Knowledge, Attitudes, and Practices in Pediatric Pain Management: Cross-Cultural Adaptation and Initial Psychometric Evaluation of the Polish HUPEDCARE-Q Among Healthcare Students and Professionals

Abstract

Background/Objectives: Pediatric pain management remains a significant clinical challenge, with contemporary biopsychosocial models increasingly emphasizing humanized care and non-pharmacological strategies. This study aimed to culturally adapt and evaluate the psychometric properties of the Polish version of the HUPEDCARE-Q (Humanisation of Pediatric Care in Pain Management with a Non-Pharmacological Approach) questionnaire among healthcare professionals and students. An additional objective was to explore differences in knowledge, attitudes, and self-reported practices across different age groups and stages of professional development. Methods: An observational, cross-sectional study was conducted. The cross-cultural adaptation process included independent forward translations, reconciliation, back-translation, and an expert panel review. Data were collected using online surveys. Construct validity was evaluated through confirmatory factor analysis (CFA), while internal consistency reliability was assessed using McDonald’s omega coefficient and the Kuder–Richardson Formula 20 (KR-20). Group differences were analyzed utilizing the Mann–Whitney U test. Results: Because the original factor structure exhibited a suboptimal fit to the data, a revised and reduced Polish version was proposed, which demonstrated significantly improved fit indices (CFI = 0.91 for the attitudes and knowledge domains; CFI = 0.99 for the pain management domain). Exploratory bivariate analyses showed higher knowledge and attitudes scores among older participants and working professionals, whereas no statistically significant differences were observed in self-reported pediatric pain management practices. Conclusions: The revised Polish short-form adaptation of the HUPEDCARE-Q showed improved model fit and domain-specific psychometric performance, with strong internal consistency for the pediatric pain management domain, acceptable reliability for the knowledge domain, and moderate reliability for the attitudes domain. Therefore, the instrument should be interpreted as a preliminary screening and assessment tool rather than as a fully established measure with uniformly strong reliability across all domains. The observed discrepancy between higher knowledge and attitude scores and the absence of significant differences in self-reported practices may suggest that knowledge and attitudes alone are not sufficient to explain differences in self-reported pediatric pain management practices.

1. Introduction

Pain in pediatric patients remains a significant clinical and ethical challenge, despite substantial advances in its assessment and management. Children, particularly in early developmental stages, often have limited ability to verbalize pain, which increases the risk of under-recognition and inadequate treatment [1,2,3]. In clinical practice, pain associated with routine medical procedures—such as venipuncture, injections, or diagnostic interventions—continues to be one of the most frequent and distressing experiences in pediatric care [2,4,5,6].

Contemporary approaches to pediatric pain emphasize a biopsychosocial model, integrating not only pharmacological treatment but also non-pharmacological strategies and the broader concept of humanized care [7,8]. This perspective highlights the importance of communication, emotional support, and individualized care, recognizing the child as an active participant in the therapeutic process rather than a passive recipient of procedures [9,10]. In this context, healthcare professionals play a pivotal role in shaping both the quality and effectiveness of pain management.

However, a growing body of evidence indicates gaps in knowledge, attitudes, and clinical practices related to pediatric pain among healthcare professionals [11,12,13]. Similar deficiencies have been observed among students of medical and health-related disciplines, suggesting that current educational frameworks may not sufficiently prepare future clinicians for comprehensive pain management [14]. Although interdisciplinary pain education is increasingly promoted worldwide, discrepancies between theoretical knowledge and clinical practice remain an important concern.

Several validated instruments have been developed to assess knowledge and attitudes toward pain, such as Pediatric Nurses Knowledge and Attitudes Survey [11,15,16]. These tools have contributed significantly to identifying educational needs and improving training strategies. Nevertheless, they primarily focus on general aspects of pain assessment and pharmacological management, and may not fully capture the broader concept of humanization in pediatric pain care, particularly in relation to non-pharmacological approaches and patient-centered practices.

The Humanisation of Pediatric Care in Pain Management with a Non-Pharmacological Approach Questionnaire (HUPEDCARE-Q) was developed to address this gap by providing a more comprehensive evaluation of knowledge, attitudes, and self-reported practices related to pediatric pain within a humanized care framework. Building on this, cultural adaptation and validation of such instruments in other countries have enabled the identification of educational gaps, the tailoring of interventions to local contexts, and meaningful international comparisons, as well as the monitoring of systemic changes over time [11,16,17,18]. However, the applicability of such instruments across different healthcare systems requires careful cultural adaptation and psychometric validation to ensure their reliability and relevance in specific contexts.

