The Oucher: A Summary

What is the Oucher?

The OUCHER is a poster developed for children to use to help them communicate how much pain or hurt they feel. There are two types of scales on the OUCHER: a number scale for older children and a picture scale for younger children. Only the children themselves should be rating their own pain on the Oucher. (Adults should NOT compare the child’s face with the faces on the Oucher. That is not a valid indicator of levels of pain).

There are five versions of the Oucher: Caucasian, Hispanic, Asian, African American, and First Nations. All have been thoroughly researched except for the First Nations. It can be used but with the understanding that the research on it was not completed so it may or may not have construct validity. However, children ordered the pictures from no hurt to the biggest hurt, so both the boy and girl scales have content validity.

Which scale should be used?

Children, who can count to 100 by ones or tens and who understand that 71 is larger than 43, can use the numerical scale. Children who do not understand numbers should use the picture scale. Most 4-year-olds can use the Oucher. Many 3- year-olds can also use the Oucher, however, in order to make sure that they are mature enough to understand ratings, it would be best to have them take a little test. This is described in the Users’ Manual on page 3. Briefly, 3-year-olds would need to show that they can rank-order several items of increasing size correctly from largest to smallest. For example, cardboard circles can be used, and children are asked to “pick the biggest circle” among six circles laid out in front of them until all are chosen, and they are picked in the correct order. Some children who can use the number scale might prefer to use the picture scale. Children can be asked which scale they would prefer. See the attached video that shows how a younger child is unable to correctly use the Oucher. Hannah is 2 ½ years old and is too young to be able to rank objects in correct order.

How do I use the OUCHER?

Picture scale

The following is an example of how to explain the picture scale to a younger (~3-7 year old) child.

This is a poster called the OUCHER. It helps children tell us how much hurt they have. (For younger children, it may be useful to ask: Do you know what I mean by hurt? The child might say “Yes, like when I fell off the swing and my head got all bloody.” If the child is not sure, then an explanation or example should be provided). Here’s how this works. This picture shows no hurt (point to the bottom picture), this next picture shows just a little bit of hurt (point to the second picture), this picture shows a little more hurt (point to the third picture), this picture shows even more hurt (point to the fourth picture), this picture shows a lot of hurt (point to the fifth picture), and this picture shows the biggest hurt you could ever have (point to the sixth or top picture). Can you point to the picture that shows how much hurt you are having right now?

Once children select a picture, their selection is changed to a number score from 0-10.

10 – Picture at the top of the scale
8 – Second picture from the top
6 – Third picture from the top
4 – Fourth picture from the top
2 – Fifth picture from the top
0 – Picture at the bottom of the scale

Number scale

The following is an example of how to explain the number scale to older children (~8-12 years old).

This is a poster called the OUCHER. It helps children tell us how much hurt they have. Here’s how it works. 0 means no hurt. This (point to the lower third of the scale, about 1 to 3) means you have little hurts; this (point to the middle third of the scale, about 3 to 6), means you have middle hurts. If your hurt is here (point to the upper third of the sale, about 6 to 9), it means you have big hurts. If you point to 10, it means you have the biggest hurt you could ever have. Can you tell me the number your hurt is right now?

The pain score for the number scale is the exact number from 0-10 (for example, 1, 2, 3, and 4) that the child gives you.

What does the score mean? How should it be used?

The person who has the pain is the expert or the one who knows best how the pain feels. It’s the child who must do the rating. The OUCHER score gives parents, teachers, nurses, doctors and others some idea of how much pain the child is feeling. OUCHER scores can be used to see whether or not certain actions used to relieve pain, such as rest, applying heat or cold, eating or drinking, and medicine make a difference in how much pain the child feels. OUCHER scores can be recorded over a period of hours or days and would be useful information to share with nurses and doctors.

Remember, the child’s OUCHER scores only communicate how much pain the child is feeling. Other observations, such as changes in activity, location of the pain, what it feels like, and how long it lasts are also important.

©All versions of the OUCHER were copyrighted by members of Pain Associates in Nursing, (Drs. Judith E. Beyer, Antonia Villarruel, Mary Denyes, and Chao Yeh, 1983, 1990, and 2003)