Analysis of the concept of pain

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					Journal of Advanced Nursing, 1999, 29(4), 935±941                        Nursing theory and concept development or analysis

An analysis of the concept of pain
Lucy Montes-Sandoval RN MSN
College Assistant Professor, Department of Nursing,
New Mexico State University, New Mexico

Accepted for publication 13 April 1998

                                       MONTES-SANDOVAL L. (1999)
                                       MONTES-                        Journal of Advanced Nursing 29(4), 935±941
                                       An analysis of the concept of pain
                                       This paper presents a conceptual analysis of the phenomenon of pain. The
                                       strategic process of developing a conceptual analysis is a cognitive exercise of
                                       critical thinking applied to a very common, but complex and poorly understood,
                                       experience. Within the classic framework developed by Walker & Avant (1995),
                                       pain is analysed and critical attributes are distilled. A model case, a related case
                                       and a contrary case are constructed in the course of creating conceptual clarity.
                                       Empirical referents that exemplify the concept of pain are identi®ed. The
                                       concept analysis provides a forum for dialectics, offering one defensible
                                       interpretation of a complex human occurrence. Nursing implications are
                                       discussed in the conclusion.

                                       Keywords: concept analysis, pain, noxious stimuli, anguish, critical thinking,
                                       conceptual clarity, nursing

                                                                       A concept analysis is a useful technique to promote
                                                                     conceptual clarity. An analysis is a `formal linguistic
Pain is a universal factor and a common human experi-                exercise' to examine critical attributes of a particular
ence. Yet, despite its universality, pain is a very complex          concept (Walker & Avant 1995). A careful analysis of pain
concept to de®ne and understand. In nursing practice,                and distillation of its attributes will enhance understanding
pain is probably one of the most widely experienced and              and result in an operational de®nition that can be assessed
expressed phenomena. Its magnitude and application                   empirically (Chinn & Kramer 1995, Walker & Avant 1995).
suggest that nurses have an adequate understanding of                  The purpose of this paper is to engage in this cognitive
its meaning. However, Zalon (1995) suggests that nurses              exercise of critical thinking to examine the concept of pain
lack basic knowledge about pain and its management.                  and to re¯ect on its meaning, rather than to draw a solitary
   Poor relief of pain is well-recorded and has been noted           conclusion. Ironically, the only assured outcome of this
in nursing literature for over 20 years (Zalon 1995). This is        exercise is ambiguity that leads to continued exploration.
both thought-provoking and troublesome, as it re¯ects the            This concept analysis is intended to provide a workable
incompleteness of the nursing process. Suffering pain                approximation from which the nursing profession can
needlessly raises ethical concerns and is a barrier to               draw and expand the conceptual clari®cation of pain.
nursing's goal of enhancing an individual's quality of               Such analysis is part of an evolutionary process to develop
living. Pain cannot be assessed adequately if it remains             and strengthen the substantive knowledge that guides our
vague, ambiguous and arbitrarily de®ned. Conceptual                  practice. This being the case, the analysis of the concept of
clarity of pain is important as the nursing profession               pain is conducted within the classic framework developed
continues to establish itself as a distinguished discipline.         by Walker & Avant (1995).

Correspondence: Lucy Montes-Sandoval, College Assistant Professor,   CONCEPT USAGE AND DEFINITIONS
Department of Nursing, MSC 3185, New Mexico State University,
PO Box 30001, Las Cruces, NM 88003-8001, New Mexico.                 To clarify the meaning of the concept of pain it is
Tel.: (505) 646 3812; Fax: (505) 646 2167.                           important to identify as many uses of the term as possible.

Ó 1999 Blackwell Science Ltd                                                                                                 935
L. Montes-Sandoval

The ®ndings allow for richer meaning and are used to               the arm. The hook had merely pierced the heavy materials of his
validate the selection of de®ning attributes (Walker &             coat and shirt (p. 152).
Avant 1995). Historical applications, dictionary and en-
                                                                   Muse's example conveys the fact that pain can be attrib-
cyclopedia de®nitions and the nursing literature provide
                                                                   uted to psychological and emotional components.
invaluable information.

