Journal of Advanced Nursing, 1999, 29(4), 935941

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

MONTESMONTES-SANDOVAL L. (1999)

Journal of Advanced Nursing 29(4), 935941 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 identied. 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

INTRODUCTION
Pain is a universal factor and a common human experience. Yet, despite its universality, pain is a very complex concept to dene and understand. In nursing practice, pain is probably one of the most widely experienced and expressed phenomena. Its magnitude and application suggest that nurses have an adequate understanding of its meaning. However, Zalon (1995) suggests that nurses lack basic knowledge about pain and its management. Poor relief of pain is well-recorded and has been noted in nursing literature for over 20 years (Zalon 1995). This is both thought-provoking and troublesome, as it reects the incompleteness of the nursing process. Suffering pain needlessly raises ethical concerns and is a barrier to nursing's goal of enhancing an individual's quality of living. Pain cannot be assessed adequately if it remains vague, ambiguous and arbitrarily dened. Conceptual clarity of pain is important as the nursing profession continues to establish itself as a distinguished discipline.

A concept analysis is a useful technique to promote conceptual clarity. An analysis is a `formal linguistic exercise' to examine critical attributes of a particular concept (Walker & Avant 1995). A careful analysis of pain and distillation of its attributes will enhance understanding and result in an operational denition that can be assessed empirically (Chinn & Kramer 1995, Walker & Avant 1995). The purpose of this paper is to engage in this cognitive exercise of critical thinking to examine the concept of pain and to reect on its meaning, rather than to draw a solitary conclusion. Ironically, the only assured outcome of this exercise is ambiguity that leads to continued exploration. This concept analysis is intended to provide a workable approximation from which the nursing profession can draw and expand the conceptual clarication of pain. Such analysis is part of an evolutionary process to develop and strengthen the substantive knowledge that guides our practice. This being the case, the analysis of the concept of pain is conducted within the classic framework developed by Walker & Avant (1995).

Correspondence: Lucy Montes-Sandoval, College Assistant Professor, Department of Nursing, MSC 3185, New Mexico State University, PO Box 30001, Las Cruces, NM 88003-8001, New Mexico. Tel.: (505) 646 3812; Fax: (505) 646 2167.

CONCEPT USAGE AND DEFINITIONS

To clarify the meaning of the concept of pain it is important to identify as many uses of the term as possible.

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L. Montes-Sandoval The ndings allow for richer meaning and are used to validate the selection of dening attributes (Walker & Avant 1995). Historical applications, dictionary and encyclopedia denitions and the nursing literature provide invaluable information.
the arm. The hook had merely pierced the heavy materials of his coat and shirt (p. 152).

Muse's example conveys the fact that pain can be attributed to psychological and emotional components.

HISTORICAL USE
Pain is a universal phenomenon that is deeply rooted in history. Several scholars contemplated the meaning of pain. The ancient Greek philosopher, Aristotle, dened pain as the opposite of pleasure (Francis & Munjas 1975). The 16th century French philosopher, Rene Descartes, viewed the mind and body as separate entities, with pain functioning as a warning system within the body urging the body to seek relief (Locke & Colligan 1986, Mahon 1994). Sigmund Freud believed pain and pleasure had a reciprocal interaction. Freud, a classical pychoanalytical personality theorist of the 19th century, speculated that the `id', a component of personality, operated on the `pleasure principle'. The goal of the `id' is to reduce or eliminate discomfort or pain as quickly as possible to achieve pleasurable feeling (Allen 1994). Florence Nightingale also recognized the importance of understanding pain. Nightingale (1859/1992) wrote about pain in her book Notes on Nursing: what it is and is not. She stated `the sick suffer to excess from mental as well as bodily pain' (p. 34). She believed a common misconception among the healthy was that sick individuals had a choice to `dismiss painful thoughts which aggravate their disease' (p. 35). Her writings suggest that physiological and psychological factors are powerful inuences in the experience of pain and disease. Another historical medical reference to pain is made in the 1934 edition of The Merck Manual. It identied pain as a response to `excitation, probably summation of stimuli, of certain sensory nerve structures, which may be located anywhere, from peripheral expansion to receptive center' (p. 706). Physical pain consisted of discomfort of local disease of organ or tissue, muscle pain and nerve pain. Psychological pain or `psychalgia' was described as `an abnormal mental perception, often due to suggestion and curable by psychotherapy' (p. 707). 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 experience `pain hallucinations' and supported this with the following description.
A butcher while attempting to hang a side of beef on a high hook slipped from the top of the ladder and was himself suspended from the hook. Since he appeared to be suffering acute agony he was carried across the street to a chemist shop. He was pale, pulseless, and cried out whenever his arm was touched or moved. His sleeve was carefully cut away but not a scratch was found on

