CLINICAL ISSUES

Understanding inadequate pain management in the clinical setting: the

value of the sequential explanatory mixed method study
Eloise CJ Carr

Aim. The purpose of this paper is to critically explore the sequential explanatory mixed method research design and how it can
enhance our understanding of pain management.
Background. The general prevalence of pain after surgery has not changed significantly over several decades despite the
widespread introduction of new pain relieving technologies. The majority of postoperative pain studies use quantitative
methods which offer little understanding of the underlying processes of care. Understanding can be illuminated by using an
explanatory mixed method research design.
Design. Discursive paper.
Method. This paper focuses on the methodological considerations when using a mixed method design. Two previously published mixed methods studies illustrate how findings can inform practice. In the first, 85 women undergoing surgery completed
questionnaires to measure pain, anxiety and depression. Telephone interviews explored their pain experiences. The second study
considered frequency and patterns of anxiety in the immediate pre and postoperative period. Semi-structured telephone
interviews, identified contributing events/situations amenable to nursing intervention.
Discussion. Reasons for growing popularity, criticisms, paradigmatic considerations and epistemological roots of pragmatism
are explored. The two explanatory mixed method studies provide examples of these studies and how inferences from quantitative and qualitative data can inform practice.
Conclusion. This paper connects quantitative and qualitative data, drawing on two research studies, to give greater understanding to the management of pain. Knowledge of the processes responsible for inadequate pain management can be
illuminated by using explanatory mixed methods research designs.
Relevance to clinical practice. Nursing requires knowledge which reflects the complexity of human health. The explanatory
mixed method study can elucidate the problem under scrutiny, e.g. prevalence of pain or anxiety. The qualitative phase can
generates an understanding of contributing factors and insights for care delivery. The implicit desire to change and influence
practice makes it relevant for those closely aligned to practice.
Key words: anxiety, nurses, nursing, pain management, postoperative, practice
Accepted for publication: 9 February 2008

Introduction
The International Association for the Study of Pain defines
pain as:
an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such
damage. (Merskey & Bogduk 1994)

Author: Eloise CJ Carr, BSc, MSc, PhD, RGN, PGCEA, RNT,

Associate Dean Postgraduate Students, School of Health & Social
Care, Bournemouth University, Royal London House, Christchurch
Road, Bournemouth, Dorset, UK

124

The inadequacies of the management of pain have been

reported consistently for nearly thirty years (Marks & Sachar
1973, Fagerhaugh & Strauss 1977, Svensson et al. 2000). In
the UK deficiencies in the provision of postoperative analgesia exist in many hospitals (Audit Commission 1997, Wu
2002, Powell et al. 2004) with other countries reporting
similar failings; e.g. Italy (Visentin et al. 2005), Hong Kong

Correspondence: School of Health and Social Care, Bournemouth

University, Royal London House, Christchurch Road, Bournemouth,
Dorset, BH1 3LT, UK. Telephone: (01202) 962163.
E-mail: ecarr@bournemouth.ac.uk

2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 124131
doi: 10.1111/j.1365-2702.2008.02428.x

Clinical issues

(Chung & Lui 2003), Australia (Schoenwald & Clark 2006),

Canada (VanDenKerkhof & Goldstein 2004) and the USA
(Easton 2004). Many of these studies rarely provide insight or
understanding as to why pain continues to be so prevalent
and what can be done about it.
The mixed method sequential explanatory research design
is characterised by the collection and analysis of quantitative
data followed by the collection and analysis of qualitative
data (Creswell 2003). The purpose of this design is to use
the qualitative findings to explain or give greater understanding to the quantitative data. Pain research is challenging and new approaches are needed to broaden our
understanding. In this paper two studies are drawn upon
to illustrate how a sequential explanatory mixed methods
design contributed a greater understanding of the problem
and led to real changes and improvements in patient care. It
is not the intention to give details of the data collection and
analysis as these have been reported elsewhere (Carr 2000,
Carr et al. 2006) but to use these studies as exemplars to
explicate how this design can contribute to better understanding of pain management.