                                                                   HISTORICAL FUNCTIONS
                                                                   Pain is often described in the literature as serving a
Pain is a universal phenomenon that is deeply rooted in
                                                                   function. Analysis of pain from this functional perspective
history. Several scholars contemplated the meaning of
                                                                   is useful to further synthesize de®ning attributes. Harry
pain. The ancient Greek philosopher, Aristotle, de®ned
                                                                   Stack Sullivan, known for his interpersonal theory of
pain as the opposite of pleasure (Francis & Munjas 1975).
                                                                   personality development, described the function of pain
The 16th century French philosopher, Rene Descartes,
                                                                   as a learning experience.
viewed the mind and body as separate entities, with pain
                                                                     Sullivan (1953) believed that the in¯iction of pain, in
functioning as a warning system within the body urging
                                                                   the form of punishment, `¼is used in its own right as an
the body to seek relief (Locke & Colligan 1986, Mahon
                                                                   educative in¯uence, this means a new type of learning Ð
1994). Sigmund Freud believed pain and pleasure had a
                                                                   namely, learning enforced by a growing discrimination of
reciprocal interaction. Freud, a classical pychoanalytical
                                                                   the connection between certain violations of imposed
personality theorist of the 19th century, speculated that
                                                                   authority and pain' (p. 204). The implication is that pain
the `id', a component of personality, operated on the
                                                                   can be a modi®er of behaviours.
`pleasure principle'. The goal of the `id' is to reduce or
                                                                     Francis & Munjas (1975) looked at pain as serving the
eliminate discomfort or pain as quickly as possible to
                                                                   function of providing a protective mechanism. Pain
achieve pleasurable feeling (Allen 1994).
                                                                   signals that something is wrong and is the symptom that
   Florence Nightingale also recognized the importance of
                                                                   most frequently causes an individual to seek assistance for
understanding pain. Nightingale (1859/1992) wrote about
                                                                   health problems. They de®ned pain further as an unwant-
pain in her book Notes on Nursing: what it is and is not.
                                                                   ed, lonely, anxiety-producing experience that really
She stated `the sick suffer to excess from mental as well as
                                                                   cannot be shared or perceived by another. Pain generates
bodily pain' (p. 34). She believed a common misconcep-
                                                                   anxiety and in turn, anxiety, potentiates pain creating a
tion among the healthy was that sick individuals had a
                                                                   threat to body and mind.
choice to `dismiss painful thoughts which aggravate their
                                                                     Another function of pain, as discussed by DiMatteo &
disease' (p. 35). Her writings suggest that physiological
                                                                   Friedman (1982), is a form of communication. The
and psychological factors are powerful in¯uences in the
                                                                   sensation and expression of pain generally draws com-
experience of pain and disease.
                                                                   passion and assistance from others; the expression of
   Another historical medical reference to pain is made in
                                                                   pain may be a request for comfort. Pain may be a
the 1934 edition of The Merck Manual. It identi®ed pain
                                                                   symbolic expression of a problem within an interpersonal
as a response to `excitation, probably summation of
                                                                   relationship. For example, an individual may actually
stimuli, of certain sensory nerve structures, which may
                                                                   feel neck pain whenever `the boss' is around. In addition,
be located anywhere, from peripheral expansion to recep-
                                                                   DiMatteo & Friedman stated it was misleading to consid-
tive center' (p. 706). Physical pain consisted of discomfort
                                                                   er pain to be exclusively mental or physical. They
of local disease of organ or tissue, muscle pain and nerve
                                                                   believed pain to be an example of how mental and
pain. Psychological pain or `psychalgia' was described as
                                                                   physical factors are intertwined and supported this with
`an abnormal mental perception, often due to suggestion
                                                                   the phenomena of pain-free surgical procedures perform-
and curable by psychotherapy' (p. 707).
                                                                   ed under hypnosis.
   In 1931 Maude Muse, author of Psychology for Nurses,
addressed the concept of pain within the framework of
hallucinations. She suggested that it was possible to              DICTIONARY AND ENCYCLOPEDIA
experience `pain hallucinations' and supported this with           DEFINITIONS
the following description.
                                                                   Dictionary and encyclopedia de®nitions assist in clarify-
A butcher while attempting to hang a side of beef on a high hook   ing prevalent usages and thoughts for conceptual mean-
slipped from the top of the ladder and was himself suspended       ing. Existing de®nitions often do not provide a complete
from the hook. Since he appeared to be suffering acute agony he    sense of meaning but they are useful in identifying basic
was carried across the street to a chemist shop. He was pale,      elements, perceptions or feelings related to the concept.
pulseless, and cried out whenever his arm was touched or moved.    Dictionaries and encyclopedias convey commonly accept-
His sleeve was carefully cut away but not a scratch was found on   ed ways in which a word is used and are bene®cial in