The HUPEDCARE-Q was selected because it operationalizes a construct that is not fully captured by existing instruments assessing pediatric pain knowledge and attitudes. While previous tools primarily focus on general pain assessment, pharmacological management, or professional knowledge, the HUPEDCARE-Q integrates several dimensions that are particularly relevant to contemporary pediatric care: attitudes toward children’s pain, knowledge and training in pain management, self-reported practices, the use of non-pharmacological interventions, communication with the child, family involvement, and the broader concept of humanized care. This broader scope was considered especially relevant in the Polish context, where validated instruments addressing these combined dimensions are lacking. In addition, the selection of the HUPEDCARE-Q was aligned with the objectives of the international HUPEDCARE project, which focuses on strengthening higher education and healthcare professionals’ competencies in the humanization of pediatric pain care [19].

Pain relief constitutes a fundamental duty of medical personnel, and the patient’s right to pain treatment is guaranteed by law in Poland. Despite progressive professionalization, pain in children remains a common phenomenon and is often insufficiently identified and managed. This issue is particularly critical in the pediatric population, where inadequately treated acute pain can lead to lasting changes in the nervous system, resulting in persistent pain syndromes and neurobehavioral disorders [20].

The organization of pediatric pain care in hospital settings across the country remains underdeveloped. Research from 2025 indicates that Hospital Pain Treatment Teams dedicated to pediatrics operate in only 41% of surveyed hospitals, with the active (so-called Swedish) model—based on close physician-nurse collaboration—implemented in just 15% of institutions [21]. A significant gap between guidelines and clinical practice is evident in healthcare personnel’s knowledge and attitudes. In the emergency medical system, pain assessment in children is rare; retrospective studies have shown that pain scales were used in only 1% of patients [22,23]. Similar deficiencies are reported in neonatal units, where nearly 60% of physicians base therapeutic decisions solely on their own experience rather than on objective assessment tools [24].

Accordingly, a culturally adapted instrument covering these dimensions may support the evaluation of educational needs, the design of targeted interventions, and the monitoring of improvements in clinical practice. This represents a significant barrier to the evaluation of educational needs, the design of targeted interventions, and the monitoring of improvements in clinical practice.

Therefore, this study aimed to culturally adapt the HUPEDCARE-Q and evaluate the psychometric properties of its Polish version among healthcare professionals and students. If the original factor structure was not supported, a revised Polish structure was to be considered based on psychometric diagnostics and content relevance. Additionally, the study sought to explore differences in knowledge, attitudes, and practices related to pediatric pain management across age groups and stages of professional development. The expected differences in knowledge and attitudes were based on the assumption that age and professional experience are associated with greater exposure to clinical situations, formal and informal learning opportunities, and repeated contact with pediatric patients experiencing pain [16]. In contrast, reported clinical practices may be less directly dependent on individual knowledge or attitudes, as they are also shaped by organizational routines, institutional protocols, workload, availability of resources, and local clinical culture [25]. For this reason, higher knowledge or more favorable attitudes may not necessarily translate into clearly different self-reported pain management practices. Based on this rationale, exploratory analyses examined whether knowledge, attitudes, and self-reported pediatric pain management practices differed across age groups and professional status categories.

2. Materials and Methods

2.1. Study Design

An observational, cross-sectional study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [26]. The study aimed to culturally adapt and evaluate the psychometric properties of the Polish version of the Humanisation of Pediatric Care in Pain Management with a Non-Pharmacological Approach Questionnaire (HUPEDCARE-Q), originally developed and validated by García-Valdivieso et al. [27].

In contrast to the original study, which focused on the development and initial validation of the instrument, the present study was designed to evaluate its applicability, reliability, and structural validity within the Polish healthcare and educational context. The original factor structure was tested first. Because the original structure showed suboptimal fit in the Polish sample, item-level diagnostics and content considerations were subsequently used to develop a revised short-form Polish adaptation.

2.2. Participants and Sample Size

The target population comprised healthcare professionals and university students enrolled in medical and healthcare degree programs, with a particular focus on pediatric care. A total of 291 participants were included in the final analysis.

The final sample of 291 participants was considered adequate for the confirmatory factor analyses performed in this study. This assessment was based on the relatively simple structure of the tested CFA models and the separate evaluation of the questionnaire domains [28]. In the most complex tested model, the participant-to-estimated-parameter ratio was approximately 17:1, which was considered sufficient for the purposes of the present psychometric assessment. The sample size was therefore regarded as adequate for the initial assessment of model fit and reliability of the Polish adaptation. Detailed exclusion criteria and participant flow are presented in Section 2.5.

2.3. Cross-Cultural Adaptation Process

The cross-cultural adaptation of the HUPEDCARE-Q questionnaire was conducted in accordance with established international guidelines for the translation and validation of measurement instruments [29].

Two independent bilingual translators, native speakers of Polish with proficiency in Spanish, performed separate forward translations of the original questionnaire. The two translated versions were compared and reconciled into a single consensus version, ensuring conceptual rather than literal equivalence.

The reconciled version was then back-translated into Spanish by an independent translator blinded to the original instrument. This step was performed to verify semantic consistency and identify potential discrepancies.