HISTORICAL FUNCTIONS
Pain is often described in the literature as serving a function. Analysis of pain from this functional perspective is useful to further synthesize dening attributes. Harry Stack Sullivan, known for his interpersonal theory of personality development, described the function of pain as a learning experience. Sullivan (1953) believed that the iniction of pain, in the form of punishment, `is used in its own right as an educative inuence, this means a new type of learning namely, learning enforced by a growing discrimination of the connection between certain violations of imposed authority and pain' (p. 204). The implication is that pain can be a modier of behaviours. Francis & Munjas (1975) looked at pain as serving the function of providing a protective mechanism. Pain signals that something is wrong and is the symptom that most frequently causes an individual to seek assistance for health problems. They dened pain further as an unwanted, lonely, anxiety-producing experience that really cannot be shared or perceived by another. Pain generates anxiety and in turn, anxiety, potentiates pain creating a threat to body and mind. Another function of pain, as discussed by DiMatteo & Friedman (1982), is a form of communication. The sensation and expression of pain generally draws compassion and assistance from others; the expression of pain may be a request for comfort. Pain may be a symbolic expression of a problem within an interpersonal relationship. For example, an individual may actually feel neck pain whenever `the boss' is around. In addition, DiMatteo & Friedman stated it was misleading to consider pain to be exclusively mental or physical. They believed pain to be an example of how mental and physical factors are intertwined and supported this with the phenomena of pain-free surgical procedures performed under hypnosis.

DICTIONARY AND ENCYCLOPEDIA DEFINITIONS

Dictionary and encyclopedia denitions assist in clarifying prevalent usages and thoughts for conceptual meaning. Existing denitions often do not provide a complete sense of meaning but they are useful in identifying basic elements, perceptions or feelings related to the concept. Dictionaries and encyclopedias convey commonly accepted ways in which a word is used and are benecial in

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Nursing theory and concept development or analysis tracing the origins of specic words (Chinn & Kramer 1995). The dictionary is a logical place to begin. Merriam Webster's Collegiate Dictionary (1996) has dened pain as:
1: PUNISHMENT 2: usu. localized physical suffering associated with bodily disorder (as a disease or an injury); also: a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action b: acute mental or emotional distress or suffering: GRIEF.

Analysis of concept of pain hemisphere, suggesting both a physical and/or psychological response. The gate control theory acknowledges the inuence of external factors and expands its interpretation of pain to include the existence of sensory, affective and cognitive dimensions. Development of this theory continues to further rene the pain experience. Walding (1991) explored postoperative pain and acknowledged the difculties of dening pain, as it is not purely physical or psychological experience. Multiple factors affecting pain are strongly indicative of this unique and personal experience. More specically, Walding hypothesized that pain, anxiety and powerlessness are interrelated. Pain and anxiety illicit similar physiological responses, thus one may enhance the other. The link between anxiety and powerlessness hinges on a state of helplessness from a real or perceived lack of control over a situation. Walding postulated that because the relationship between anxiety and pain exists and a link between anxiety and powerlessness had been identied, it is likely that there is a relationship between pain and powerlessness. Villarruel & Ortiz de Montellano (1992) supported the importance of socio-cultural inuences on pain. They suggested that attitudes and reactions to pain are learned in early childhood within a cultural context. Meanings and attitudes related to pain are culturally different and, therefore, behavioural responses will vary. Several themes specic to the Mexican-American culture have been identied. For example, there may be an admiration for enduring pain stoically as a reection of courage; or pain may be viewed as a punishment from God for unacceptable behaviour. Villarruel & Ortiz de Montellano's ndings emphasized the importance of understanding the socio-cultural framework within which pain is experienced and expressed. Waddie (1996) found that pain is an everyday experience that is expressed through the use of language and is then legitimized. The expression of pain is not a separate occurrence but rather is part of the pain experience, which is inuenced by socio-cultural factors. Language is learned within the various socio-cultural entities, therefore pain too can have a variety of expressions. Verbal transmission can consist of many words to describe pain; however, the lack of verbal transmission or expression does not imply that there is no pain. Non-verbal expression must also be considered as part of the pain experience. Socio-cultural inuences determine how and if the experience of pain will be expressed. Mahon (1994) conducted an extensive literature review in her phenomenological approach to the analysis of pain. She concluded that the following are the dening attributes of pain: 1 a personal experience; 2 an unpleasant experience;