936                                                    Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 935±941
Nursing theory and concept development or analysis                                                 Analysis of concept of pain

tracing the origins of speci®c words (Chinn & Kramer                hemisphere, suggesting both a physical and/or psycholog-
1995).                                                              ical response.
   The dictionary is a logical place to begin. Merriam                 The gate control theory acknowledges the in¯uence of
Webster's Collegiate Dictionary (1996) has de®ned pain as:          external factors and expands its interpretation of pain to
                                                                    include the existence of sensory, affective and cognitive
1: PUNISHMENT 2: usu. localized physical suffering associated
                                                                    dimensions. Development of this theory continues to
with bodily disorder (as a disease or an injury); also: a basic
                                                                    further re®ne the pain experience.
bodily sensation induced by a noxious stimulus, received by
                                                                       Walding (1991) explored postoperative pain and ac-
naked nerve endings, characterized by physical discomfort (as
                                                                    knowledged the dif®culties of de®ning pain, as it is not
pricking, throbbing, or aching), and typically leading to evasive
                                                                    purely physical or psychological experience. Multiple
action b: acute mental or emotional distress or suffering: GRIEF.
                                                                    factors affecting pain are strongly indicative of this unique
The Greek, Latin and French derivatives of the word pain            and personal experience. More speci®cally, Walding hy-
all imply punishment or penalty.                                    pothesized that pain, anxiety and powerlessness are inter-
   The Psychiatric Dictionary (Campbell 1996) has de®ned            related. Pain and anxiety illicit similar physiological
psychic pain, psychalgia, as discomfort or distress located         responses, thus one may enhance the other. The link
in the head, which `accompanies mental activity (obses-             between anxiety and powerlessness hinges on a state of
sions, hallucinations, etc.), and is recognized by the              helplessness from a real or perceived lack of control over a
patient as being emotional in origin' (p. 587). Psychalgia          situation. Walding postulated that because the relationship
is thought to be due to the presence of intolerable anxiety.        between anxiety and pain exists and a link between anxiety
For example, a schizophrenic patient may complain of                and powerlessness had been identi®ed, it is likely that
pain in his head as a result of electrical currents and             there is a relationship between pain and powerlessness.
depressed patients often complain of headaches. Pain is a              Villarruel & Ortiz de Montellano (1992) supported the
`perceived aversive or unpleasant sensation that originates         importance of socio-cultural in¯uences on pain. They
from a speci®c region of the body' (p. 504). Pain can arise         suggested that attitudes and reactions to pain are learned
without activity from the nerve cell receptors, and psy-            in early childhood within a cultural context. Meanings
chological factors can clinically account for its onset,            and attitudes related to pain are culturally different and,
severity or exacerbation.                                           therefore, behavioural responses will vary. Several themes
