Wong Baker's Scale

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WONG BAKER’S FACES PAIN SCALE

The Wong–Baker Faces Pain Rating Scale is a pain scale that was developed by Donna Wong and Connie Baker.
The scale shows a series of faces ranging from a happy face at 0, or "no hurt", to a crying face at 10, which
represents "hurts like the worst pain imaginable". Based on the faces and written descriptions,
the patient chooses the face that best describes their level of pain.

About the creators

The Wong-Baker FACES Pain Rating Scale was created by Donna Wong and Connie Baker in 1983 to help children
effectively communicate about their pain.

Connie Baker Donna Wong

Dr. Donna Lee Wong was an American nursing researcher and a consultant. She was initially a Registered Nurse in
Oklahoma, and a certified paediatric nurse practitioner. She eventually became a consultant at Hillcrest Medical
Centre, Oklahoma, where she, along with Connie Baker, created the FACES Pain Scale, and carried out the
research for the same.

Connie Baker is an American child life specialist, who, along with Dr. Donna Wong, developed the FACES Pain
Scale. She currently serves as the executive director at the Wong-Baker FACES Foundation.

Developing the scale

When Connie and Donna met, and Connie expressed her concern about the children in pain, the two learnt they
shared common ground on a problem faced every day by children, and child health specialists every day. This was
also of interest to Donna. They agreed that children needed a better method to communicate about pain so they
could get the relief they needed. With the proper tools, children could participate in assessing their pain, leading
to more success in overall pain management.

With the assistance of Peggy Cook, the hospital librarian, Connie and Donna learned everything they could about
pain assessment and management. Through a thorough literature review, they eventually uncovered a few scales
used with adults and some tools developed for children. Adapting a few of the adult scales and using the existing
paediatric tools, Connie and Donna began introducing new assessment tools to patients

Young children had considerable difficulty using any scale with unfamiliar words or scales based on numbering or
ranking concepts. The use of the Numeric Rating Scale was growing in popularity at this time, but young children
had trouble using the numbers. When children used a color scale, the color choices were not consistent with their
peers, making the use of color challenging to replicate on a larger scale.

However, the children responded well to facial expressions. In hopes of creating a new assessment tool, school-
aged patients were given a piece of paper with six empty circles, about the size of a quarter, in a horizontal line.
The children were asked to think back to their own experiences and draw facial expressions to show how they
had felt when they experienced different levels of pain.

An early sketch by a 13-year-old child

Children from the burn unit and the general paediatric unit readily participated and often created elaborate faces
and hairstyles to demonstrate the gradation from “no pain” to “worst pain they could ever imagine.” Over 50
children participated. Each child’s series of faces was unique, but a pattern soon developed in terms of the shape
of the eyes, nose, and mouth. A composite of the most frequently drawn features became a part of a pilot
introduction with a new group of 25 children to evaluate their ability to use the faces.

To determine if children could use the scale to distinguish between different pain intensities, Connie asked
children to mark their areas of pain on a drawing of a human figure then rate each area using the faces scale.
Many of the children were burned on parts of the body more likely to be painful than others. This round of
discovery showed that children quite accurately assessed pain intensity.

Connie Baker drew this quick sketch of the faces at a child’s bedside to help the child articulate pain using the
human figure drawing.
Participants in tool development

Participants of the study to determine the validity, reliability, and effectiveness of the tool were children who met
the following criteria-

- Children who were alert


- Children who were not in pain during testing
- Children who spoke English
- Children without any developmental delays
- Children who agreed to participate in the study
- Children whose parents consented to their children’s participation in the study

The children belonged to the paediatric units of two general hospitals in the South-Central United States. The
study was approved by the Institutional Review Boards of both hospitals.

Methodology of developing the tool

A convenience sample consisted of 150 hospitalized children in three age groups: 3 to 7 years (n=52), 8 to 12
years (n=52), and 13 to 18 years (n=46). These age groups represented Piaget’s three major cognitive periods of
childhood: preoperational, concrete operational and formal operational stage respectively. There were 87 males
and 63 females, the majority of the subjects were Caucasian. Of the 150 children tested, up to 13 sets of data
were incomplete on one or more measures. For example, some children only listed one painful event, which did
not allow for validity testing. Therefore, data analysis was not performed on the total number of subjects for all
measures. 79 children were retested.

Validity and Reliability Overview: The validity and reliability of the scale was tested along with those of 5 other
scales- the Simple Descriptive Scale, the 0 to 10 Scale, the Glasses Scale, the Chips Scale, and the Colour Scale. The
raw data indicated that the scale with the highest validity for all the age groups except 13 to 18 years was the
chips scale. In the 13-to-18 age group, the glasses scale had the highest validity. The scales with the highest
reliability were chips scale for the age group 8 to 12 years and overall, glasses scale for ages 3 to 7 years, and
colors scale for ages 13 to 18 years. With all scales, validity increased with advancing age. However, reliability in-
creased only from the 3-to-7-year age group to the 8-to-12-year age group. Reliability decreased in the 13-to-18-
year age group for all the scales except the color scale and the simple descriptive scale, which continued to
increase or remain constant respectively.

Validity of the tool

Concurrent validity was determined by the following procedure:

1. The ranking of painful events by each subject was compared with the ranking of pain scores for each pain
scale to determine the consistency (validity) of each pain scale.
2. Each pain scale which showed a consistent response according to step one was given a score of one;
otherwise it was given a score of zero.
3. The number of consistent responses for each pain scale was totalled for each age group.
4. The number of consistent responses for each pain scale was divided by the total number of subjects in
each age group to arrive at a percentage of consistent responses.

Reliability of the tool

Reliability was determined using the same approach as for validity except that the pain ratings for the painful
events on the first test were compared with the pain ratings on the retest. The chi square was used to test the
null hypothesis that there were no differences between preference, validity, and reliability of the six scales. The
alpha level was p‹.05. The chi squares for preference ranking for each age group and overall were statistically
significant at p‹.001, thus rejecting the null hypothesis. Significant differences do exist between preference
ranking of the pain scales. The most preferred scale for all age groups was the faces scale. For children ages 8 to
18 years, the faces scale was followed by the colors, chips, glasses, numeric, and simple descriptive scales. In the
3-to-7-year age group, the preference order was the same, except for the colors and glasses scales, which were
ranked fourth and second, respectively. The chi square was not statistically significant at p <.05 for differences in
validity or reliability. Therefore, the null hypothesis was not rejected. No significant differences exist among the
scales or for any age group.

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