The Greek, Latin and French derivatives of the word pain all imply punishment or penalty. The Psychiatric Dictionary (Campbell 1996) has dened psychic pain, psychalgia, as discomfort or distress located in the head, which `accompanies mental activity (obsessions, hallucinations, etc.), and is recognized by the patient as being emotional in origin' (p. 587). Psychalgia is thought to be due to the presence of intolerable anxiety. For example, a schizophrenic patient may complain of pain in his head as a result of electrical currents and depressed patients often complain of headaches. Pain is a `perceived aversive or unpleasant sensation that originates from a specic region of the body' (p. 504). Pain can arise without activity from the nerve cell receptors, and psychological factors can clinically account for its onset, severity or exacerbation. Encyclopedia reviews (The New Encyclopaedia Britannica 1988, The New Grolier Multimedia Encyclopedia 1993) have dened pain as an uncomfortable, unpleasant, distressful, somatic sensory and emotional experience associated with injury, threat of injury, or some type of damage to the body. Pain serves as a protective measure to withdraw from harmful stimuli. The experience of pain is physiological, psychological and subjective.

USES IN NURSING
Nursing views pain from a holistic perspective. This conceptual orientation of physiological, psychological and socio-cultural interaction is a very traditional approach to nursing. The analysis of pain within this framework is supported with the following literature review. Melzack & Wall's gate control theory of pain (as cited in Clancy & McVicar 1992, Davis 1992, Stevens & Johnson 1993) details neurophysiological functions and the concept of pain regulation by a `gating mechanism' located in the spinal cord. This is a very complex theory that basically denes a mechanism that increases or decreases the sensory impulses generated by injury-sensitive nerve cell receptors, called nociceptors. The term nociceptors has its origins in the word noxious, which means physically harmful or destructive (PAIN-L 1996). Nociceptorgenerated impulses are interpreted as pain in the cerebral

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L. Montes-Sandoval 3 a dominating force; 4 endless in nature. In her model, `pain is represented as a circle signifying the unending and ceaseless qualities of pain. Also, the pain encircles the person having the experience, which denotes the dominating nature of pain and how it separates the individual and interferes with relationships' (p. 20). Mahon's contribution to the body of nursing knowledge provides fertile ground for continued dialogue on the universal concept of pain. Her ndings, in conjunction with the literature review of other identied uses of the concept of pain, provide the opportunity to develop the critical attributes of this analysis. example in the creation of meaning for the phenomenon of pain. Alicia is an attractive, 32-year-old, married, Hispanic woman. She is recovering, 3 days postoperative, from a mastectomy. The nurse enters the room to change her dressings and nds her silently crying. The nurse gently comments on her tears. Alicia avoids eye contact and says nothing. As the nurse changes the dressings, Alicia turns her head away and closes her eyes. The nurse notices that Alicia is diaphoretic and tense. Her blood pressure and heart rate are elevated and the nurse inquires if she is in pain. As she grimaces and guardedly repositions herself, Alicia responds, `I' m not sure, I guess I am just tired'. The nurse offers Alicia pain medication, reaches for her hand and acknowledges the loss Alicia must feel, as well as the discomfort of postoperative pain. Alicia bursts into tears and cries, `I don't know what I feel. I'm so tired and I feel terrible all over. My chest hurts and I'm worrying about what my husband is going to think. I'm so ugly now and scared my husband is never going to want me again. For sure he can't love half a woman'.