An expert panel consisting of four specialists reviewed all stages of the translation and adaptation process. The panel included academic teachers and researchers with clinical and scientific experience in pediatric pain management and child health, as well as specialists representing anaesthesiology nursing, neonatal and pediatric care, palliative care, pediatrics, and clinical care of children. The panel assessed semantic, conceptual, and cultural equivalence of the translated items, with particular attention to the clarity and appropriateness of terminology related to humanized care, non-pharmacological interventions, and pediatric pain management. Discrepancies were discussed collectively and resolved by consensus. Minor linguistic refinements were introduced where necessary to improve clarity and cultural relevance.

Before the full rollout of the survey, the preliminary Polish version was pilot-tested among target users to assess its clarity, comprehensibility, and cultural appropriateness. The pilot phase included 80 completed questionnaires. Based on feedback and response patterns obtained during this stage, minor terminological refinements were introduced to improve the clarity of selected items. Since these modifications were made after the pilot phase, pilot responses were not included in the final analytical sample.

No major structural or conceptual changes were made to the questionnaire at the translation and cultural adaptation stage. The final Polish version of the HUPEDCARE-Q was used in this study with the permission of the original authors.

2.4. Questionnaire HUPEDCARE-Q Description

The HUPEDCARE-Q questionnaire was originally developed as a multidimensional tool to assess attitudes, beliefs, knowledge, training, and self-reported practices related to pediatric pain management, with a particular focus on non-pharmacological approaches and the humanization of care.

The instrument consists of four sections. The first section collects sociodemographic and professional data (e.g., age, gender, professional status, field of study/work). The second section evaluates attitudes and beliefs regarding pediatric pain using Likert-scale items (11 items in the original version, reduced to 7 items in the final Polish version: A&B 1, 3, 5, 8, 9, 10, 11). The third section assesses knowledge and training in pediatric pain management (7 items in the original version, reduced to 6 items in the final Polish version: K&T 1, 2, 3, 5, 6, 7). The final section evaluates self-reported practices through dichotomous (yes/no) items reflecting real-world decision-making; this section includes 8 items in the revised Polish version (PPM 1, 2, 4, 5, 6, 7, 8, 9).

The scoring system allows for separate evaluation of the main domains (attitudes, knowledge, and practices), providing a domain-specific assessment of competencies related to pediatric pain management.

In accordance with the original scoring procedure, selected items were reverse-coded prior to analysis. In the attitudes and beliefs domain, items 1, 2, 3, 5, 8, 9, 10, and 11 were reversed, while in the knowledge and training domain, item 4 was reverse-coded. Dichotomous items in the self-reported practice section were coded as 0 (no) and 1 (yes), as recommended by the original authors, with a score of 1 assigned when the response indicates appropriate knowledge or recommended practice. Higher summary scores (range 0–8) reflect more favorable self-reported practices aligned with humanized pediatric pain management. All items in this section are coded in the same direction; no reverse coding was applied.

2.5. Data Collection, Participant Flow and Exclusion Criteria

Data collection was conducted continuously from the third quarter of 2025 to the end of the first quarter of 2026. The questionnaire was distributed online via verified institutional email addresses to ensure participant authenticity. Invitations were sent to healthcare institutions, clinical centers, and higher education institutions offering medical and health science programs.

A total of 358 responses were initially collected. This number refers only to responses collected during the main study rollout and does not include the 80 questionnaires completed during the pilot phase. Before analysis, responses were screened according to predefined data-quality and eligibility criteria. Completion time was used as an indicator of response quality in the online survey. Responses completed in less than 3 min were considered unlikely to reflect careful reading of the questionnaire. Responses exceeding 15 min were treated as potentially interrupted or non-continuous survey sessions and were therefore excluded to reduce the possible influence of unmeasured external factors occurring during completion. In addition, respondents who did not meet the target population criterion, defined as being a healthcare professional or a student enrolled in a medical or health-related degree program, were excluded.

Following the application of these criteria, 67 observations were excluded from the final analysis:

• implausible or potentially non-continuous questionnaire completion time, defined as less than 3 min (n = 11) or more than 15 min (n = 10);
• non-medical or non-healthcare educational/professional background, not meeting the target population criterion (n = 44);
• incomplete responses (n = 2).

The participant selection process and final analytical sample are presented in Figure 1.

Ultimately, 291 verified responses were included in the final analysis. Participants accessed the survey via a secure, encrypted link. The first section included an informed consent form, ensuring voluntary and anonymous participation. Data were stored in an encrypted database and used exclusively for research purposes.

2.6. Participants Characteristics

The final sample included both healthcare professionals and students in medical and health-related fields. Detailed sociodemographic and professional characteristics of the study population are presented in

Table 1. Sociodemographic and professional characteristics of the study sample.

