You are on page 1of 10

Running head: WONG-BAKER FACES SCALE 1

Wong-Baker Faces Scale

Elizabeth Ping – T-012

Sand Richards

Spring Arbor University

Contemporary Medical-Surgical Nursing NUR 442

September 22, 2009


Running head: WONG-BAKER FACES SCALE 2

Wong-Baker Faces Scale

The purpose of a pain assessment tool is to understand pain from a patient’s perspective.

Pain assessments guide pain management routines and attempt to provide interventions that are

the most appropriate. Management of pain has become a standard of care for the Joint

Commission, which now requires accredited hospitals to assess and treat pain because patients

have the right to pain relief (“Health care issues”, 2009). As pain becomes the “fifth vital sign”,

health care workers struggle to find a pain assessment tool that adequately describes the

multidimensional experience of pain (Riegel, n.d.). The many pain assessment tools available

vary from strictly verbal to pictorial to numerical. The Wong-Baker Faces Scale is the pain

assessment tool designated for pediatric patients ages seven through seventeen at Mercy

Memorial Hospital (ER Triage, 2009). The following will discuss the design of the Wong-Baker

Faces Scale, the barriers and facilitators of the Wong-Baker Faces Scale, and further

recommendations to improve the Wong-Baker Faces Scale.

Design Assessment

The Wong-Baker Faces Scale is a visual scale designed to measure pain intensity

among children and cognitively impaired adults (Hunsley and Mash, 2009, p. 557). The scale

consists of six cartoon-like faces ranging from no pain (a happy face) to severe pain (a crying,

sad face). Each of the six facial expressions is accompanied by a number, usually on a scale of

one through six (six being severe pain and one being no pain) or two through ten (ten being

severe pain and two being no pain). Under each face, there is a short description indicating what

kind of pain goes with each facial expression. When using the scale, patients are first told which

picture belongs with which intensity level of pain, and then are asked to point to the face that

best describes the pain that they are feeling.


Running head: WONG-BAKER FACES SCALE 3

Age appropriateness. The Wong-Baker Faces Scale is primarily used with children

three years of age and older. Before the age of three, infants and children must rely on their

caregiver’s interpretation of the signs and symptoms of pain based on physical signs, such as

grimacing, flailing, and crying (Riegel, n.d.). According to Fleisher, Ludwig, and Henretig

(2005), the Wong-Baker Faces Scale is a valid tool for assessing pain, especially within the ages

of four to seven because pediatric patients are not yet adept with numerical scales but are able to

easily relate their pain to facial expressions (p. 64). Though the Wong-Baker Faces Scale was

initially designed for the pediatric patient, it can also be used with adult and elderly patients,

especially those with intellectual and developmental disabilities (Bodfish, Harper, J. M. Deacon,

J. R. Deacon, and Symons, 2006, pp. 149-172).

Acute and chronic pain. The Wong-Baker Faces Scale can be used with acute and

chronic pain; however the Wong-Baker Faces Scale is principally concerned with the intensity of

pain experienced by the patient and does not assess every possible physiological and emotional

sign and symptom that a patient might present with. According to Lois (2004), while chronic

pain demonstrates little change in physiological signs and symptoms, acute pain symptoms are

demonstrated through elevated blood pressure, elevated heart rate, elevated respiratory rate,

muscle tension, dilated pupils, and pallor (p. 463).

Behavioral symptoms of acute pain are demonstrated through moaning, rubbing the

painful site, restlessness, clenching fists, frowning, and grimacing; behavioral symptoms of

chronic pain are demonstrated more by depression, hopelessness, and listlessness. Although the

Wong-Baker Faces Scale does not directly assess the acute physiological manifestations of pain,

it has been suggested by Ferrel and Coyle (2005) that the scale has the ability to detect emotions
Running head: WONG-BAKER FACES SCALE 4

such as sadness and anger, depending on how the scale was presented (p. 110). In such cases, it

may be possible to assess chronic and acute pain on a behavioral level only.

Settings. The Wong-Baker Faces Scale has been used in a variety of settings and is not

confined to hospital institutions. According to Pasero (1997), the Wong-Baker Faces Scale has

been successfully used throughout the United States in hospices, hospitals, and homes. The

portability of the Wong-Baker Faces Scale becomes apparent when laminated copies of the scale

are easily brought from room to room to measure intensities of pain experienced by patients.