CRITICAL ATTRIBUTES
Attributes of a concept appear repeatedly and are derived from the literature review to identify specic phenomena and to serve the function of differentiation. They are not irrevocable but instead are subject to change. The goal is to cluster the distinctive features commonly afliated with the concept and that allow for broad insight (Walker & Avant 1995). The characteristics that surfaced in this analysis of pain are synthesized as the following critical attributes: 1 dominating, unpleasant, distressful, unwanted, uncomfortable experience; 2 neurophysiological, psychological, socio-cultural, response to a noxious stimulation; 3 variable, subjective and difcult to explain sensation that cannot really be shared or perceived by others; 4 aversive sensation to an actual or potential threat of injury or damage to body and/or mind; 5 form of verbal and/or non-verbal communication; 6 unique experience that serves as a protective mechanism for self-preservation; 7 reciprocal interaction with anxiety; 8 mental misperception leading to distressful thoughts. The critical attributes described add to the evolution and renement of a useful and adequate meaning of pain. In the process of creating conceptual meaning, it is also benecial to construct cases that are representative of the phenomenon. Scenarios in the form of model, related and contrary cases aid in representing the concept of pain (Chinn & Kramer 1995, Walker & Avant 1995).

Discussion
This model case includes all the critical attributes of pain. Alicia responds with distress, displeasure and discomfort to the mastectomy, which is a dominating, unwanted, aversive, noxious sensation. Alicia's bodily pain is evident in obvious tissue damage and the neurophysiological manifestations. It is difcult for her to communicate her experience as demonstrated in her initial vague and minimal response. The nurse notes Alicia's verbal and non-verbal communication and shares her subjective perception of what Alicia may be experiencing and expressing. The removal of Alicia's breast is laden with socio-cultural signicance and her Hispanic heritage will inuence how she will experience and express her physical and psychological injury. The quiet crying, poor eye contact, derogatory selfappraisal and avoidance of interaction with the nurse all reect psychological pain. In addition to her pain, Alicia expresses her `worries' as she experiences anxiety over the loss of a signicant body part associated with her female body image. With the added anxiety, Alicia has misperceptions of being ugly, incomplete and undesirable. These 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 psychologically present in this situation. Alicia's unpleasant thoughts are in anticipation of rejection and withdrawal from her husband. Her thoughts serve as a protective mechanism as she sets up a psychological safety net for self-preservation. If Alicia's husband responds as she anticipates, Alicia can preserve her psychological integri-

MODEL CASE
The critical attributes of pain can be applied in the construction of a model case to illustrate the occurrence of the concept. A model case is one in which there is certainty of its representation of the concept. The following model case of pain represents a paradigmatic

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Nursing theory and concept development or analysis ty as her misperceived and aversive thoughts begin to prepare and protect her from additional mental anguish.

Analysis of concept of pain cannot really be shared or perceived by others. Fifthly, as would be expected, there is a variety of verbal and nonverbal communication occurring in this dilemma. Sixthly, Frank and Sarah are engaged in a tenacious process; the nal decision could be viewed as the protective mechanism for preservation of their family. Finally, it is reasonable to assume that anxiety is present as Frank and Sarah wrestle with a choice between two loathsome circumstances. Despite the similarities between pain and anguish, the critical attribute of mental misperception leading to distressful thoughts is not present. Upon close examination, painful thoughts are distinctly and unmistakably evident; however, these thoughts are not generated from mental misperceptions. Frank and Sarah are very realistic when they state, `Adam's chances of living are poor no matter what we decide'. They are not misinterpreting their dilemma, they understand and know the prognosis is poor whether they choose the surgery or not.

