropriate tools

to assess pain and are being used in the correct manner.

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Protection of Human Subjects

For this study all the questionnaires included informed consent forms so

parents/guardians could agree to their child’s participation in the study. The survey was initiated

following approval from the University of Ostrava Faculty of Medicine and University Hospital

Ostrava ethics committees. The survey had been approved by the management of individual

institutions prior to initiation. The study complied with the Charter of Fundamental Rights and

Basic Freedoms, Convention on the Rights of Persons with Disabilities, Convention on the

Rights of a Child, Nuremberg Code, Declaration of Helsinki, Declaration of Tokyo, International

Ethical Guidelines for Biomedical Research Involving Human Subjects and IASP Declaration of

Montreal stating that access to pain management is a fundamental human right. With the process

this study had to go through for the protection of these children and getting consent, I would say

makes it a very ethical study.

Replication

This study is clear enough to be replicated. The tools used are extremely valid and

reliable to be used successfully again. The data collection was done in a hospital setting which is

accessible and appropriate setting for this research. The subjects that make up the sample are

specific due to the fact that they have to be disabled, 3-18 year old patients that can’t verbalize

their pain. The process of how the researchers gathered their sample was not stated very clearly.

This could make finding a big enough population difficult due to the specifics and needing

parental consent. Overall, I believe this study is replicable due to the success of the tools but the

narrow population could make appropriate sample size difficult.

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Data Analysis

Descriptive

The subjects in this study were patients ages 3-18 with severe multiple disabilities. The

sample was very specific, the children had to be unable to communicate and verbalize their pain,

had to be living in the Czech Republic and had to have consent from a parent/guardian to

participate in the study (p. 246). The article laid out the criteria for the sample well but did not

give much information about the sampling method or how these patients were selected. Which

like I stated above, could make replication of this study difficult.

There was no power analysis within the article which is very unfortunate. Power analysis

helps the researcher determine the smallest sample size that can be suitable to detect the effect of

a given test at the desired level of significance. Having a power analysis can reduce the chance of

a type II sampling error. This article lacking a power analysis and having a small sample size of

43 children (21 being male and 22 being female) could mean a type II sampling error could of

occurred. “This group of children is so heterogenous that a uniform classification system cannot

be developed. Multiple disabilities may have numerous forms and degrees of severity” (p. 248).

Study Results/Understanding

There was a statistically significant difference (p=0.023) when it comes to the older

children perceiving pain more intensely than the younger children. When it comes to the

variation of pain between the two genders there is no statistical significant difference. The results

show statistically significant correlations between all three scales. There is an exception when it

comes to the rFLACC and PPP scales not having statistical significance (p=0.2674), and this

may be explained by the small sample. The statistical tests were evaluated at a p-value of five

percent. For something to be considered statistically significant means the results are probably
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not caused by chance (Grove, Gray, & Burns, p. 512); meaning all three of these scales This

study is also clinically significant in the fact that having multiple pain assessment tools in

practice would be very beneficial and clinically possible.

The results were given in narrative form and in table form. Giving results this way is

beneficial due to the fact that some people are more visual and can understand better in that way.

I believe the results given are confusing. The whole aim of the study is to compare the

significance of each scale and going into the significance of age and gender takes away from the

main purpose of the study.

Discussion and Conclusion

Discussion of Findings

The findings presented in this study were presented objectively by the authors. The

authors compared the data to multiple other studies with similar populations of children,

“according to authors of several studies, pain is an everyday experience for children with severe

multiple disabilities” (p. 249). The researchers compared their study to another study researching

pain in severely disabled children. However, “the comparison of these two studies may be

limited by the fact that they used different methods for pain measurement” (p. 249). They also

used a comparative study, that was done to show how much higher pain levels in disabled

children are compared to children without disabilities. A lot of research was used to defend their

reasoning on the importance of their study. The statistics given discussing the reasoning behind

needing this pain assessment in the Czech Republic for disabled children keeps the reader drawn

in and gives you empathy towards these children. Unfortunately, there is no theoretical

framework in this study to relate the findings back to but the implied comfort theory relates to
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the main goal of all of these studies conducted, which is to provide these children with

interventions to comfort their pain.

Conclusions

The conclusions stated by the authors are logically related to the implied hypothesis of

the study. I believe they are related, because the authors state over and over again the need for

standardized scales for pain assessment in children with severe multiple disabilities throughout

this article. The implied hypothesis of this study states the use of these standardized scales makes

assessing these children’s pain level more efficiently. Even though there was no stated

hypothesis the conclusion fits perfectly with the implied hypothesis of this study. They do not

bring in any new knowledge that would contradict the results of the study or shift it in any way.

The conclusion is very specific to the target population and their families. It includes the doctor

and nurses knowledge of these children’s disabilities, but I believe that is very appropriate. I

believe bringing up the nurses and doctors knowledge in the conclusion wraps up the importance

of the healthcare team knowledgably assessing pain in this target population.

Limitations

The authors did not state their limitations clearly but they certainty had them. This study

lacked a hypothesis which is there as the starting point for further investigation. A hypothesis is

important when conducting a study so you can relate your results back to it. This study was also

lacking a theoretical framework which is another tool to relate your findings back to. The

theoretical framework introduces you to the theory that explains why the problem of the study

exist. The last thing this study is lacking is a power analysis which is there to help the

researchers understand the smallest sample size possible that can still be statistically significant.

This study not having a power analysis and having a small sample size makes a sampling error
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possible. The researchers did state the need for further study relating to the psychometric

properties of the PPP and NCCPC-R.

Confidence

The main reasoning for believing the results of this study are valid and usable is due to

the tools used. The three scales in this study were all very successful tools in measuring pain due

to their validity and reliability. Although this study did not include a hypothesis, it was simple to

make an implied one. One thing that makes me question if the results are valid is due to the small

sample size, lack of sampling plan and lack of power analysis. Overall, I do believe these results

are valid due to their statistical significance, tools used and clear problem statement.
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References

Chromá, J., & Sikorová, L. (2014). Use of specific methods for assessment of pain in children

with severe multiple disabilities. Central European Journal of Nursing and Midwifery,

6(2), 245-252. doi:10.1542/CEJNM.2015.06.0011

Grove, S., Gray, J., & Burns, N. (2015). Understanding nursing research: Building an

evidence-based practice (6th ed.) Maryland Heights, MO: Elsevier Saunders.

(2013). Comfort Theory. In Nursing theories a companion to nursing theories and models.

Retrieved from http://currentnursing.com