   Encyclopedia reviews (The New Encyclopaedia Britan-              speci®c to the Mexican-American culture have been
nica 1988, The New Grolier Multimedia Encyclopedia                  identi®ed. For example, there may be an admiration for
1993) have de®ned pain as an uncomfortable, unpleasant,             enduring pain stoically Ð as a re¯ection of courage; or
distressful, somatic sensory and emotional experience               pain may be viewed as a punishment from God for
associated with injury, threat of injury, or some type of           unacceptable behaviour. Villarruel & Ortiz de Montel-
damage to the body. Pain serves as a protective measure to          lano's ®ndings emphasized the importance of understand-
withdraw from harmful stimuli. The experience of pain is            ing the socio-cultural framework within which pain is
physiological, psychological and subjective.                        experienced and expressed.
                                                                       Waddie (1996) found that pain is an everyday experi-
USES IN NURSING                                                     ence that is expressed through the use of language and is
                                                                    then legitimized. The expression of pain is not a separate
Nursing views pain from a holistic perspective. This
                                                                    occurrence but rather is part of the pain experience, which
conceptual orientation of physiological, psychological
                                                                    is in¯uenced by socio-cultural factors. Language is learned
and socio-cultural interaction is a very traditional ap-
                                                                    within the various socio-cultural entities, therefore pain
proach to nursing. The analysis of pain within this
                                                                    too can have a variety of expressions. Verbal transmission
framework is supported with the following literature
                                                                    can consist of many words to describe pain; however, the
                                                                    lack of verbal transmission or expression does not imply
   Melzack & Wall's gate control theory of pain (as cited in
                                                                    that there is no pain. Non-verbal expression must also be
Clancy & McVicar 1992, Davis 1992, Stevens & Johnson
                                                                    considered as part of the pain experience. Socio-cultural
1993) details neurophysiological functions and the con-
                                                                    in¯uences determine how and if the experience of pain
cept of pain regulation by a `gating mechanism' located in
                                                                    will be expressed.
the spinal cord. This is a very complex theory that
                                                                       Mahon (1994) conducted an extensive literature review
basically de®nes a mechanism that increases or decreases
                                                                    in her phenomenological approach to the analysis of pain.
the sensory impulses generated by injury-sensitive nerve
                                                                    She concluded that the following are the de®ning attri-
cell receptors, called nociceptors. The term nociceptors
                                                                    butes of pain:
has its origins in the word noxious, which means phys-
ically harmful or destructive (PAIN-L 1996). Nociceptor-            1 a personal experience;
generated impulses are interpreted as pain in the cerebral          2 an unpleasant experience;