Variable	Category	n	%
Gender	Men	18	6.19
	Women	273	93.81
Age	18–20 years	67	23.02
	21–30 years	137	47.08
	31–40 years	26	8.93
	41–50 years	31	10.65
	>50 years	30	10.31
Professional status	Studying	154	52.92
	Working	137	47.08
Professional field of study/work	Physician	42	14.43
	Nursing/Midwifery	249	85.57
Having children below 18 years	No	240	82.47
	Yes	51	17.53
Care for the elderly	No	231	79.38
	Yes	60	20.62
Care for people with disabilities	No	242	83.16
	Yes	49	16.84

Note: The sample was predominantly composed of women and participants representing nursing or midwifery, while physicians constituted a smaller subgroup. In addition, slightly more than half of the participants were students. Therefore, the sample should be interpreted as reflecting primarily nursing/midwifery students and professionals rather than the full spectrum of healthcare professions.

.

2.7. Statistical Analysis

Data were analyzed using Jamovi 2.6 and Statistica 13.3 software. Confirmatory factor analysis (CFA) was conducted to assess the construct validity of the instrument. The weighted least squares (WLS) estimation method was applied for the analysis of the attitudes and knowledge domains, while the diagonally weighted least squares (DWLS) method was used for the pain management domain due to the dichotomous nature of the items in this section. CFA for the Likert-type attitudes and knowledge domains was based on polychoric correlation matrices, whereas CFA for the dichotomous pediatric pain management domain was based on tetrachoric correlation matrices. Internal consistency reliability for the attitudes and knowledge domains was assessed using McDonald’s omega coefficient (ωM), given the unequal contribution of item variances to the overall scale structure. The reliability of the pain management scale, consisting of dichotomous items, was evaluated using the Kuder–Richardson Formula 20 (KR-20), which is equivalent to Cronbach’s alpha for binary data. Group differences were analyzed using the Mann–Whitney U test. Effect sizes were calculated using the rank-biserial correlation coefficient (rg). A significance level of α = 0.05 was adopted for all analyses. The present psychometric evaluation focused on factorial validity and internal consistency. Test–retest reliability, convergent validity, discriminant validity, and measurement invariance across groups were not assessed, as repeated measurements and external validation instruments were not included in the study design. Therefore, group comparisons should be interpreted as exploratory.

3. Results

3.1. Construct Validity and Reliability of the Culturally Adapted Instrument

To evaluate the construct validity of the instrument, a confirmatory factor analysis (CFA) was conducted. The original version of the questionnaire was compared with a new, revised model proposed due to the sub-optimal psychometric properties of the original structure within the Polish cultural adaptation. The results of the CFA model fit are presented in

Table 2. Attitudes and knowledge about pain confirmation factor analysis model fit results.

Tested Model		χ2	df	p	χ2/df	RMSEA	95% CI		CFI	TLI
							LL	UL
Original scale proposition	Attitudes and beliefs Knowledge and training	302.97	134	<0.01	2.26	0.07	0.06	0.08	0.78	0.75
	Pediatric Pain Management	109.05	35	<0.01	3.12	0.09	0.07	0.10	0.91	0.88
Revised scale proposition	Attitudes and beliefs Knowledge and training	118.57	64	<0.01	1.85	0.05	0.04	0.07	0.91	0.90
	Pediatric Pain Management	25.83	20	0.17	1.29	0.03	0.00	0.06	0.99	0.99

.

The original structure for evaluating attitudes, beliefs, and knowledge demonstrated an acceptable but weak fit to the data. The low values of the Comparative Fit Index (CFI = 0.78) and the Tucker–Lewis Index (TLI = 0.75) suggested that the scale required improvement. To further illustrate the suboptimal performance of the initial structure, the standardized factor loadings for the original full version are presented in Figure S1 (Supplementary Materials). Figure S1 was included to document item-level performance before structural refinement and to identify items that contributed weakly to their respective latent domains. Several items exhibited notably low or negative factor loadings, indicating limited contribution to the measurement of the intended constructs. These factor-loading results were considered together with item discrimination, reliability indices, including alpha and omega coefficients if an item was deleted, and conceptual relevance. Together, these criteria informed the subsequent item reduction process and supported the development of the revised short-form Polish adaptation. Because the Polish adaptation involved structural refinement rather than only linguistic translation, item deletion was treated as a data-informed process supported by psychometric diagnostics and content considerations. The procedure focused on items that showed consistently weak performance across the factor-analytic and reliability analyses, while preserving the conceptual coverage of each domain.

Decisions regarding item reduction were based on a combined evaluation of standardized factor loadings, item discrimination, and reliability indices, including alpha and omega coefficients if an item was deleted. After each item removal, the model was re-estimated to verify whether the modification improved model fit and internal consistency. Thus, the final HUPEDCARE-Q-PL should be interpreted as a revised short-form adaptation rather than a direct one-to-one validation of the full original instrument. The final version includes 21 domain-specific items: 7 items in the attitudes and beliefs domain, 6 items in the knowledge and training domain, and 8 items in the pediatric pain management domain. The retained and excluded items are presented in Appendix A.1, while the final short-form Polish version is provided in Appendix A.2. Because of these structural modifications, direct cross-national comparisons with studies using the full original HUPEDCARE-Q should be interpreted with caution.

