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Pain is the most frequent nursing diagnosis and the most common problem for which patients in the clinical setting seek help (Mobily, Herr, & Kelley, 1993). Pain refers to an unpleasant, distressful and uncomfortable feeling. Several studies have showed that unrelieved pain can affect the quality of life of the individual, cause physical and emotional distress, impact family, as well as increase the costs for health care, the individual, and society (Ferrell, 1995). Thus, pain is a critical problem in the health care system.
The purpose of this paper is to expand the understanding of the concept of pain. It is my intention to define the attributes of pain and identify antecedents that influence the perception of pain and the possible consequences of pain by using a concept analysis. Recent studies note that pain may not be controlled completely even with state-of –the-art technology and pharmacologic therapies (Kotzer, 2000; Kotzer, Coy, & LeClaire, 1998; Kotzer & Foster, 2000). Beyer (2000) concluded that 715 of the children she interviewed who have sickle cell anemia had moderate to severe pain.
It seems all the efforts of researchers still cannot adequately relieve children’s pain. Children continue to suffer. Health care providers’ lack the knowledge of pain management has been documented as one of the major reasons for this gap (Hester & Foster, 1993).
Another reason may be due to broadly define the concept of pain. Mahon (1994) and Montes-Sandoval (1999) used Walker and Avant’s method of concept analysis and defined critical attributes for pain. These two concepts analyses of pain are currently the only found in the CINAHL data research.
The similarities of both analyses are that pain is a personal experience, an unpleasant, distressful, unwanted, uncomfortable experience. Concept analysis is one way to clarify the definition of pain. Therefore, the purpose of this paper is to expand the understanding of the concept of pain. The aim of this analysis is to clarify the defining attributes of pain and identify antecedents that influence the perception of pain and the possible consequences of pain. Walker & Avant’s (2010) concept analysis serves as a guideline to direct this paper.
A review of the literature revealed what pain is, general health care definitions are used to explore basic information about pain. To define pain, it is described as (a) the sensation which one feels when they hurt (b) suffering, distress, the opposite of pleasure; (c) body suffering, mental suffering, trouble, grief, sorrow; (d) trouble as taken for the accomplishment of something difficult. Originally, pain was defined as suffering, loss inflicted for a crime or offence, punishment, penalty, or fine. Pain is rarely related to punishment or crime. Concepts of suffering, and discomfort are closely related to pain. However, these concepts are not the concept of pain. Pain is always subjective. Each individual learns the meaning of pain based on early life experiences. Pain can act as a warning sign related to tissue trauma or a diagnosis and treatment aid. In nursing, pain can be defined as when an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation.
Pain experience included not only pain sensation and automatic response but also certain associated feeling states. Zborowski (1969) believed social and cultural patterns of the patient have a significant influence on pain experience. He used pain expectancy and pain acceptance to express the individual’s attitude in moving forward. How individuals respond to pain also depend on specific social situations and their culture.
The definition of pain based on McCaffery (1977) and the International Association for the Study of Pain (IASP) (1986) is used most frequently. McCaffery (1977) defined pain as “whatever the experiencing person says it is. According to Ross & Ross (1988), pain serves as both positive and negative functions. Pain can act as warning signs for tissue trauma or treatment aid. The sensation of pain depends more on physical stimulus; however the perception of pain seems to emphasize a more psycho-socio-cultural aspect. Suffering & Discomfort related to Pain
Loeser and Egan (1989) defined suffering as “the negative affective response to pain or to other emotionally laden events, such as fear, anxiety, isolation or depression”. Thus, pain may induce suffering: however, not all pain will induce suffering. Cassell (1992) believed that suffering is “the state of distress induced by the threat of the loss of intactness or disintegration of a person from what cause.” Suffering is a unique experience to each person. Discomfort is another concept related to pain. However, no nursing literature directly defines what discomfort is, although the term is used. Mild pain could be referred to as discomfort. How pain related to discomfort is a contrary viewpoint.
Some attributes of pain, suffering, and discomfort overlap; the most obvious overlapping attribute is unpleasantness. These concepts involve negative and positive responses to events. The level of discomfort is viewed as pain, but an individual can view pain and distinguish the differences between the two.
Defining attributes are consistently occurring characteristics of a concept that help distinguish it from others (Walker & Avant, 2005). Defining attributes is to list the characteristics that are associated with a concept. Any concept analysis will consist of more than one defining attribute; however, one need to determine which attributes are appropriate for the purpose of exploration of the concept (Walker & Avant, 2010). Based on this principle, the critical attributes of the concept of pain include: (a) unpleasant and distressful experiences originating from physical sensation and having both positive and negative meanings for an individual; (b) an individual human experience; (c) a state of feeling in both sensation and emotion (verbal), and behavioral components; (d) physical and psychological responses to the stimulus; (e) function of pain, including protective warning signs; (f) pain responses are learned and influenced by personality, environment, emotions, social and culture.
A model case should include all attributes of the concept and should be a paradigmatic example. It also illustrates the attributes of the concept (Walker & Avant, 2010). The following example presents a model case for the concept of pain.