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 935±941                                                   937
L. Montes-Sandoval

3 a dominating force;                                           example in the creation of meaning for the phenomenon
4 endless in nature.                                            of pain.
                                                                  Alicia is an attractive, 32-year-old, married, Hispanic
In her model, `pain is represented as a circle signifying the
                                                                woman. She is recovering, 3 days postoperative, from a
unending and ceaseless qualities of pain. Also, the pain
                                                                mastectomy. The nurse enters the room to change her
encircles the person having the experience, which denotes
                                                                dressings and ®nds her silently crying. The nurse gently
the dominating nature of pain and how it separates the
                                                                comments on her tears. Alicia avoids eye contact and says
individual and interferes with relationships' (p. 20).
                                                                nothing. As the nurse changes the dressings, Alicia turns
  Mahon's contribution to the body of nursing knowledge
                                                                her head away and closes her eyes. The nurse notices that
provides fertile ground for continued dialogue on the
                                                                Alicia is diaphoretic and tense. Her blood pressure and
universal concept of pain. Her ®ndings, in conjunction
                                                                heart rate are elevated and the nurse inquires if she is in
with the literature review of other identi®ed uses of the
                                                                pain. As she grimaces and guardedly repositions herself,
concept of pain, provide the opportunity to develop the
                                                                Alicia responds, `I' m not sure, I guess I am just tired'. The
critical attributes of this analysis.
                                                                nurse offers Alicia pain medication, reaches for her hand
                                                                and acknowledges the loss Alicia must feel, as well as the
CRITICAL ATTRIBUTES                                             discomfort of postoperative pain. Alicia bursts into tears
                                                                and cries, `I don't know what I feel. I'm so tired and I feel
Attributes of a concept appear repeatedly and are derived       terrible all over. My chest hurts and I'm worrying about
from the literature review to identify speci®c phenomena        what my husband is going to think. I'm so ugly now and
and to serve the function of differentiation. They are not      scared my husband is never going to want me again. For
irrevocable but instead are subject to change. The goal is to   sure he can't love half a woman'.
cluster the distinctive features commonly af®liated with
the concept and that allow for broad insight (Walker &
Avant 1995). The characteristics that surfaced in this          Discussion
analysis of pain are synthesized as the following critical      This model case includes all the critical attributes of pain.
attributes:                                                     Alicia responds with distress, displeasure and discomfort
1 dominating, unpleasant, distressful, unwanted, un-            to the mastectomy, which is a dominating, unwanted,
  comfortable experience;                                       aversive, noxious sensation. Alicia's bodily pain is evi-
2 neurophysiological, psychological, socio-cultural, re-        dent in obvious tissue damage and the neurophysiological
  sponse to a noxious stimulation;                              manifestations.
3 variable, subjective and dif®cult to explain sensation           It is dif®cult for her to communicate her experience as
  that cannot really be shared or perceived by others;          demonstrated in her initial vague and minimal response.
4 aversive sensation to an actual or potential threat of        The nurse notes Alicia's verbal and non-verbal communi-
  injury or damage to body and/or mind;                         cation and shares her subjective perception of what Alicia
5 form of verbal and/or non-verbal communication;               may be experiencing and expressing. The removal of
6 unique experience that serves as a protective mecha-          Alicia's breast is laden with socio-cultural signi®cance
  nism for self-preservation;                                   and her Hispanic heritage will in¯uence how she will
7 reciprocal interaction with anxiety;                          experience and express her physical and psychological
8 mental misperception leading to distressful thoughts.         injury.
                                                                   The quiet crying, poor eye contact, derogatory self-
  The critical attributes described add to the evolution        appraisal and avoidance of interaction with the nurse all
and re®nement of a useful and adequate meaning of pain.         re¯ect psychological pain. In addition to her pain, Alicia
In the process of creating conceptual meaning, it is also       expresses her `worries' as she experiences anxiety over the
bene®cial to construct cases that are representative of the     loss of a signi®cant body part associated with her female
phenomenon. Scenarios in the form of model, related and         body image. With the added anxiety, Alicia has misper-
contrary cases aid in representing the concept of pain          ceptions of being ugly, incomplete and undesirable. These
(Chinn & Kramer 1995, Walker & Avant 1995).                     distressful thoughts lead her to believe she will be rejected
                                                                by her husband who will no longer love her.
                                                                   A protective mechanism for self-preservation is psycho-
                                                                logically present in this situation. Alicia's unpleasant
The critical attributes of pain can be applied in the           thoughts are in anticipation of rejection and withdrawal
construction of a model case to illustrate the occurrence       from her husband. Her thoughts serve as a protective
of the concept. A model case is one in which there is           mechanism as she sets up a psychological safety net for
certainty of its representation of the concept. The fol-        self-preservation. If Alicia's husband responds as she
lowing model case of pain represents a paradigmatic             anticipates, Alicia can preserve her psychological integri-

938                                                 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 935±941
Nursing theory and concept development or analysis                                               Analysis of concept of pain