The revised Polish version of the attitudes scale retained items 1, 3, 5, 8, 9, 10, and 11, while the knowledge scale retained items 1, 2, 3, 5, 6, and 7. As demonstrated in Table 2, the newly proposed scale exhibited a substantially improved fit to the data (CFI = 0.91, TLI = 0.90). The reliability of the newly formed scales also increased, reaching ωM = 0.66 for attitudes and ωM = 0.73 for knowledge. However, the reliability of the attitudes scale remained moderate and below conventional thresholds for robust internal consistency, whereas the knowledge scale reached an acceptable level of reliability. Given that the attitudes and beliefs domain was reduced to seven items and retained only moderate internal consistency, this domain may have narrower conceptual coverage than in the original HUPEDCARE-Q.

Regarding the pediatric pain management domain, the structure of the original instrument showed an adequate fit to the data and demonstrated good reliability (αC = 0.84). However, specific items in the original version exhibited poor fit within the structure. Consequently, certain questions were excluded in the Polish version, which improved the model’s data fit (CFI = 0.99, TLI = 0.99). The reduced Polish version demonstrated an even higher reliability coefficient (αC = 0.89). The revised pediatric pain management scale ultimately utilized items 1, 2, 4, 5, 6, 7, 8, and 9. The standardized factor loadings for the new, modified versions of the instruments are presented in Figure 2. Although the revised models demonstrated improved global fit indices, some retained items still showed relatively low standardized factor loadings. This indicates that these items were weaker indicators of their respective latent domains, despite the overall improvement in model fit. These items were retained because item deletion decisions were based not only on factor loadings, but also on item discrimination, reliability diagnostics, and conceptual relevance. In particular, excessive item removal could have narrowed the content coverage of the shortened Polish version. Therefore, the revised structure should be interpreted as an initial short-form adaptation requiring further item-level evaluation in future studies.

The factor loading observed for item PPM 5 exceeding 1.00 was examined and did not indicate a reporting error, but rather an estimation artifact associated with the model. This result is likely attributable to item-level distributional properties, particularly high negative skewness (−8.40), as well as moderate to high inter-item correlations (φ = 0.10–0.61). In the pain model, item PPM 5 was retained for several reasons. First, sensitivity analyses indicated that its removal had only minimal impact on global model fit (ΔCFI = 0.01; ΔTLI = 0.01; ΔRMSEA = 0.03), suggesting that the overall factor structure remained stable. Second, exclusion of the item resulted in a slight reduction in internal consistency (ΔαC = 0.04), indicating a trade-off between model fit and reliability. Most importantly, PPM 5 was the only indicator capturing the social and school-related dimension of pain. Its removal would therefore have reduced the content coverage of the construct. Such localized Heywood cases have been shown to occur in CFA models with highly informative indicators, strong inter-item correlations, and distributional violations, without necessarily indicating substantive model misspecification [30].

3.2. Comparative Analysis of Pain Management Competencies

The revised instrument is scored by calculating the mean of the results for the attitudes and knowledge domains (ranging from 1 to 5 points) and summing the results for the pain management domain (ranging from 0 to 8 points).

The scores obtained from the attitudes, knowledge, and pain management scales were subjected to a comparative analysis based on the participants’ age and professional development stage. The values obtained in these analyses are depicted in Figure 3.

In exploratory bivariate analyses, scores differed significantly between age groups in the attitudes domain (z = 3.55, p < 0.01, rg = 0.26) and the knowledge domain (z = 5.12, p < 0.01, rg = 0.38). However, the differences in the pediatric pain management domain were not statistically significant (z = −1.00, p = 0.32, rg = 0.07).

Similarly, exploratory bivariate comparisons by professional status showed significant differences between students and working professionals in the attitudes (z = 5.56, p < 0.01, rg = 0.38) and knowledge (z = 5.09, p < 0.01, rg = 0.35) domains, whereas no significant differences were observed for the practical aspect of pain management (z = −1.20, p = 0.23, rg = 0.08). Professional status was moderately associated with participant age (ϕ = 0.57, p < 0.01), indicating that these variables were not independent in the present sample. Therefore, the observed differences in attitudes and knowledge should be interpreted cautiously, as the bivariate analyses do not allow the independent effects of age and professional status to be disentangled. Reported pediatric pain measurement and management practices did not differ significantly according to either age or professional status. Since measurement invariance across students and professionals was not assessed, these group comparisons should be interpreted cautiously and treated as exploratory.

4. Discussion

The present study provides the first cross-cultural adaptation and initial psychometric evaluation of a revised short-form Polish version of the HUPEDCARE-Q questionnaire, originally developed by García-Valdivieso et al. [27]. The findings indicate that the revised short-form Polish adaptation demonstrated improved construct validity and domain-specific psychometric performance following structural refinement. However, the strength of the evidence varied across domains, with strong reliability for the pediatric pain management domain, acceptable reliability for the knowledge domain, and only moderate reliability for the attitudes domain. The initial analysis of the original factor structure revealed only moderate model fit and suboptimal internal consistency, particularly within the attitudes and knowledge domains. This observation is consistent with the complexity of constructs such as knowledge and attitudes, which are inherently multidimensional and may affect model fit and internal consistency in psychometric validation studies [31]. The need to modify the original structure in the Polish adaptation does not indicate a limitation of the instrument itself but rather reflects the context-dependent nature of psychometric performance. Cultural differences, variability in clinical training, and differences in healthcare systems may all influence how individual items are interpreted and responded to [32,33].