Mixed methods research

The combination of quantitative and qualitative methods in
the health and social sciences has seen an accelerated
presence as evidenced by the extensive range of published
papers and books over the past decade. Indeed the launch of
a journal dedicated to the topic commenced in 2007
(Tashakkori & Creswell 2007). The complexity of nursing
and the continual interaction between the art and science of
practice makes it an ideal context for the use of mixed
method approaches. Indeed, triangulation has been proposed
as offering a multifaceted view to mirror the complexity and
multidimensional nature of nursing practice (Wendler 2001,
Foss & Ellefsen 2002). Twinn (2003) outlines the status of
mixed method design in nursing research and raises important questions about its contribution to nursing knowledge
and the issues arising from attempts to use the design within
the context of nursing practice. There are many examples of
how mixed method designs have been used to address
important nursing questions, pertaining to a variety of
topics, including; vulnerable families (Shepherd et al.
2002), cancer care (McPherson & Leydon 2002), clinical
learning environments (Dunn & Hansford 1997) and skill
mix (McKenna & Hasson 2002). It has also populated
disciplines beyond health and social care to include; computing and maths (Arbogast & Chen 1995), education
(Mertens 2004), program evaluation (Lucke et al. 2001) and
geography (Crang 2002).

Mixed methods for pain research

Development and popularity of mixed methods

approaches
Despite this recent interest and usage of mixed methods in
health and social sciences, its history is extensive. Campbell
and Fiske (1959) describe convergent methodology, multitrait and multiple methods. In 1979 Jick published a paper in
Administrative Science Quarterly that discussed triangulation
and criticised those advocating it who failed to describe how
triangulation was actually performed. He highlighted that
the method might capture something more than scaling,
reliability and convergent validation. He suggested that
triangulation might capture a more complete, holistic, and
contextual portrayal of the unit(s) under study; emphasising
that qualitative methods, in particular, had a role to play.
Triangulation of methods was viewed, by some, as a way of
increasing reliability, validity and accuracy of the study;
compensation for methodological weaknesses as different
methods had different strengths (Duffy 1987). Green et al.
(1989) proposed that mixed method studies offer five
functions: triangulation, complementary, development, initiation, and expansion. Others saw it as a check for validity in
that data collected through, say observation, could be
checked with data from interviews and compared (Sapsford
& Jupp 1996). Sale et al. (2002) suggest that quantitative and
qualitative methods cannot be combined for cross-validation
or triangulation purposes but only complementary purposes.
A point supported by others, where multiple data sources (or
triangulation) is viewed as an alternative to validation to
ensure an in-depth understanding or completeness (Knafl &
Breitmayer 1991, Denzin & Lincoln 2000, Tobin & Begley
2004). The purpose of using mixed methods, for the
research questions posed in the pain studies illustrated in
this paper, was to give a greater understanding to the
findings; an explanation. It is this particular approach that
forms the central focus of this paper. Creswell and PlanoClark (2006):
The purpose of this form of research is that both quantitative and
qualitative methods, in combination, provide a better understanding
of a research problem or issue than either method alone.

Criticisms of mixed methods

There is no doubt that there has been a burgeoning number of
published papers reflecting a mixed method stance. The
reasons for this are probably several fold and include: a
disquiet of the experimental approach to answer all questions
(Howe 2005), a concern that research findings are not
routinely used by practitioners (Seymour et al. 2003, Winch

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125

ECJ Carr

et al. 2005), a questioning of the nature of the evidence-base

informing clinical practice (Barbour 2000, Berwick 2005)
and a strengthening of interprofessional collaboration bringing different research perspectives together. This growth and
popularity, a methods whose time has come (Johnson &
Onwuegbuzie 2004) is not without its critics.
Freshwater has argued that the discipline of mixed methods
is not new and has been readily adopted by health and social
care researchers in their attempt to belong to academia,
despite the constraints it may bring in its ability to reveal
truth (Freshwater 2007). The popularity of this approach is
evidenced by a burgeoning range of taxonomies with 41
models cited in one textbook alone (Teddlie & Tashakkori
2003). Whilst accepting that such typologies can guide
researchers they also add to the confusion and lack of
consistency concerning this body of work. There is no doubt
that the complexities are not for the faint hearted. In her
article, Johnstone (2004) presents a synthesis of the literature
that informed the decision to adopt a mixed methods, mixed
methodology, dominantly naturalistic collective case study
design in a doctoral-level health service research study. The
complexity of the decision-making illuminates and makes
transparent a richness that might resonate with practitioners
researching their practice but perhaps negates encouraging
more followers. Indeed, writing up such approaches is not
without challenges and further work is needed to explicate
how mixed methods findings can be integrated and the
connectivity made explicit in this process (Bryman 2007).
Interestingly a point made by Jick (1979) who observed those
using multiple techniques often failed to make their data
collection and interpretation explicit. Concerns such as these
also relate to the incorporation of qualitative strategies into
quantitative research, where methodological principles have
not been developed (Morse 2005). It may also be viewed as a
quick fix and perpetuates the positivist hegemony dominating current research (Giddings 2006). Underpinning some of
these concerns are further questions pertaining to where
mixed-methods is situated vis-a-vis its paradigmatic home.