Mothers of ill children or caregivers of the elderly can easily refer to the Wong-Baker Faces

Scale in the comfort of their own homes to determine when their loved ones need pain

medication. Furthermore, access and duplication rights to the Wong-Baker Faces Scale can

easily be obtained by filling out a request form on the Web site “Wong on the Web.”

Literacy level. Since the Wong-Baker Faces Scale is highly visual in nature, reading

and writing skills are not required. According to Ferrel and Coyle (2005), poorly educated

African-Americans and Caucasians prefer using the Wong-Baker Faces Scale over less pictorial

pain assessment tools (p. 110). Adults and school-aged children who are not competent with

numerical scales might feel more comfortable using a pain scale that uses faces to illustrate

different degrees of pain. The lack of literacy and numeracy needed to successfully self-report

pain using the Wong-Baker Faces Scale dramatically increases the population that the scale can

serve, ranging from children, the mentally slow, the poorly educated, and even those who speak

a foreign language.

Barriers and Facilitators

Disabilities. Overall, the Wong-Baker Faces Scale is an ideal tool for assessing those

with a variety of disabilities when other scales of measurement are inappropriate. According to
Running head: WONG-BAKER FACES SCALE 5

Bodfish et al. (2006), the Wong-Baker Faces Scale is a reliable tool for assessing pain among

patients with intellectual and developmental disabilities where self-reporting scales are still the

gold standard of pain assessments (pp. 149-172). Furthermore, the Wong-Baker Faces Scale is

an extremely versatile instrument that can be loaded in certain speech-generating programs for

those who are nonverbal or who have limited speech capabilities (“Wong-Baker Faces” n.d.).

However, certain disabilities such as blindness and sight impairments would make the

pain assessment guide less effective, since the tool relies on pictures for patients to relate their

levels of pain. Additionally, Finley (2007) suggests that the Wong-Baker Faces Scale may

convey different meanings for those who use American Sign Language because symbols similar

to the Wong-Baker Faces Scale are commonly used to convey emotions such as humor and

teasing in the deaf community (pp. 133-135). Therefore, healthcare workers need to be mindful

when using the Wong-Baker Faces Scale with those who primarily use American Sign Language

as their form of communication.

Cultural sensitivity. One of the greatest advantages of the Wong-Baker Faces Scale is its

ability to transcend race, culture, ethnicity, and language. According to Baeyer, Wood, and

Jannista (2007), instructions for administering the Wong-Baker Faces Scale have been translated

into at least 31 languages from Albanian to Wallisian, and the work toward additional

translations and revisions is current today (pp. 1-18). However, lingual sensitivity is not the only

way in which the Wong-Baker Faces Scale highlights cultural attentiveness. According to

Schiavenato, Byers, Scovanner, Windyga, and Shah (2007), the Wong-Baker Faces Scale is

more ideal than other pain assessment tools because the scale’s cartoon-like depiction does not

attempt to imitate any particular age, gender, race, or ethnicity (p. 3560). By avoiding biases that

may be present when presenting pictures of faces, the Wong-Baker Faces Scale has become a
Running head: WONG-BAKER FACES SCALE 6

choice model in assessing pain. In fact, according to Luffy and Grove (2003), the Wong-Baker

Faces Scale is preferred over African-American representations of pain such as the Oucher Scale

among African-American children experiencing sickle cell anemia.

Recommendations

Improvement of the Wong-Baker Faces Scale may take a variety of forms, including

further research into how the Wong-Baker Faces Scale can be used to assess chronic pain

behaviors through the identification of facial expressions signifying emotions such as sadness. It

would also be interesting to determine whether men have less preference for the Wong-Baker

Faces Scale, since males might perceive the cartoon’s crying face as unmasculine and may not

want to admit that their pain is at the greatest level. Findings from studies such as those

suggested may help guide health care workers in determining what kind of pain assessment tool

to use with what kind of patient and for what kind of pain.

The hallmark of the Wong-Baker Faces Scale is its reliance on a display of faces to

represent different levels of pain. It would be useful to animate the faces with a computer

program so patients could choose which animation reflects their pain the most. A soft and

soothing voice could be added to describe and clarify what each face means. Sound effects

could be added to each face to enhance the facial description. For instance, the face representing

the most intense pain could have the voice of a person crying loudly, while the face representing

no pain could have silence. There could be an option for controlling which voice the patient

heard: male or female, elderly or pediatric, and screaming or crying. In this way, healthcare

workers and families could modify the scale to fit their patients and loved ones more

appropriately.