Following item reduction, the revised Polish version demonstrated a clear improvement in model fit and domain-specific reliability. These psychometric results indicate the need for further research in larger and more diverse samples. The proposed questionnaire appears to be a solid starting point; however, further testing is needed to confirm its performance. Internal consistency was not uniformly strong across all domains. The attitudes scale improved compared with the original structure but remained only moderately reliable, indicating that this domain may require further refinement in future studies. In contrast, the knowledge scale demonstrated acceptable reliability, while the pediatric pain management domain showed strong reliability.

Nevertheless, the item-level results require cautious interpretation. Several retained items showed relatively weak standardized loadings, indicating that they contributed less strongly to the measurement of their respective latent domains. This is particularly relevant for the attitudes and knowledge domains, which represent complex and heterogeneous constructs. The decision to retain selected weaker-loading items reflected a balance between psychometric performance and content validity, as further item deletion could have resulted in an overly narrow representation of pediatric pain knowledge, attitudes, and humanized care. Future studies should therefore examine whether these items require rewording, replacement, or further refinement. These findings support the general relevance of the underlying conceptual framework of the HUPEDCARE-Q while highlighting the importance of careful cultural adaptation. Similar patterns have been observed in validation studies of other instruments assessing pain-related knowledge and attitudes, where item performance varies across populations and requires contextual adjustment, which may reflect differences in educational background, clinical experience, and cultural context [34,35].

At the same time, the improvement in psychometric indices should be balanced against the potential reduction in content validity resulting from item deletion. The shortened Polish version may not fully capture the entire conceptual breadth of the original HUPEDCARE-Q, particularly in complex domains such as attitudes, humanized care, and the biopsychosocial understanding of pediatric pain. This limitation is particularly relevant to the attitudes and beliefs domain, which retained only seven items and demonstrated only moderate internal consistency. During item reduction, conceptual relevance was considered in order to preserve the core dimensions of the construct; however, some narrowing of construct coverage cannot be excluded. Therefore, the revised HUPEDCARE-Q-PL should be interpreted as a short-form adaptation with promising but still preliminary psychometric evidence, rather than as a fully equivalent replacement for the original instrument.

The exclusion of item A&B 6 deserves specific comment. This item originally read: “Pain in children is a personal experience influenced by biological, psychological, and social factors” and reflects a core component of the biopsychosocial model. In the Polish sample, however, its standardized factor loading was close to zero (see Supplementary Figure S1), indicating no meaningful association with the latent attitudes construct. The most plausible explanation is a ceiling effect [36]: the biopsychosocial model is so strongly emphasized in Polish health sciences education that nearly all respondents agreed with the statement, leaving virtually no variance. Social desirability bias may have further inflated endorsement rates, as agreement with such a statement is widely perceived as a marker of a modern, humane professional attitude [37,38]. While the removal of this item was psychometrically justified, it somewhat narrows the theoretical breadth of the attitudes scale. Nevertheless, the remaining items continue to capture multiple dimensions of humanized pediatric pain management, including neurological development, non-pharmacological strategies, parental presence, and opioid safety. This observation also underlines the importance of cross-cultural validation, as item performance can vary significantly across populations [39].

An important contribution of the present study lies in extending the applicability of the original HUPEDCARE-Q beyond its initial validation setting. While the original instrument emphasized the integration of non-pharmacological approaches and humanized care in pediatric pain management, the current findings support the relevance and measurability of these dimensions in a different cultural and healthcare environment. This is consistent with contemporary approaches to pediatric pain, which emphasize multidimensional and patient-centered care, integrating pharmacological and non-pharmacological strategies [40,41].

In exploratory bivariate comparisons, older participants and working professionals reported higher knowledge and more favorable attitudes toward pediatric pain. However, because age and professional status were moderately correlated, these findings should be interpreted cautiously. The present bivariate analyses do not allow us to determine whether professional status contributed to these differences independently of age, or vice versa. In addition, because measurement invariance across groups was not tested, it cannot be excluded that some observed differences partly reflect group-specific response patterns rather than only true differences in the latent constructs. These exploratory findings are broadly consistent with previous research suggesting that clinical exposure may be associated with greater knowledge and more appropriate attitudes toward pain management among healthcare professionals [13,42]. In contrast, the absence of significant differences in the domain of self-reported pain management practices suggests that higher knowledge and more favorable attitudes were not accompanied by clearly different reported practice patterns in this sample.