Paradigmatic considerations
Paradigms have been defined as world views (Sandalowski
2000) and represent ones own view of their role in that
world and their relationship to its parts (Guba & Lincoln
1998). One world view is the positivists and another being
interpretivists; each with distinctive methodologies. The
arguments arose when methods from each paradigm were
used in the same study generating questions about the ability
to hold multiple realities. To a certain extent the discussions
around whether to combine qualitative and qualitative
126

methodologies have moved beyond the paradigm wars

where the strengths of each were pitted against each other
(Spradley 1979, Lincoln & Guba 1985, Guba 1990, Teddlie
& Tashakkori 2003). Patton (1990) suggested that the
qualitative vs. quantitative debate should be avoided and
the investigator should adopt neutrality and seek to understand the world as it is and be true to the complexities. Whilst
this may present a somewhat simplistic approach it does link
with others who have moved beyond the either or debate
(House 1994). Datta (1994) suggests five practical reasons for
coexistence between the quantitative and qualitative paradigms including: each existing for many years, many evaluators and researchers have used both paradigms, funding
agencies have supported both paradigms, both paradigms
have influenced policy and much has been taught by both.
Johnson & Onwuegbuzie (2004) identify subjective decisions
made in a quantitative study: deciding what to study,
developing instruments, choosing specific tests/items for
measurement, selecting alpha levels (e.g. 005), drawing
conclusions & interpretations, and identifying what elements
to publish. It would appear that logical arguments clarifying
paradigmatic differences are perhaps not as clear cut as first
thought. Indeed, scrutiny of the roots of the mixed method
approach has also been a topic of considerable discussion.

Pragmatism for practice

Methodological discussions are essential to the growth and
development of a scholarly discipline and the epistemological
foundations are an important consideration. For the mixed
method discussion one perspective to emerge has been the
pragmatic or pragmatist paradigm or what works (Howe
1988). Pragmatism embraces the use of mixed method and
mixed models because it provides a very practical and applied
research philosophy (Tashakkori & Teddlie 1998). Despite
criticisms regarding a lack of epistemological rigour for the
mixed method (Bryman 1984, Giddings 2006) there have
been strong arguments that its epistemological roots are
embedded in the classical pragmatists, such as John Dewey
and William James (Johnson & Onwuegbuzie 2004). Pragmatism is a school of philosophy which originated in the USA
in the late 1800s and is characterised by consequences, usage
and practicality as vital components of truth. The pragmatists
rejected positivism and anti-positivism and reoriented to a
third criterion: the theories capacity to solve human problems
(Rorty 1989, cited Pansiri 2005). Thus for a pragmatist the
purpose of science was not to find truth or reality but to
facilitate human problem solving (Powell 2001, Berwick
2005). A point endorsed in a detailed consideration of
paradigms used for nursing research (Weaver & Olsen 2006).

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Clinical issues

Mixed methods for pain research

They argue that nursing enquiry could be effectively evaluated through the pragmatic approach as it embraces several
aspects which are highly relevant for nursing; commitment to
what works in practice, appreciation of plurality and the
desire for integration of results. It is this implicit desire to
change and influence practice which makes it appealing for
those closely aligned to practice. The effective management of
pain continues to be an elusive outcome and the reasons for
this state of affairs is complex and multifactorial. Using a
research paradigm which is able to embrace the complexity
and yet offer new insights which can influence the practice is
of considerable importance for nursing.

The sequential explanatory mixed method

design for pain research
In the first study, 85 women having major gynaecological
surgery completed the Brief Pain Inventory (Cleeland & Ryan
1994) and the Hospital Anxiety and Depression Scale
(Zigmond & Snaith 1983), preoperatively and on days 2, 4
and 10 following surgery (Carr 2000). Additionally analgesic

prescribing and consumption, pain documentation and fieldnotes were taken. This comprised the quantitative phase of
the study with sequential semi-structured telephone interviews one month after surgery; to give depth and understanding to the data. Table 1 illustrates how the qualitative
phase elicited greater understanding of the quantitative
findings. Triangulation and complementary functions are
linked to the ability of mixed methods to draw inferences
from the data which complement or confirm each other. The
notion of inferences from mixed method studies can be
either a process or an outcome and is one of the main areas
where mixed method designs are superior to single method
approaches (Teddlie & Tashakkori 2003). They suggest that
inference is the researchers construction of relationships
among people, events and variables.
One of the most important findings from this study related
to the consistently high levels of pain which continued to
exist, despite the availability of new pain technologies, and
how a range of barriers prohibited the potential benefits of
analgesics prescribed. The majority of acute pain studies have
used single interventions under controlled conditions, which