ty as her misperceived and aversive thoughts begin to           cannot really be shared or perceived by others. Fifthly, as
prepare and protect her from additional mental anguish.         would be expected, there is a variety of verbal and non-
                                                                verbal communication occurring in this dilemma. Sixth-
                                                                ly, Frank and Sarah are engaged in a tenacious process;
                                                                the ®nal decision could be viewed as the protective
A related case demonstrates an instance that is similar to      mechanism for preservation of their family. Finally, it is
the concept, yet is different when examined closely. The        reasonable to assume that anxiety is present as Frank and
case provides understanding of concept linkage and              Sarah wrestle with a choice between two loathsome
clarity of the attributes central to the concept being          circumstances. Despite the similarities between pain and
examined (Chinn & Kramer 1995, Walker & Avant 1995).            anguish, the critical attribute of mental misperception
For the development of the related case, the concept of         leading to distressful thoughts is not present. Upon close
anguish is used. Although anguish may have characteris-         examination, painful thoughts are distinctly and unmis-
tics in common, it is different from pain.                      takably evident; however, these thoughts are not gener-
   Frank and Sarah's 5-year-old son, Adam, will not             ated from mental misperceptions. Frank and Sarah are
survive without liver transplant surgery. He is gravely ill     very realistic when they state, `Adam's chances of living
and not expected to live long. When Frank and Sarah visit       are poor no matter what we decide'. They are not
Adam, he sadly states, `I want to go home. I don't like it      misinterpreting their dilemma, they understand and
here'. They talk to Adam about the possibility of surgery       know the prognosis is poor whether they choose the
and he begins to cry, `I don't want no more booboos, I want     surgery or not.
to go home now'. Frank and Sarah are consumed with
grief and sorrow, they must make an excruciating
                                                                CONTRARY CASE
decision. In addition to a poor surgical prognosis, Adam
has expressed his opposition to further hospitalization or      A contrary case is a lucid presentation of `not the concept'.
treatment.                                                      Similarities may be present; however, the contrary case
   They share their agony with one another and seek the         has characteristics that are easily recognized as not
support of family and friends, often stating, `We don't         representative of the concept (Chinn & Kramer 1995,
know what to do, Adam's chances of living are poor no           Walker & Avant 1995). Development of this type of case
matter what we decide'. Frank and Sarah are sorrow-             assists in clear identi®cation of the critical attributes of the
stricken with this predicament. They seek solace in one         concept of pain.
another as they are tormented by Adam's wishes and their          Gina is admitted to the psychiatric unit with various
own needs. They struggle with the weight of this dilemma        welts, bruises and super®cial lacerations. As the nurse
and experience a great deal of anguish.                         interviews and assesses Gina, she notes that she is not in
                                                                any particular distress. In fact, Gina seems to be some-
                                                                what titillated. When the nurse comments on this, Gina
                                                                giggles and responds, `Have you ever been in love? I have
Anguish is a phenomenon similar to pain. It is de®ned as        the greatest boyfriend, he makes me so happy'. Upon
extreme pain, distress or anxiety (Merriam Webster's            further assessment, it is discovered that Gina has a
Collegiate Dictionary 1996). This couple experiences            history of physically and sexually abusive relationships.
profound grief and sadness over the imminent threat to          Her current boyfriend is the perpetrator of her physical
their child's life. Frank and Sarah are in¯icted with           injuries. Gina is diagnosed with the psychosexual disor-
intense personal suffering. With close analysis, the            der of masochism.
similarities become apparent but the differences are also
   The phenomenon of anguish is similar to pain in many
ways. First, Frank and Sarah are engaged in an obvious          The critical attributes of pain are not present in this
process that is dominating, unpleasant, distressful, un-        example. Gina's behaviours are in direct and unequivocal
wanted and uncomfortable. Secondly, they must respond           opposition to the normal mind and body sensation of
to the noxious stimulation of impending surgery and the         pain. She responds with pleasure, both verbally and non-
threat to Adam's life. Thirdly, it is reasonable to assume      verbally, to a welcome but aversive encounter threatening
Frank, Sarah and Adam will have a neurophysiological,           her wellbeing. Gina may or may not experience anxiety;
psychological and socio-cultural response to this threat of     regardless, she does not perceive the physical or sexual
injury or damage to body and mind. Fourthly, as with            abuse as a noxious stimulus that prompts her to respond
most personal experiences, anguish is a variable, subjec-       with a protective mechanism. Finally, Gina's mispercep-
tive and dif®cult to explain sensation. Although Frank          tions lead her to pleasant impressions of love and happi-
and Sarah have the support of friends and family, it            ness versus distressful thoughts.

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 935±941                                                  939
L. Montes-Sandoval