Mr. T is a 42-year old single Chinese male who was diagnose with colon cancer several years ago. Recently, his tumor was found to be enlarged and his doctor advised him to have surgery, which would require him to have a colostomy. When he was hospitalized for the surgery to remove the tumor, Allison was the nursing student assigned to take care of him. When Allison went to Mr. T’s bedside, she found Mr. T. lying on his right side with his knees bent. He was holding his arms close to his chest. His eyebrows were furrowed, and he looked exhausted. He closed his eyes when Allison talked to him, but was very cooperative. Mr. T’s blood pressure and heat rate were slightly elevated. Mr. T told Allison that he was in pain and pointed to the lower left abdominal area. So Allison gave him the prescribed pain medications.
Two hours later, Allison asked Mr. T how he felt and Mr. T responded, “I feel better.” Mr. T paused for a few seconds and said “ I had abdominal pain and bloody stool when I was having bowel movements a few years ago. I was worried that I might have cancer, so I went to the hospital and was checked. I was diagnosed with colon cancer (he pauses for a few seconds). My family had bad genes. My father died of lung cancer and my brother died of leukemia. I am the only one left in my family. I was diagnosed with cancer as well.” He shook his head and continued, “ I knew what would happen to me sooner or later, and I accepted this fact. It is better that I am not married; otherwise, I would be a burden to my wife and my children.” Analysis
This case illustrates all attributes of pain. Mr. T. complained of having abdominal pain and showed the protective position and facial expression of pain. Thus he showed his pain as unpleasant and distressful experience through both verbal and behavioral responses. Mr. T had warning signs prior to his diagnosis. He believed it was his responsibility to care for his family, so he was relieved to not be a burden. Mr. T had accepted his illness and pain. Alternative Cases
Mr. D is a 64-year-old male who was a minister. He was diagnosed with renal cancer. His doctor recently found out it had metastasized to his left femoral bone. When Allison took care of him, she found that Mr. D always closed his eyes and lay on his right side with legs bent. He usually held a cross and prayed. When his family was present they always prayed together. Allison would ask how Mr. D was doing, and he would always say fine. Allison asked if he was in any pain and he said, “ God was crucified on the cross and died for the mankind. He suffered for all humans and His love is more that anything else in the world. I only have physical discomfort. This kind of discomfort cannot compare to how God suffered for us. So I would like to experience how God suffered for us and understand how God loves people.” Mr. D never answered Allison’s question about whether he was in pain or not. One week later, Mr. D died. Analysis
This example does not represent all the critical attributes of pain, but it does relate to pain. Mr. D never expressed his pain verbally, but his behavioral cues of pain were noted. He did present the psychological pain with avoidance learning behavior. Allison observed that when his family was with him, they prayed together. This action represents how the family social patterns influenced the patient’s pain responses. Contrary Case
A contrary case is the example, which presents “not the concept”; People can easily recognize this concept as not the main concept (Walker & Avant, 2010).
Sally is a 4-year-old girl whose mother brought her to the clinic for immunizations last month. Her mother brought her again for a routine well check. When Sally arrived, she would hold to her mother, close her eyes, and not let her mother put her down. When the nurses would talk to her she would cry and say, “I don’t want to go to the clinic, I want to go home.” The nurses explained what they were doing today, but Sally continued to cry and cling to her mother, saying “Let’s Go Home!”
The defining attributes of pain are absent from this example. It presents the concept of fear. Fear is a reaction to a specific danger or event, which is identifiable. Once the threat is removed, the feeling of fear is forgotten easily. (Yocom, 1984).
Antecedents are the events or incidents that happen before the existing concept (Walker & Avant, 2010). Environmental, personal and cultural values act as antecedents related to the concept of pain. These three antecedents are interrelated.
Environment is related to the event that triggers pain. The individual’s body, mind or both may be affected by pain. The individual’s knowledge and attitude related to the event also play an important role (Nelson, 1993).
Consequences are the events or incidents that happen as results of the concept (Walker & Avant, 2010). The consequences of pain are related to pain reaction and the individual’s own interpretation of the meaning of pain. Pain reaction has a more physical and biological focus; coping with pain refers to the prescription of pain and is psychologically focused.
Pain reaction is viewed as pain behavior. Pain behavior is categorized into involuntary and voluntary responses. Involuntary response wouldn’t involve direct conscious control of the individual. Voluntary responses require consciousness and motor activity. Empirical Referents
The final step of Walker and Avant’s method of concept analysis is empirical references. Empirical references present how the concept is to be measured or what the observation of a phenomenon should in reality be. It is the event that demonstrates the existence of the concept. Determining is the final step in concept analysis. From the analysis of pain, the critical attributes may be abstract; empirical references present how these attributes exist in reality. Thus, analysis of the concept can be used for instrument development. Conclusion
In summary, the concept of pain was selected for concept analysis because pain has been recognized as a serious problem by both patient and health care providers. Nursing studies and literature also present evidence of the consequences of unrelieved pain. I have learned during this analysis that, learning about providing pain relief seems to be an ongoing process. It is beneficial to nurses and other health care providers to gain a better understanding of the concept of pain and in implementing appropriate care and interventions to relieve a patients’ pain. I also learned that not every patient’s pain tolerance or level is the same.
Many patients have different concepts of pain and measures to relieve their pain. Not every patient wants to be medicated. Some patients are strong in the faith and belief of channeling the pain and can tolerate pain better than a child or younger adult. Young or old, the age doesn’t matter, it is up to us as health care professionals and nurses to relieve their pain and make them as comfortable as possible. During this review of literature I have gained a better understanding of the concept of pain and the influence of the perception of pain.
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