The apparent discrepancy between higher knowledge and attitudes scores and the absence of significant differences in self-reported practices should be interpreted cautiously. In the present study, self-reported practices were assessed using self-reported dichotomous items rather than direct observation of reported practice patterns or objective assessment of clinical performance. Therefore, this result should be understood as indicating a potential gap between theoretical competencies and reported practice patterns, rather than as direct evidence of differences in observed clinical behavior. One possible interpretation, consistent with previous literature, is that pediatric pain management practices may be influenced not only by individual knowledge and attitudes but also by systemic and organizational factors, such as the availability of protocols, tools, institutional support, workload, and local clinical culture [12,14,25]. In the Polish context, these systemic barriers are well documented. Studies indicate that the most frequently reported obstacles to effective pediatric pain management include insufficient training (63.1%), time pressure and staff shortages (59.1%), and reluctance to change established routines (40.3%). Additionally, a fear of opioid-related adverse effects and skepticism toward the reliability of pain assessment scales remain prevalent [24]. The use of non-pharmacological methods—such as kangaroo care, sweet solutions, distraction, and parental presence—is uneven across clinical settings, with some practices of unproven effectiveness (e.g., heel warming) still being used [2,43]. These observations may suggest that knowledge and attitudes alone are not sufficient to explain differences in self-reported pediatric pain management practices, which may also be shaped by broader organizational and system-level conditions.

The structural and organizational context of pediatric pain care in Poland presents multiple challenges that extend beyond individual knowledge and attitudes. While national expert guidelines for acute pain management in children exist [20], their implementation remains uneven across clinical settings. Neonatal units frequently lack written pain management protocols, contributing to inconsistent practices, including the inappropriate use of paracetamol [24]. In the prehospital setting, the absence of standardized algorithms for pain assessment and treatment has been repeatedly documented [23]. Compounding these issues, specialized outpatient pain clinics for children operate in merely three centers nationwide, severely limiting access to comprehensive pain care [21].

The use of non-pharmacological methods in Polish clinical practice, while recognized as essential, is unevenly distributed across settings. In emergency and trauma care, cooling is applied in approximately 63% of children with burns, and immobilization in 22% of injured patients [22]. In neonatal intensive care units, kangaroo mother care is acknowledged as effective by over 90% of nursing staff, alongside the administration of sweet solutions and skin-to-skin contact [44]. However, practices of unproven effectiveness, such as heel warming before puncture, remain prevalent [24]. In hospital wards and emergency departments, distraction techniques—including active methods such as virtual reality and passive methods such as music or cartoons—are increasingly utilized, along with parental presence, clown therapy, and efforts to create child-friendly environments [2].

The HUPEDCARE-Q offers a valuable contribution in this context by capturing dimensions that are often underrepresented in traditional assessment tools. Unlike instruments that focus primarily on pharmacological management or theoretical knowledge, the HUPEDCARE-Q incorporates elements related to humanization, communication, and non-pharmacological strategies. This broader perspective aligns with current evidence emphasizing the importance of emotional support, patient engagement, and individualized care in pediatric pain management [25,45].

From a different perspective, the availability of a revised Polish short-form version of the HUPEDCARE-Q creates new opportunities for both research and clinical practice. The instrument may be cautiously used as a preliminary tool to identify educational gaps among healthcare professionals and students, evaluate the effectiveness of training programs, and support the development of targeted interventions aimed at improving pediatric pain management [2,46,47].

Moreover, the use of standardized and culturally adapted tools such as the HUPEDCARE-Q may facilitate cross-national comparisons and contribute to the harmonization of pediatric pain management practices. This is particularly relevant in the context of increasing emphasis on interdisciplinary and patient-centered care, where consistent assessment frameworks are important for evaluating progress and guiding policy development [48,49,50].

The findings of this study, considered alongside the documented structural gaps in Polish pediatric pain care, underscore the urgent need for systemic interventions. National pediatric and neonatal pain management guidelines, mandatory structured education for healthcare professionals, and the integration of pain assessment into routine clinical algorithms represent essential steps toward aligning daily practice with existing standards and ensuring children’s legal right to effective pain relief [20,21,23,24].

In conclusion, the revised short-form Polish adaptation of the HUPEDCARE-Q supports the relevance of the original conceptual framework in the Polish context, while also indicating the need for structural refinement. The instrument may be considered a useful preliminary tool for assessing competencies in pediatric pain management; however, its reliability should be interpreted by domain, and the attitudes scale requires further evaluation. The findings are consistent with a potential gap between knowledge and self-reported practice patterns and may indicate the need to consider educational, organizational, and humanized care-related factors in future research and practice improvement efforts.