ANTECEDENTS AND CONSEQUENCES                                     area, vigilant guarding of the involved area, restlessness or
                                                                 avoidance of movement, ¯inching, wincing, grimacing,
Antecedents                                                      strained facial expression or altered eye contact.
                                                                    Objective empirical referents of the pain experience can
Prior to the occurrence of a concept, certain events called
                                                                 be identi®ed by various bodily manifestations. Observable
antecedents must take place. These antecedents help to
                                                                 and concrete physiological determinants include altera-
re®ne further the critical attributes of the concept (Walker
                                                                 tions in muscle tone, diaphoresis, vomiting, weakness,
& Avant 1995). The following are antecedents of pain:
                                                                 syncope, increased or decreased respirations, alterations
1 Internal or external circumstances arise, creating nox-        in cardiac rate and blood pressure, dilated pupils or sleep
  ious stimuli to the nociceptors and/or aversive sensa-         disturbances. These more direct empirical indicators are
  tions creating the likelihood of discomfort.                   readily observed, assessed and measured utilizing various
2 The individual is either physically or psychologically         instruments.
  aware of the stimuli or discomfort.
3 The noxious stimulation or aversive sensation is per-
                                                                 CONCLUSION AND IMPLICATIONS
  ceived as pain.
                                                                 TO NURSING PRACTICE
                                                                 Pain is a subjective experience and it would be misleading
                                                                 to represent pain as having an exclusive de®nition. As a
As a result of the occurrence of a concept there are             natural human response, pain decidedly remains a
outcomes, called consequences. Consequences are the              synthesis of complex interacting operations. However,
events or incidents that occur after the concept (Walker &       exercising the application of the concept analysis to the
Avant 1995). The following are consequences of pain:             phenomenon of pain leads to increased understanding
                                                                 and agreement, therefore improving nursing interventions
1 The individual, with verbal and non-verbal communi-
                                                                 and allowing for the completion of the nursing process.
  cation, demonstrates neurophysiological, psychologi-
                                                                 The identi®ed attributes, antecedents, consequences and
  cal and/or socio-cultural responses to the perception of
                                                                 empirical referents of pain are useful in providing the
                                                                 nurse with a frame of reference from which pain can be
2 The individual's response to the pain may or may not
                                                                 holistically addressed. Use of this analysis of pain is
  provide relief.
                                                                 innate to nursing practice as nursing recognizes and
3 Using available protective mechanisms, the individual
                                                                 understands the richness of the dynamic interactions of
  ventures to relieve the pain, cope with the pain and/or
                                                                 the physical, psychological and socio-cultural being.
  seek assistance in efforts of self-preservation.
                                                                    Conceptual clarity is a key factor in distinguishing the
4 Others will respond to the individual and provide
                                                                 nursing profession as it provides the underpinnings for a
  various interventions in relieving or coping with the
                                                                 sound theoretical and scienti®c basis for professional
                                                                 practice. This concept analysis can serve as a foothold
5 The individual's pain will remain the same, decrease,
                                                                 toward the development of a comprehensive theory of
  or increase.
                                                                 pain. Although existing theories on the phenomenon of
                                                                 pain provide the nursing profession with a framework,
                                                                 results of this analysis may become a foundation for
                                                                 structural components in the process of continued theory
The ®nal step of the concept analysis is identi®cation of        re®nement.
empirical referents. Empirical referents are indicators that        A crucial component of theory is determining the
exemplify the existence of the concept itself. They are          relationship between various concepts. The following
used to measure the concept or validate its existence in         critical attributes of pain distilled in this analysis suggest
reality (Walker & Avant 1995). In the analysis of pain,          several interconnections:
subjective and objective empirical referents are identi®ed.
                                                                 1 Pain has a reciprocal interaction with anxiety.
   The subjective empirical referents of pain are evident in
                                                                 2 Pain results from the distressful thoughts of mental
the verbal and non-verbal experience and expression of
feelings. Although feelings such as displeasure, discom-
                                                                 3 Pain serves as a protective mechanism for self-preser-
fort, distress or anxiety described by the individual may be
abstract, they are features of the concept that can be used to
develop approximate empirical measurements. Observable           These are tentative statements that are fertile for the ®eld
behaviours of these feelings include silence, withdrawal         of inquiry. In the re¯ective process of theory development,
from social interaction, impaired thinking, altered atten-       this analysis can provide direction in the discovery of the
tion span, irritability, crying, moaning, holding the painful    meaning of pain.

940                                                  Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 935±941
Nursing theory and concept development or analysis                                                   Analysis of concept of pain

   The interface of the results of this concept analysis with     Clancy J. & McVicar A. (1992) Subjectivity of pain. British Journal
the research process may add to nursing's body of know-             of Nursing 1(1), 8±12.
ledge. For example, the empirical referents of pain can           Davis G.C. (1992) The meaning of pain management: a concept
provide valid and measurable indicators in the develop-             analysis. Advances in Nursing Science 15(1), 77±86.
                                                                  DiMatteo M.R. & Friedman H.S. (1982) Social Psychology and
ment of a pain questionnaire or research tool. The critical
                                                                    Medicine. Oelgeschlager, Gunn, and Hain Publishers Inc.,
attributes could also be useful in the development of
                                                                    Cambridge, Massachusetts.
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Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 935±941                                                        941

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