Table 1 Postoperative pain: quantitative data, qualitative data and inferences

Quantitative findings

Qualitative findings

Inference

On day 2, 58 (682%), experienced worst

pain of 5 > and 964% of patients had
stopped taking opioids.

When patients were asked why their PCA

had been discontinued the main reason
given for the PCA being discontinued
was because the nurse took it down.
I mentioned that there was a lot of pain
there and they [consultant] had
explained because they had to make so
many cuts that I would have to
expect that. (P80)
When I said to the doctor [ward house
officer and registrar ] that Ive never had
so much pain in my life they didnt make
any comment really. (P75)
When the nurses ask do you want
anything for pain? I assume they mean
painkillers but Im never too sure. (P118)

Rigid hospital routines contributed to

inadequate pain management
Surgical consultants preference rather
than patients pain score
Doctors and nurses expected patients
to have pain

69 patients (81%) were asked a general

question about their pain, 12 patients
(14%) did not remember being asked
about their pain, three patients were
asked to rate their pain on a 010 scale
and one patient was shown a formal
pain rating tool by a student nurse.
Pain was clinically significant after
discharge from hospital. The intensity of
pain, for some patients, continued to be
a problem as indicated by twenty-one
patients (247%) scoring 5 or more and
one patient 10/10 on day 10.
Activity was one of the predictive
variables for pain, on day 10.

I felt more pain walking around and I was

probably doing more...not resting. You
seem to come out quite early. It was silly
things, like getting out of your own bed
or sofa. Unless you have an upright
one...it was quite a shock. The first
5 days were the worst. The bath....had
no handrails and I thought
Im stuck. (P36)

Pain was not formally assessed in

hospital

Patients were generally more active at

home than they had been in hospital but
were often inadequately prepared
for this

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ECJ Carr

fail to take into account how a particular intervention

functions in the real world of practice. The study identified
several areas where changes in the management of pain might
lead to a reduction in the pain experienced postoperatively
including: using a protocol for the discontinuation of
parenteral opioids through the patient controlled analgesia
system (PCAS); introduction of a pain assessment tool, pain
education for doctors (including surgical teams) and nurses,
and patient education about pain management. The study
illustrates how the sequential explanatory mixed method
design identified deficits or gaps in the provision of effective
pain management and offers a greater understanding of how
these deficits might be addressed. Whilst these issues have
been identified in research studies few have managed to
encapsulate the breadth afforded by this design in a single
study. Mixed methods can offer a strong contribution of
nursing knowledge to the complexity of human health and
the experience of pain after surgery.
There is some preliminary evidence that research in acute
pain is beginning to move beyond the physiological concerns,
to consider psychological well-being during the postoperative
period (Puntillo & Weiss 1994, The Royal College of
Psychiatrists and the Royal College of Surgeons 1997, Carr
2000, Perkins & Kehlet 2000, Carr et al. 2006). In the second

mixed methods study a sequential explanatory design was

used to study the prevalence and patterns of anxiety and pain
experience in eighty patients undergoing gynaecological
surgery (Carr et al. 2006). The women were assessed using
the State Trait Anxiety Inventory (STAI) (Spielberger et al.
1970) at six time points prior to and following surgery.
Postoperative pain was measured on a 10 cm visual analogue
scale and taped semi-structured telephone interviews conducted one week after discharge (n = 45).
The findings revealed that State anxiety rose steadily from
the night before surgery to the point of leaving the ward to go
to theatre. Anxiety then increased sharply prior to entering
the anaesthetic room and decreased sharply afterwards.
Patients with higher levels of trait anxiety were more likely
to experience higher levels of anxiety throughout their
admission (p < 00001). Elevated levels of pre (p < 001)
and postoperative (p < 00001) anxiety were associated with
increased levels of postoperative pain.
Interviews were taped and transcribed and then a thematic
analysis was undertaken (Aronson 1994). From the semistructured interviews several themes emerged which gave
insight into the reasons for the raised anxiety levels (see
Table 2). From this study clear inferences emerged which
pointed to improvements that have been made to reduce

