Concept analysis has been gaining popularity in medical research during recent years as it acts as a perfect tool that allows achieving conceptual clarity about various issues related to health care. It can be attributed to the fact that it has been recognized by a number of prominent researchers that building a scientific base is impossible without developing major concepts and organizing them into a coherent framework. Concept analysis allows understanding abstract notions that are often controversial or ambiguous and therefore require clarification to be used as a part of a theory (Pielech, Vowles, & Wicksell, 2017).
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The nursing concept that will be discussed in the paper at hand is the concept of pain. It was chosen for the reason of being the most commonly cited problems in the medical histories of patients who seek pain relief.
Despite numerous theories that address the concept, there is still a lack of knowledge of pain as a personal experience: its meaning, functions, responses to it as well as consequences pain may bring about. Such a vague understanding may considerably affect the way people perceive themselves when they suffer from pain. Thus, the purpose of the research at hand is to clarify the definition of pain, investigate its attributes, antecedents, and consequences, and distinguish it from related concepts.
Gate Control Theory (GCT), proposed by Melzack and Wall, was chosen as the most suitable one for the purpose of the present research as it unites the major advantages of the Specificity Theory and the Pattern Theory. Besides, it is the one that is most commonly used in nursing. Walker and Avant’s concept analysis model will be applied as the most suitable for meeting the objectives of the study. These scholars analyzed concepts as a bundle of attributes and characteristics that distinguish them from other similar or related ones.
They claim that concept analysis is required to find out its similarities and differences as compared to such closely connected concepts as pain and suffering, pain and discomfort, etc. The componential analysis is suggested as one of the most effective ways to single out defining and irrelevant attributes of a concept. The authors suggest analyzing concepts (including the concept of pain) following eight basic steps: 1) defining it; 2) identifying what the purpose of the examination is; 3) enumerating all usages of the concept; 4) describing attributes; 5) making up a model case; 6) building related, border, contrary, invented, and illegitimate cases; 7) finding out antecedents and consequences, 8) providing empirical referents.
Thus, the paper will have the following sections: 1) definition/explanation of the selected nursing concept; 2) literature review; 3) defining attributes; 4) antecedent and consequence; 5) empirical referents; 6) model cases; 7) alternative cases; 8) conclusion.
Definition/Explanation of the Selected Nursing Concept
In order to understand what effects pain may produce, first and foremost, it is necessary to define it from the general and healthcare-specific points of view. For a better understanding of the concept, it would be reasonable to use dictionaries that provide the etymology of the word that gives additional information about its nature and the human perception of it. Different dictionaries provide dissimilar definitions of the concept; however, most of them agree that: 1) pain is the sensation that mostly emerges when a person is injured or hurt physically or mentally; 2) it is opposite of pleasure and is typically connected with sufferings, distress, sorrow, and a number of other unpleasant feelings and emotions.
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Historically, the pain was usually understood as punishment that could be inflicted upon a person for violation of law: If someone disobeyed the accepted rules (no matter if they concerned legal or religious practices), he/she deserved a penalty. This definition goes as far back as the 13th century CE. In the present works (books, encyclopedias, peer-reviewed articles, etc.), pain is never understood as retribution and has no connection to any crimes or violations whatsoever. Most researchers interpret the concept as a highly unpleasant feeling (which can be both physical and psychological), causing suffering, grief, anger, and other dissatisfying sensations that are caused by the stimulation of nurse endings. The purpose of pain is mostly seen as protective: If a person feels pain, it means that his/her body is claiming that some of its systems are being damaged and is intentionally provoking a reaction (Mendell, 2014).
The specific definition of pain is provided by the International Association for the Study of Pain (IASP) that understands the concept as a disturbing physical or emotional experience that most frequently result from a real (or only anticipated) injury or hard done to one of the body organs or systems. It is emphasized that pain is always subjective and cannot be measured theoretically as each individual learns the essence of the concept only though empirical experiences.
However, this definition induces a lot of debate as some scholars involved in pain studies to claim that this experience is not always unpleasant and should not be regarded as the one serving only negative functions. It has been proven that some people can feel pleasure coming from pain. Moreover, the presence of discomfort can be positive as it indicates that the tissue reacts to outer stimuli and therefore is not dead. This makes pain a complex physical, psychological, and cultural phenomenon that cannot be viewed exclusively from one perspective (Kendall & Hollon, 2013).