Conclusion
Running head: WONG-BAKER FACES SCALE 7

Pain management has become the responsibility of nurses, requiring them to assess and

treat pain appropriately. While self-reports of pain are the predominant tools health care

providers have, it is essential that providers of care are aware of the advantages and

disadvantages of different pain assessment tools. Health care workers must be able to decide

what pain assessment tool is most appropriate for the person they are caring for, based on the

patient’s age, cognitive and physical abilities, and cultural factors. The Wong-Baker Faces Scale

is appropriate for use with differing ages, disabilities, literacy levels and ethnicities, and in a

variety of settings. Furthermore, suggestions have been made to improve the Wong-Baker Faces

Scale, including the idea to create computer software that would enhance the scale’s utility.
Running head: WONG-BAKER FACES SCALE 8

References

Baeyer, Wood, & Jannista (2007, August). Instructions for administering the Faces Pain

Scale: Revised in languages other than English. 5th ed. Retrieved from

http://painsourcebook.ca/pdfs/fps-r-multilingual-instructions-aug07.pdf

Bodfish, J. W., Harper, V.N., Deacon, J. M., Deacon, J. R., Symons, F. J. (2006). Issues

in pain assessment for adults with severe to profound mental retardation. Pain in children

and adults with developmental disabilities. Baltimore: Brooks Publishing Company.

Computer Faces Scale for Measuring Pediatric Pain and Mood. (Report). Feb 2009 v10 i2 p.

173(7) Journal of Pain, 10,2. p. 173(7). Retrieved from Health Reference Center

Academic via Gale:http://find.galegroup.com.ezproxy.arbor.edu/gtx/start.do?prod

ID=HRCA

ER Triage. (2009). Monroe: Mercy Memorial Hospital.

Kabes, A., Graves, J., & Norris, J. (2009, February). Further validation of the nonverbal pain

scale in intensive care patients. Critical Care Nurse, 29(1), 59-66. Retrieved from

CINAHL Plus with Full Text database.

Ferrel, B. & Coyle, N. (2005). Textbook of palliative nursing. Oxford University Press.

Finley, Lewis. (2007). Focus on nonverbal communication. Nova Science Publishers.

Fleisher, R., Ludwig, S. & Henretig, F. (2005). Textbook of pediatric emergency

medicine (5th ed.). Lippincott Williams & Williams.

Hunsley, J. & Mash, E. (2008). A guide to assessments that work. Oxford University.

Joint Commission on Accreditation of Health Care. (2009). Health care issues. Retrieved

from http://www.jointcommission.org/NewsRoom/health_care_issues.htm

Luffy, R., & Grove, S. K. (2003, January-February). Examining the validity, reliability,
Running head: WONG-BAKER FACES SCALE 9

and preference of three pediatric pain measurement tools in African-American children.

(Practice Applications of Research). Pediatric Nursing, 29, 1. p.54(6). Retrieved from

Health Reference Center Academic via Gale:

http://find.galegroup.com.ezproxy.arbor.edu/gtx/start.do? prodID=HRCA

Pasero, Christine. (1997, July). Using the faces scale to assess pain. American Journal of

Nursing 97(7). Retrieved from http://journals.lww.com/ajnonline/pages/articleviewer

aspx?year=1998&issue=07000&article=00024&type=fulltext.

Riegel, B. (n.d). Pain assessment. Retrieved fromhttp://www.burnsurvivorsttw.org/articles/

painass.html

Schiavenato, M., Byers, J., Scovanner, P., Windyga, P. & Sharh, M. (2007). Is there a

primal face of pain?: A methodology answer. Retrieved from

http://server.cs.ucf.edu/`~vision/papers/EMBSPaperPFP.pdf

White, Lois. (2004). Foundations of nursing (2nd ed.). Delmar Cengage Learning.

Wong-Baker FACES Pain Rating Scale (n.d.). AAC AS A FAMILY. Retrieved from

http://dobs.google.com/gview?

a=v&q=cache:OKPou2ZFaWoJ:gregoconnor.wikispaces.com/file/view/PJH_FACES.pdf

+speech+generating+devices+can+use+wong-baker&hl=en&gl=us
Running head: WONG-BAKER FACES SCALE 10

You might also like