RELATED CASE
A related case demonstrates an instance that is similar to the concept, yet is different when examined closely. The case provides understanding of concept linkage and clarity of the attributes central to the concept being examined (Chinn & Kramer 1995, Walker & Avant 1995). For the development of the related case, the concept of anguish is used. Although anguish may have characteristics in common, it is different from pain. Frank and Sarah's 5-year-old son, Adam, will not survive without liver transplant surgery. He is gravely ill and not expected to live long. When Frank and Sarah visit Adam, he sadly states, `I want to go home. I don't like it here'. They talk to Adam about the possibility of surgery and he begins to cry, `I don't want no more booboos, I want to go home now'. Frank and Sarah are consumed with grief and sorrow, they must make an excruciating decision. In addition to a poor surgical prognosis, Adam has expressed his opposition to further hospitalization or treatment. They share their agony with one another and seek the support of family and friends, often stating, `We don't know what to do, Adam's chances of living are poor no matter what we decide'. Frank and Sarah are sorrowstricken with this predicament. They seek solace in one another as they are tormented by Adam's wishes and their own needs. They struggle with the weight of this dilemma and experience a great deal of anguish.

CONTRARY CASE
A contrary case is a lucid presentation of `not the concept'. Similarities may be present; however, the contrary case has characteristics that are easily recognized as not representative of the concept (Chinn & Kramer 1995, Walker & Avant 1995). Development of this type of case assists in clear identication of the critical attributes of the concept of pain. Gina is admitted to the psychiatric unit with various welts, bruises and supercial lacerations. As the nurse interviews and assesses Gina, she notes that she is not in any particular distress. In fact, Gina seems to be somewhat titillated. When the nurse comments on this, Gina giggles and responds, `Have you ever been in love? I have the greatest boyfriend, he makes me so happy'. Upon further assessment, it is discovered that Gina has a history of physically and sexually abusive relationships. Her current boyfriend is the perpetrator of her physical injuries. Gina is diagnosed with the psychosexual disorder of masochism.

Discussion
Anguish is a phenomenon similar to pain. It is dened as extreme pain, distress or anxiety (Merriam Webster's Collegiate Dictionary 1996). This couple experiences profound grief and sadness over the imminent threat to their child's life. Frank and Sarah are inicted with intense personal suffering. With close analysis, the similarities become apparent but the differences are also present. The phenomenon of anguish is similar to pain in many ways. First, Frank and Sarah are engaged in an obvious process that is dominating, unpleasant, distressful, unwanted and uncomfortable. Secondly, they must respond to the noxious stimulation of impending surgery and the threat to Adam's life. Thirdly, it is reasonable to assume Frank, Sarah and Adam will have a neurophysiological, psychological and socio-cultural response to this threat of injury or damage to body and mind. Fourthly, as with most personal experiences, anguish is a variable, subjective and difcult to explain sensation. Although Frank and Sarah have the support of friends and family, it

Discussion
The critical attributes of pain are not present in this example. Gina's behaviours are in direct and unequivocal opposition to the normal mind and body sensation of pain. She responds with pleasure, both verbally and nonverbally, to a welcome but aversive encounter threatening her wellbeing. Gina may or may not experience anxiety; regardless, she does not perceive the physical or sexual abuse as a noxious stimulus that prompts her to respond with a protective mechanism. Finally, Gina's misperceptions lead her to pleasant impressions of love and happiness versus distressful thoughts.

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ANTECEDENTS AND CONSEQUENCES Antecedents

Prior to the occurrence of a concept, certain events called antecedents must take place. These antecedents help to rene further the critical attributes of the concept (Walker & Avant 1995). The following are antecedents of pain: 1 Internal or external circumstances arise, creating noxious stimuli to the nociceptors and/or aversive sensations creating the likelihood of discomfort. 2 The individual is either physically or psychologically aware of the stimuli or discomfort. 3 The noxious stimulation or aversive sensation is perceived as pain.

area, vigilant guarding of the involved area, restlessness or avoidance of movement, inching, wincing, grimacing, strained facial expression or altered eye contact. Objective empirical referents of the pain experience can be identied by various bodily manifestations. Observable and concrete physiological determinants include alterations in muscle tone, diaphoresis, vomiting, weakness, syncope, increased or decreased respirations, alterations in cardiac rate and blood pressure, dilated pupils or sleep disturbances. These more direct empirical indicators are readily observed, assessed and measured utilizing various instruments.

