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GNUR 5410 – Theory Critique: Pain

Linda M. Edenfield

University of Virginia School of Nursing

On my honor, I have neither given or received assistance on this paper

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Abstract

Pain is a complex. Although unique to each patient, pain is a common condition that

nurses in the acute-care setting must assess, treat and evaluate. The etiology, sources and type of

pain patients experience in the acute care setting varies dramatically, challenging nurses to

employ both pharmacologic and nonpharmacologic therapies to effectively manage acute pain,

while minimizing negative side effects often seen with pharmacologic pain management. This

paper examines the middle-range theory of management of acute pain and side effects through

developmental theories of pain control, the middle-range theory and implications for nursing

research and nursing practice.

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GNUR 5410 – Theory Critique: Pain

Introduction

Pain is defined as “a complex, multidimensional phenomenon that originates from

sensory stimuli, which has obvious motivation-affective properties, demands attention, disrupts

thought and behavior and results in activity aimed to stop the pain.” (Blanchard, 2010). Beyond

an unpleasant sensory stimuli, “pain can also delay healing and recovery” (Good, 1998). Poorly

managed pain is a patient dissatisfier, and has been shown to be contributory in a number of

undesirable outcomes for hospitalized patients including infection, reduced mobility, urinary

retention, and stimulation of unhealthy stress responses, among others (Good 1998).

With institutions focused on patient satisfaction, reductions in hospital length of stay as

well as reductions in post-operative complications, it is critical for nurses to appropriately assess

and treat pain for hospitalized patients. Use of appropriate nursing assessment skills is crucial to

assess pain in patients and determine if interventions designed to reduce pain are effective

(Watson-Miller, 2005). Watson-Miller also proposes that the use of theory, such as middle –

range theory, can help to clarify and guide nursing practice.

The middle-range theory of pain control is based on the acute pain management

guidelines along with theoretical definitions, nursing interventions and measures to accurately

assess and treat pain for hospitalized patients. (Good, 1998). This paper explores and evaluates a

middle-range theory with a physiological focus on pain and the balance between analgesia and

side effects. This paper also considers the use of adjuvant and complementary therapies to

manage acute pain and discusses limitations of this theory in the management of acute pain in the

complex hospitalized patient.

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Background of Pain Theory

Peterson and Bredow (2009) credit Descartes with the first illustration of pain theory in

his drawing of a boy whose foot was too close to a fire. Our modern-day understanding of pain

sensory transmission pathways in the human body has come a long way from the 17th century

drawing by Descartes. However, complete theories for managing pain must address both

physiological and psychological components.

In 1965, Melzack, a psychologist, and Wall, a neurophysiologist, published the Gate

Control Theory. This theory revolutionized our understanding of how the psychological

components of pain can attenuate the physiological transmission of pain impulses in the body.

Later in the 20th century, new discoveries that further differentiated pain receptors provided

researchers and practitioners with additional theories regarding the mechanisms of pain: how

pain occurs and is modulated in the body (Peterson & Bredow 2009). With this new knowledge

practitioners and researchers were able to identify and test pharmacologic and adjuvant

treatments for acute pain.

With expanded knowledge of pain transmission pathways, pain receptors and associated

pharmacologic treatments for pain, two nursing researchers and theorists, Good and Moore,

proposed a middle-range theory of acute pain management to establish a balance between

analgesia and side effects for the management of acute pain (Good, 1996). This middle-range

theory provides an excellent framework to assist nurses in understanding and guiding nursing

practice as it relates to management of acute pain (Watson-Miller, 2005).

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Pain: A Balance Between Analgesia and Side Effects

Good’s middle-range theory of “balance between analgesia and side effects to manage

acute pain” provides a framework for nurses to structure a pain management plan that can

provide an outcome of good pain control while minimizing negative side effects often associated

with potent pain medications. This middle-range theory is structured around three main

propositions which are comprised of intervention or assessment concepts for the management of

acute pain (Good, 1998):

1. Multimodal interventions that incorporate the use of potent pain medications with

adjunctive pharmacologic and nonpharmacologic measures to achieve good pain control

with minimal negative side effects.

2. Attentive care that incorporates frequent and regular assessments of pain and

pharmacologic-related side effects, along with interventions and reassessment designed to

maximize pain control while minimizing negative side effects.

3. Patient participation that provides patient teaching and encourages patient goal setting

for acute pain management.