As far as the Gate Control Theory is concerned, it claims that our perception of pain is actually determined by three interactive and interrelated cerebral processes: These are sensory-discriminative, motivational-affective, and cognitive-evaluation aspects that are to be discussed in the literature review section.
Due to the fact that neurons were discovered not so long ago, pain could not be scientifically explained in nursing theories of the past. Nevertheless, even early scholars attempted to define it: For instance, Hippocrates supposed that pain appeared as a result of an imbalance of vital fluids of the body. Later, Avicenna included pain into senses. However, the concept was never connected to brain functioning before the discovery of neurons (Knoerl, Lavoie Smith, & Weisberg, 2016). Even during the scientific Renaissance, it was believed that it exists outside the body.
The first to link pain to nerve fibers and brain was René Descartes, who thereby transformed its perception form religious to physical. After him, four major theories can be named that profoundly explain the pain as a medical concept: Specificity Theory, Gate Control Theory, Behavioral Theory, and Pattern Theory (Jacoby, Bruneau, Koster-Hale, & Saxe, 2016).
According to Melzack and Wall, who developed Gate Control Theory (which united Specificity Theory and Pattern Theory), sensory-discriminative, motivational-affective, and cognitive-evaluation dimensions of pain cannot be viewed separately as they overlap and complete one another. The first one is connected with the transmission of an impulse from the brain periphery to the spinal cord; sensory-discriminative information about the location, character (including duration, intensity, etc.) of pain is processed in our neospinothalamic projecting system. The second dimension involves the formation of the brainstem reticular and the function of our limbic system that serves to create motivation. Finally, the third aspect is based on the processing of multi-modal data, an unceasing continuity of impulses and responses to them. They also include strategies that help the patient to cope with pain (Mendell, 2014).
This theory is often intertwined with the Behavioral approach that stresses the role of education, personality, psychological state, cultural background, and other factors that may influence pain experience. Some scholars perceive this concept as an opportunity to learn from respondent and operant conditions (that is either as an antecedent stimulus or as a response to the environment). Pain behavior is likely to persists if the conditions are aggravated (Kendall & Hollon, 2013).
It is generally agreed that pain always involves the psychological aspect, which, however, does not have a decisive impact on pain behavior that follows as it is determined by numerous factors including cognitive, emotional, physical, cultural, and other types of evaluation. Pain experience is not limited to a stimulus and a response–it encompasses all associated states and feelings. From the sociological perspective, pain is seen as a feeling shaped by social patterns as they may have a considerable impact on pain expectancy and pain acceptance. Individual perception of pain should also be taken into account as it predetermines reactions as well as the ability to terminate it (Dahlke, Sable, & Andrasik, 2017).
All researchers who study the topic specifically emphasize that the concept of pain should be differentiated from related concepts of discomfort and suffering. The latter is defined as a negative response to pain, fear, anxiety and other experiences, which means that not all kinds of pain may provoke suffering since it is rather a moral and psychological state, a consequence of personhood and individuality. In its turn, discomfort is also connected with pain but is usually understood as a milder version of it (although it is more intense than distress) (Papini, Fuchs, & Torres, 2015).
It may be inferred that some attributes of pain, discomfort, suffering, distress overlap and are sometimes difficult to differentiate. However, pain is distinguished as it always involved both physical and psychological aspects, which are equally influential.
Defining attributes are characteristic features that are associated with the concept and are often mixed up with it. Regardless of the complexity of the concept, there is always more than one defining attribute. However, researchers usually select only those attributes that can produce an impact on the outcomes of their studies. The key attributes of the given concept are (Kaiser & Nilges, 2015):
- irritating, unpleasant or distressful experiences that arise from the physical aspect;
- positive and negative perceptions of such experiences;
- cultural, psychological, and other domains;
- responses to a stimulus;
- warning and protective functions of pain;
- environmental factors affecting the experience.
Antecedent and Consequence
Antecedents can be defined as events that occur before the concept and precondition it. The concept of pain has personal, environmental, and cultural aspects as antecedents. The first one related to the peculiarities of body (sleeping pattern, muscle state, reaction to stimuli, etc.) and mind (emotional state, stress level, etc.), personality, gender, and other factors that influence the individual perception of pain. The second one refers to events that led to the occurrence of pain. The third includes the impact of socio-economic class: It has been proven that people belonging to higher classes tend to be more sensitive to pain. Moreover, culture may determine the reaction to pain, pain expectancy, and acceptance (as a willingness to experience it) (Mendell, 2014).