Table 2 Anxiety and pain: quantitative data, qualitative data and inferences
Quantitative findings

Qualitative findings

Inferences

There was a clear correlation between the

patients preadmission trait anxiety score
and the overall anxiety profile (AUC 50)
over time (rs = 0587, p < 0001)
A positive correlation was also observed
between postoperative state anxiety and
postoperative pain on day one (rs = 0382,
p = 0001) and day two (rs = 0515,
p < 00001)

I was feeling very worried, and I wasnt

feeling well at all that day, and to be told
that day that I wasnt going in. I didnt
know if I was going to be able to cope with
the rest of that day. (P2)
I had to be in for 130 and absolutely nothing
at all was checked or done with me on that
day at all. So I went in from 130 and stayed
there all afternoon for absolutely no good
reason at all. (P40)
It was awful, the clinic was full of screaming
kids and I was in my nightie and slippers
everyone else was in their outdoor clothes. It
had been raining and they were all in coats
and I was in my nightie. I was pushed to one
side of the room and I just sat there and felt
very nervous and really very vulnerable.
(P21)
Well when you are in a ward like that you
hear other people being ill. Yes, I worry
about the other people who are obviously in
distress. (P68)
I spoke to two or three patients while I was
on the ward because they looked very
anxious and worried and a bit alone. (P51)

Admission procedures cause anxiety

Excessive waiting times exacerbated anxiety

State anxiety rose steadily from the night

before surgery to the point of leaving
the ward to go to theatre

Individual differences in the anxiety

profiles were highly variable between
women

128

Unexpected feelings of helplessness and

vulnerability contributed to preoperative
anxiety

Concern about other patients could

influence anxiety levels

2008 The Author. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 124131

Clinical issues

anxiety prior to surgery. These included: revising the surgical

admissions bed allocation so decisions about admission were
not left to the day of admission, encouraging patients to wear
their day clothes and walk to clinic appointments or x-ray,
and where possible walking to theatre rather than being
wheeled in a chair or lying on a trolley. The provision of
individualised patient care that recognises and helps maintain
personal identify and control, facilitates the alleviation of
anxiety. The provision of patient services, informed by
patients experiences and point of view, is likely to offer care
that better means their needs.

Conclusion
It has been argued that the emergence of mixed method
approaches and in particular the explanatory mixed method
design, have considerable relevance for those endeavouring
to gain a better understanding of the management of pain.
Mason argues for a multidimensional logic where different
methods can help understand multidimensionality and
social complexity (Mason 2006). She suggests that such
approaches can push the boundaries of social science
philosophy, knowledge and practice. Indeed there are critics
of the traditional intervention study which fails to illuminate why the intervention did or did not work (Pawson et
al 2005). It is perhaps timely to consider other approaches
without throwing the baby out with the bathwater.
Published papers on the philosophical and theoretical
underpinnings of the explanatory mixed method design
abound. It is appropriate to focus attention on methodologies which will expedite the findings into the practice
arena and bring tangible improvements to those experiencing the unpleasantness and distress of inadequately managed pain.
In this paper, the researchers motive for conducting the
studies was to illuminate the experience of people having
surgery and use the findings to change practice. The
patients voice as a legitimate and integral part of the
research process was central to my understanding and
actions as a researcher. In these pain studies, the voice of
the patient not only provided a validation of the quantitative findings but more importantly offered insight into
processes of care which contributed to pain and anxiety: the
explanation.
One consistent barrier to the implementation of research
findings has been a criticism from those responsible for
implementation that the research has little relevance for
practice. The explanatory mixed method design can offer
those researching pain management outcomes that not only
give greater understanding but offer opportunities for

Mixed methods for pain research

practice improvement. Benner et al. (1996) called for nursing

research designs that reflect the multidimensionality and
complexity of practical nursing knowledge. The explanatory
mixed method design optimises opportunities to influence
practice which is essential if research is to contribute to
increased quality of care.

Acknowledgements
The author would like to thank the following for comments
on earlier drafts of the paper: Professor Immy Holloway,
School of Health and Social Care, Bournemouth University,
UK and Professor Lynne Giddens, Associate Professor,
School of Nursing, Auckland University of Technology,
New Zealand.

Conflicts of interest
The author has no conflicts of interest or sources of support
to declare.

Contributions
Study design: ECJC, data collection and analysis: ECJC and
manuscript preparation: ECJC.

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