Multi-modal interventions Potent Pain Medication + Pharmacologic

Adjuvant + Nonpharmacologic Adjuvant

+

Balance Between Analgesia and Side

Effects

Attentive Care

Regular Assessment of Pain & Side

Effects+

Identification of Inadequate Relief and

Unacceptable Side Effects

+Intervention,

Reassessment, Reintervention

+

Patient Participation

Patient Teaching + Goal Setting for Pain Relief

+

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This middle-range theory is based on multiple randomized control trials and decades of

concentrated research on the topic of pain management (Good & Moore 1996). Middle-range

theories allow nursing practice to advance by creating hypotheses that can be tested and

translated into practice guidelines (Good & Moore, 1996). Broad conceptual models don’t

support hypothesis testing for the development of practice guidelines.

In Peterson and Bredow, theories are critiqued through an evaluation of internal

constructs (internal criticism) by examining how the theory components relate and external

constructs (external criticism), by examining how the theory relates to people, nursing and

health. The next sections summarize the analysis of the middle-range theory of pain: a balance

between analgesia and side effects.

Internal Criticism

Clarity:

Good’s middle-range theory clearly states the main components of acute pain

management: multi-modal interventions, attentive care and patient participation. These

components correlate with the nursing process: assess, diagnose, plan, implement, evaluate, and

are well understood by clinicians.

Consistency:

Good’s middle-range theory focuses on management of acute pain. The main

components of this theory support acute pain management and suggest recommendations for

practice that can be implemented by nursing clinicians in a variety of settings.

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Adequacy:

Good’s middle-range theory provides a complete framework for consistent assessment

and treatment of acute pain, while minimizing negative side effects associated with pain

medication. The theory clearly explains the principle concepts of multi-modal intervention,

attentive care and patient participation. The theory also clearly limits the scope to acute pain

management. Although the scope of the theory does not address chronic pain management or

pain management in pediatric populations, the basic theory is complete when considering acute

pain management in uncomplicated patients.

Logical Development:

The components of this theory are based on well-understood physiological pain

transmission pathways and proven pharmacologic treatments for acute pain. The components of

acute pain management guidelines are well grounded in clinical research, and consistent with

nursing workflow and the nursing process.

Level of Theory development:

Good’s theory on managing acute pain is appropriately structured as a middle-range

theory. The concepts and propositions are generalizable to a variety of patient populations who

might experience acute pain, but explained in sufficient detail so that interventions can be

structured with measurable outcomes.

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External Criticism

Reality Convergence:

Good’s middle-range theory addresses a topic in health care that is chronically under-

treated: Acute pain. There is real-world application of this theory in a variety of acute-care

settings. Nurses in clinical practice will find the concepts for management of acute pain in this

theory to have practical application at the bedside. Nursing researchers will be able to use this

theory to conduct research to refine best practices for a variety of adult patient populations

experiencing acute pain.

Utility

Because Good’s theory addresses a topic that is experienced by most hospitalized

patients, particularly patients undergoing surgery, this topic has wide utility. Nursing researchers

and bedside clinicians can use this theory to study acute pain management in specialty adult

patient populations to determine best practices for their practice specialty. Research can be

conducted on tools to measure pain, tools to evaluate side effects of medications,

nonpharmacologic adjuvant therapies and standards of acute pain management for a variety of

surgical populations to establish and refine best practices in acute pain management.

Significance:

Any research conducted to better manage acute pain and side effects of potent pain

medications will lead to improvements in assessment and treatment of acute pain. Because

nurses are largely responsible for assessment and treatment of acute pain, research in this area

will have a direct impact on nursing practice and patient outcomes.

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Discrimination:

Good’s theory on acute pain is unique in that it draws on the physiological and

psychological components of pain as well as the nursing process to assess, intervene, and

evaluate outcomes of current practice. Because this theory is grounded in strong research and

the nursing process, new hypotheses that translate into additional research will be of interest to

nursing researchers and bedside clinicians alike.

Scope of Theory:

Good’s middle-range theory is appropriately scoped to support further study by nursing

researchers and clinicians. This theory provides a framework that could support additional

research by specialty surgical populations, nonpharmacologic adjuvant therapies, pharmacologic

treatments with adjuvants, to name a few. The theoretical constructs support evidence-based

research with measurable outcomes: successful management of acute pain with minimal

negative side effects.

Complexity

Good’s middle-range theory focuses on acute pain. Successfully managing pain can be a

complex process. By limiting the scope to acute pain, Good has eliminated much of the

variability in caring for patients presenting with chronic pain, diabetic neuropathy or long-term

opioid use. The theoretical constructs are well understood by nurses as they are grounded in

current methods for managing pain, nursing assessment and the nursing process.