Consequences of pain are reactions to it, a personal interpretation of its implication, which is more psychological than physical. It is connected with pain behavior including both voluntary (motor activity, consciousness, complaints, moaning) and involuntary responses (reflex and heart rate reactions). Verbal expressions of pain may be realized as intrapersonal, interpersonal, and symbolic communication (allowing a person to develop a meaning for the experience). Consequences can be both positive and negative. In any case, they influence the way a person copes with pain utilizing coping strategies (Mendell, 2014).
Empirical referents define how the concept is measured and what signs prove that it actually exists. In other words, they present how attributes of pain manifest themselves in reality. In case of pain, the patient’s verbalization and presentation of it is used as the major referent. However, it should be considered that it is not always relevant and reliable (e.g. the patient’s capability of expression may be restricted). Thus, the second attribute is behavioral cues that are include movement or avoidance of movement, crying, moaning, passiveness or restlessness, etc. (Mendell, 2014).
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A model case is a paradigmatic example, which illustrates the attributes of a concept. For instance, Mr. N is a 45-years-old Indian male who suffers from colon cancer. He was recommended to undergo colostomy as he has a pain in abdominal area and bloody stool (antecedents). In hospital, a nurse notices that he is lying on his right side with his knees bent and arms on his chest and looks tired (attributes showing distressful experience). The nurse finds out that his father and brother died of cancer. This created a certain psychological consequence of pain as the patient is sure that he is going to die of cancer, too. This also reflects social and cultural aspects as in the Eastern culture cancer is seen as incurable.
A borderline case has the same attributes, but not all of them: For instance, Mr. N may be a Christian male who has a colon cancer. The attributes are the same: He lies on his side with his knees bent and has a frowning expression on his face. However, when the nurse asks him what is wrong he keeps silent as he believes that Christ suffered and he has to suffer, too. The consequences of the pain can be different as the patient may die due to his refusal to relieve pain.
A contrary case it the one that illustrates the opposite of the concept. For example, Ben is a 4-year old who comes to the hospital with his mom for a check. He does not experience any pain. However, he has a suffering expression on his face and behaves as if something is deeply wrong. However, it is caused by his fear of doctors and pain, which does not actually take place.
The concept is too broad and refers to all kinds of unpleasant and uncomfortable feelings. It requires specification to understand how to deal with it. Gate Control Theory was chosen for this purpose. Pain is one of the most acute concepts of nursing: Researchers study pain experiences, types, measurement, its effects on the patient and its outcomes. Yet, it has been proven that it is impossible to eliminate or control pain completely even using modern medications and technologies; in most severe cases pain can only be moderated, which implies that further, more profound research is needed.
Dahlke, L. A. M., Sable, J. J., & Andrasik, F. (2017). Behavioral therapy: Emotion and pain, a common anatomical background. Neurological Sciences, 38(1), 157-161.
Jacoby, N., Bruneau, E., Koster-Hale, J., & Saxe, R. (2016). Localizing pain matrix and theory of mind networks with both verbal and non-verbal stimuli. NeuroImage, 126(1), 39-48.
Kaiser, U., & Nilges, P. (2015). Behavioral concepts in the treatment of chronic pain. Schmerz, 29(2), 179-185.
Kendall, P. C., & Hollon, S. D. (2013). Cognitive-behavioral interventions: Theory, research, and procedures. London, UK: Academic Press.
Knoerl, R., Lavoie Smith, E. M., & Weisberg, J. (2016). Chronic pain and cognitive behavioral therapy: An integrative review. Western Journal of Nursing Research, 38(5), 596-628.
Mendell, L. M. (2014). Constructing and deconstructing the gate theory of pain. PAIN®, 155(2), 210-216.
Papini, M. R., Fuchs, P. N., & Torres, C. (2015). Behavioral neuroscience of psychological pain. Neuroscience & Biobehavioral Reviews, 48(1), 53-69.
Pielech, M., Vowles, K. E., & Wicksell, R. (2017). Acceptance and commitment therapy for pediatric chronic pain: Theory and application. Children, 4(2), 10-23.