5. Limitations

Several limitations of this study should be acknowledged. First, the cross-sectional design limits the ability to draw causal inferences regarding the relationships between knowledge, attitudes, and self-reported practices related to pediatric pain management. The observed associations should therefore be interpreted with caution, as they do not reflect changes over time or the effects of interventions. Second, the study relied on self-reported data, which may be subject to response bias, including social desirability bias and overestimation of competencies. Participants may have provided answers consistent with perceived best practices rather than their actual reported practice patterns. Third, the use of an online survey distributed via institutional email channels may have introduced selection bias. Individuals more interested in pediatric care or pain management may have been more likely to participate, potentially limiting the representativeness of the sample. Fourth, although the sample size was sufficient for psychometric validation and confirmatory factor analysis, the study population was limited to a specific national context. Therefore, the generalizability of the findings may be restricted to similar healthcare systems and educational environments. Moreover, although the sample size was considered adequate for the CFA models tested in this study, the revised structure was developed and evaluated within the same sample. Therefore, the proposed shortened Polish version should be interpreted as an initial validation and should be confirmed in an independent sample in future research. The internal consistency of the revised attitudes scale remained moderate (ωM = 0.66), despite improvement compared with the original structure. This indicates that the attitudes domain may require further refinement, including testing of alternative item wording or additional items in future validation studies. Some retained items showed relatively low standardized factor loadings, suggesting that further item-level refinement of the Polish short-form version is warranted. Furthermore, the study sample was predominantly female (93.8%) and consisted largely of nursing and midwifery professionals (85.6%). This distribution, while reflecting the demographic reality of these professions in many countries, including Poland [51,52,53,54], limits the generalizability of the findings to male healthcare workers and to other professional groups (e.g., physicians, physiotherapists). Therefore, the results should be interpreted with caution when considering broader healthcare populations. Although completion time was used as a data-quality indicator, excluding responses longer than 15 min may have removed some participants who completed the questionnaire carefully or after temporary interruptions. Therefore, this criterion should be interpreted as a pragmatic quality-control decision rather than a definitive indicator of invalid responding. Another limitation concerns the adaptation process, which, although conducted in accordance with established methodological guidelines, involved minor modifications to the original instrument, including item reduction. Although these changes improved model fit and reliability, they may limit direct comparability with results obtained using the original version of the HUPEDCARE-Q, as well as with future international datasets based on the full original instrument. More broadly, the removal of several original items may have narrowed the content coverage of the revised Polish short-form version, particularly in relation to attitudes and humanized care. One conceptually important item from the original questionnaire, A&B 6, which captures the biopsychosocial nature of pediatric pain, was excluded from the revised Polish version due to its poor psychometric performance. Consequently, the revised scale no longer directly assesses the biopsychosocial perspective—a limitation that should be considered when interpreting the construct coverage of the instrument. Future research might explore alternative phrasings of this concept that yield better discrimination in the Polish context. Finally, while the study assessed key psychometric properties such as factorial validity and internal consistency, other important aspects of measurement quality were not evaluated. Test–retest reliability was not assessed because the study did not include repeated measurements. Convergent and discriminant validity could not be examined because no external criterion or validation measures were administered. Measurement invariance across students and professionals was also not tested; therefore, group comparisons should be interpreted cautiously, as observed differences may partly reflect group-specific response patterns rather than only true differences in the measured constructs. In addition, group comparisons were based on bivariate analyses only. Because age and professional status were moderately correlated (ϕ = 0.57) and some age/professional-status subgroups were small, the present study could not disentangle the independent contribution of these variables. Future research should address these limitations in larger, more balanced, and professionally diverse samples. In particular, subsequent studies should use multivariable models to examine whether professional experience contributes to knowledge and attitudes independently of age and should further evaluate the psychometric properties of the revised HUPEDCARE-Q-PL, including measurement invariance and the performance of item PPM 5 in independent samples.

6. Conclusions

The original structure of the HUPEDCARE-Q was not fully confirmed in the Polish sample; therefore, the final HUPEDCARE-Q-PL should be interpreted as a revised short-form adaptation rather than as a direct confirmation of the full original instrument.

The findings of this study indicate that the revised short-form Polish version of the HUPEDCARE-Q showed improved construct validity indices and domain-specific psychometric performance. It may be considered a useful preliminary tool for assessing knowledge, attitudes, and self-reported practices related to pediatric pain management; however, the attitudes scale showed only moderate internal consistency and should be further refined and tested in independent samples. Reliability should therefore be interpreted at the domain level, as it was strong for the pediatric pain management domain, acceptable for the knowledge domain, and moderate for the attitudes domain. Because the Polish version is shorter and structurally modified, direct comparisons with data collected using the full original HUPEDCARE-Q should be made cautiously. Exploratory bivariate analyses suggested differences in knowledge and attitudes across age groups and professional status categories, while self-reported pediatric pain management practices appeared less differentiated. These observations should be interpreted with caution; however, they may suggest that knowledge and attitudes alone are not sufficient to explain differences in self-reported pediatric pain management practices.

The adapted instrument may support the identification of educational needs and contribute to the development of targeted strategies aimed at improving pediatric pain management, particularly in the context of non-pharmacological approaches and humanized care. Further research is needed to confirm these findings and to evaluate the applicability of the instrument in different settings and longitudinal designs.