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Relevance to Nursing Practice

I find the middle-range theory of the balance between analgesia and side effects to be an

invaluable resource in managing acute pain in hospitalized patients. The theory provides a

framework for assessment, intervention and patient education. Both pharmacologic interventions

and non-pharmacologic adjuvants are encouraged as interventions. Often in clinical practice,

non-pharmacologic adjuvants like massage therapy, music and relaxation are overlooked.

However, many adjuvants, like massage therapy, continue to be recognized as a beneficial

healing art that provides comfort and helps reduce pain, anxiety and tension (Anderson &

Cutshall, 2007). My clinical area offers music therapy and provides staffing for a massage

therapist. After studying this theory, I will be more proactive in offering patients the option to

receive therapeutic massage for management of acute pain.

The attentive care described in the theory focuses on regular assessment of pain and side

effects, with intervention and reassessment to achieve maximum pain control with minimal side

effects (Good 1998). The theory also addresses patient teaching and goal setting which is

critical to achieving good outcomes for pain control. Establishing a trusting relationship with

the patient is essential to establish goals and accurately assess pain. In Watson-Miller’s research

on assessing the postoperative patient, she focuses on the patients’ reactions to nursing

assessments: “During the first 24 hours after surgery, the nurse-patient relationship is initiated.

All assessments carried out during this period might have lasting consequences on the patient’s

views.” Based on recent chart reviews in my area of practice, nurses are good at completing the

initial pain assessment and intervention, but have poor follow through with pain reassessment

and reintervention. Side effects, or lack thereof, are rarely documented.

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When I consider developing hypotheses for further research for the patients I care for in

my current area of practice, I do see some limitations due to the fact that the scope of this

middle-range theory is acute pain management in adult patients. This theory does not

specifically address acute pain management in patients who have a history of chronic pain,

severe anxiety, substance abuse, high tolerance to opioids, or in patients who have reduced

hepatic or renal function.

Many hospitalized patients have medical conditions such as diabetic neuropathy or

chronic pain that complicate assessment and treatment of acute pain. Patients who have a history

of long-term ETOH or drug abuse, or have a long history of opioid use due to chronic pain also

present challenges with assessment and treatment of acute pain. When working with patients

who have decreased renal function or compromised hepatic function, nurses must exercise care

in choosing pharmacologic adjuvants for acute pain management. For example, NSAIDs, like

Ketorolac, are contraindicated in patients with decreased renal function. Nurses managing care

for complex patients must be well-versed in understanding laboratory results and the

pharmacokinetics of medications they choose to administer.

Additional research to extend this theory to include the management of acute pain in

complex patients, or in pediatric or geriatric practice areas would expand the utility of this

middle-range theory to better serve our hospitalized patients.

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Conclusion

Nurses know that pain management in the acute care setting is not “one-size-fits-all”. The

pain management plan will look very different for the 100 kg 42-year-old male status-post

CABG as compared with the 55 kg 83-year-old female status-post aortic valve replacement with

DM II and chronic renal insufficiency. The pain management plan for the first 24 hours after

surgery will look very different than the plan three days after surgery. Applying Good’s

theoretical model in the care of each patient will provide consistent assessment and re-

assessment with interventions appropriate to the patient condition.

Pain management in the acute care setting is an aspect of care that is greatly influenced

by consistent and excellent nursing care. The National Database of Nursing Quality Indicators

(NDNQI) includes pediatric pain assessment, intervention, and reassessment as one of the

nursing quality indicators to benchmark quality nursing care.

Watson-Miller states that nursing assessment forms the basis for decision making and

provides an accurate picture of the patient’s current condition She also advocates the use of

theory, such as middle-range theory, to assist nurses in understanding and guiding their practice.

The strength around the middle-range theory of the balance between analgesia and side effects is

the regular assessment of pain and side effects, with intervention and reassessment. This

structured approach to the theory of pain management increases the significance of its

application in practice. Using this theory as a sound framework allows nursing leaders and

clinicians to establish guidelines and recommendations for nursing practice and provides a

framework for future research.

Having researched this theory, I now have a framework to support my own practice in

managing acute pain and untoward side effects for cardiothoracic post-operative patients in my

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care. I will be more rigorous in my own practice and will also encourage my colleagues to be

more cognizant of assessing for and documenting side effects to the medications we use to treat

acute pain to maximize pain relief with minimal side effects.

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Appendix of Additional Citations

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