CONCLUSION AND IMPLICATIONS TO NURSING PRACTICE

Pain is a subjective experience and it would be misleading to represent pain as having an exclusive denition. As a natural human response, pain decidedly remains a synthesis of complex interacting operations. However, exercising the application of the concept analysis to the phenomenon of pain leads to increased understanding and agreement, therefore improving nursing interventions and allowing for the completion of the nursing process. The identied attributes, antecedents, consequences and empirical referents of pain are useful in providing the nurse with a frame of reference from which pain can be holistically addressed. Use of this analysis of pain is innate to nursing practice as nursing recognizes and understands the richness of the dynamic interactions of the physical, psychological and socio-cultural being. Conceptual clarity is a key factor in distinguishing the nursing profession as it provides the underpinnings for a sound theoretical and scientic basis for professional practice. This concept analysis can serve as a foothold toward the development of a comprehensive theory of 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 renement. A crucial component of theory is determining the relationship between various concepts. The following critical attributes of pain distilled in this analysis suggest several interconnections: 1 Pain has a reciprocal interaction with anxiety. 2 Pain results from the distressful thoughts of mental misperception. 3 Pain serves as a protective mechanism for self-preservation. These are tentative statements that are fertile for the eld of inquiry. In the reective process of theory development, this analysis can provide direction in the discovery of the meaning of pain.

Consequences
As a result of the occurrence of a concept there are outcomes, called consequences. Consequences are the events or incidents that occur after the concept (Walker & Avant 1995). The following are consequences of pain: 1 The individual, with verbal and non-verbal communication, demonstrates neurophysiological, psychological and/or socio-cultural responses to the perception of pain. 2 The individual's response to the pain may or may not provide relief. 3 Using available protective mechanisms, the individual ventures to relieve the pain, cope with the pain and/or seek assistance in efforts of self-preservation. 4 Others will respond to the individual and provide various interventions in relieving or coping with the pain. 5 The individual's pain will remain the same, decrease, or increase.

EMPIRICAL REFERENTS
The nal step of the concept analysis is identication of empirical referents. Empirical referents are indicators that exemplify the existence of the concept itself. They are used to measure the concept or validate its existence in reality (Walker & Avant 1995). In the analysis of pain, subjective and objective empirical referents are identied. The subjective empirical referents of pain are evident in the verbal and non-verbal experience and expression of feelings. Although feelings such as displeasure, discomfort, 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 behaviours of these feelings include silence, withdrawal from social interaction, impaired thinking, altered attention span, irritability, crying, moaning, holding the painful

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Nursing theory and concept development or analysis The interface of the results of this concept analysis with the research process may add to nursing's body of knowledge. For example, the empirical referents of pain can provide valid and measurable indicators in the development of a pain questionnaire or research tool. The critical attributes could also be useful in the development of instruments that enhance a holistic approach to pain. In addition, a qualitative research approach could be implemented, in the form of a descriptive design, to verify the critical attributes within particular populations such as patients diagnosed with diabetes versus patients diagnosed with anorexia nervosa. The implementation of this analysis in the research process can provide nurses with concrete skills and interventions to contribute to the broader goal of patient comfort. This concept analysis provides a forum for the promotion of feedback and dialogue in propelling the concept of pain to comprehensive fruition. As the human experience of pain is examined, profound thoughts and questions surface and the nursing profession has an obligation to respond. This challenge is readily addressed with the use of critical thinking skills in the process of attaining conceptual clarity. Intellectual depth and insight gained from engaging in a concept analysis supplement the integrity of the nursing discipline. Use of critical thinking skills serve as the foundation for the continued evolution and renement of nursing practice.

Analysis of concept of pain

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Acknowledgements
The author wishes to thank Ann Hales RN PhD, for her invaluable guidance and support in the preparation of this paper.

References
Allen B.P. (1994) Personality Theorists. Allyn and Bacon, Needham Heights, Massachusetts. Campbell R.J. (1996) Psychiatric Dictionary, 7th edn. Oxford University Press, Oxford, New York. Chinn P.L. & Kramer M.K. (1995) Theory and Nursing: a systematic approach, 3rd edn. Mosby Year Book, St Louis, Missouri.

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