N U R SE PE R S P E C T I V E S

The challenge of caring for patients in pain: from the nurse’s perspective
Katrin Blondal and Sigridur Halldorsdottir

Aim. To increase understanding of what it is like for nurses to care for patients in pain.
Background. Hospitalised patients are still suffering from pain despite increased knowledge, new technology and a wealth of
research. Since nurses are key figures in successful pain management and research findings indicate that caring for suffering
patients is a stressful and demanding experience where conflict often arises in nurses’ relations with patients and doctors, it may
be fruitful to study nurses’ experience of caring for patients in pain to increase understanding of the above problem.
Design. A phenomenological study involved 20 dialogues with 10 experienced nurses.
Results. The findings indicate that caring for a patient in pain is a ‘challenging journey’ for the nurse. The nurse seems to have a
‘strong motivation to ease the pain’ through moral obligation, knowledge, personal experience and conviction. The main
challenges that face the nurse are ‘reading the patient’, ‘dealing with inner conflict of moral dilemmas’, ‘dealing with gate-
keepers’ (physicians) and ‘organisational hindrances’. Depending upon the outcome, pain management can have positive or
negative effects on the patient and the nurse.
Conclusions. Nurses need various coexisting patterns of knowledge, as well as a favourable organisational environment, if they
are to be capable of performing in accord with their moral and professional obligations regarding pain relief. Nurses’ knowledge
in this respect may hitherto have been too narrowly defined.
Relevance to clinical practice. The findings can stimulate nurses to reflect critically on their current pain management practice.
By identifying their strengths as well as their limitations, they can improve their knowledge and performance on their own, or
else request more education, training and support. Since nurses’ clinical decisions are constantly moulded and stimulated by
multiple patterns of knowledge, educators in pain management should focus not only on theoretical but also on personal and
ethical knowledge.

Key words: nurses, pain, pain management, patients, patterns of knowledge, phenomenology

Accepted for publication: 17 November 2008

analgesia or other relief. They are not, however, independent

Introduction
Despite increased knowledge, technological advances and a
wealth of research, a large proportion of hospitalised patients
continue to report pain (Desbiens et al. 1996, Yates et al.
1998, Watt-Watson et al. 2001). Nurses are professionally
responsible for pain assessment and the administration of
professionals vis-à-vis drug prescriptions, as they may not
always be able to give patients what they themselves would
consider ideal for pain relief. Nurses’ concerns about pain
relief are therefore often affected by their relationship with
physicians (Van Niekerk & Martin 2002, Manias et al.
2005). Improving the quality of pain management is

Authors: Katrin Blondal, MSc, RN, CNS, Project Manager, Surgical Correspondence: Katrin Blondal, Project Manager, Surgical
Division, Landspitali-University Hospital, Reykjavik, Iceland; Division, Landspitali-University Hospital, Reykjavik, Iceland.
Sigridur Halldorsdottir, PhD, RN, MSN, Professor of Nursing and Telephone: +354-5431000.
Director of Graduate Studies, Faculty of Health Sciences, University E-mail: katrinbl@landspitali.is
of Akureyri, Akureyri, Iceland

 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 2897–2906 2897
doi: 10.1111/j.1365-2702.2009.02794.x
K Blondal and S Halldorsdottir
necessary both for humanitarian reasons and because
unrelieved pain is harmful. Unrelieved postoperative pain
delays healing and may cause life-threatening complications
such as respiratory infection and chronic pain may lead to
depression that can subsequently cause patients to take their
own lives (Pasero et al. 1999). Moreover, unsuccessful pain
relief is costly, due to unnecessary physical, psychological and
financial burdens, as well as direct healthcare expenses
caused by increased duration of stay, additional treatment
(Chung & Lui 2003) and hospital readmissions (Rawal
2001). In light of this it is unacceptable for hospitalised
patients to continue to suffer pain. It is important, therefore,
to gain an in-depth understanding of what impedes or
facilitates nurses’ performance in achieving pain relief for
patients.
Background
Many professional, organisational and patient-related hin-
drances affect patients’ pain management. McCaffery (1999)
argues that the main barriers are nurses’ anxiety about the
possible consequences of using opioid drugs, such as respi-
ratory depression and addiction. Inadequate pain assessment
by nurses also hinders successful pain relief (McCaffery &
Pasero 1999, Carr 2002). However, for various reasons
patients may not accept medication (Ferrell et al. 1991, 1993,
Schafheutle et al. 2001). Moreover, organisational barriers
such as lack of time, workload and insufficient analgesic
prescribing (Willson 2000, Schafheutle et al. 2001) add to
nurses’ inadequacies in pain management.
Previous studies, often focussing on single factors of pain
management, are often limited to a positivistic approach
where much emphasis is placed on incidence, severity and
pain-rating scales for assessment (e.g. Paice & Cohen 1997)
and on nurses’ empirical knowledge (e.g. McCaffery &
Ferrell 1997) or attitudes (e.g. Howell et al. 2000). Con-
versely, studies that have explored this subject in depth by
qualitative methods and from the nurse’s perspective are far
fewer. De Schepper et al. (1997), focussing on community
nurses’ feelings of powerlessness related to pain management
of cancer patients, report feelings of powerlessness and
helplessness that arise in relation to nurse–patient communi-
cation, use of opiates and perceived discrepancies between
nurses’ aims of the ideal versus what can realistically be
achieved. Further, nurses express satisfaction with their care,
as well as tension, when experiencing problems with addic-
tion and pain assessment (Nash et al. 1999).
Many researchers have been rather negative in their
conclusions regarding nurses and their pain management.
Although nurses are often seen as key figures in pain
2898  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 2897–2906
management (McCaffery & Ferrell 1997), they underestimate
pain (Sjöström et al. 2000, Florin et al. 2005) and are
reluctant to administer the full dose of analgesia prescribed
(Boer et al. 1997) and their education seems deficient in many
respects when it comes to pain management (Kuuppelomäki
2002, Van Niekerk & Martin 2002). Interestingly, although
some educational programmes demonstrate changes in
practice (e.g. Czurylo et al. 1999, Carr 2002), findings are
contradictory regarding the effectiveness of such pro-
grammes. Howell et al. (2000) for instance, found that the
effects of nurses’ re-education were not maintained over time
and according to Watt-Watson et al. (2001) more theoretical
knowledge does not necessarily correlate with patients
reporting less pain. Furthermore, Wilson’s (2007) survey on
nurses’ knowledge of pain also indicates that nurses may be
incapable of managing pain, despite their knowledge of the
existence of the patients’ pain. One explanation for this could
be the interplay between multiple organisational and inter-
personal features, as Willson (2000) proposes and this may
demonstrate that empirical knowledge is not the sole solution
to more effective pain relief. Taylor et al. (1993) also suggest
that nurses’ education must include professional ethical
obligations and explore the suitability of their professional
values.
In view of Carper’s (1978) fundamental ways of knowing
in nursing, nurses need ethical, aesthetic and personal
knowledge in addition to empirical knowledge taught by
school. By ignoring these other ways of knowing, some
aspects of pain management or nurses’ need for knowledge
may have gone unnoticed; this may also be attributable to the
methodology used, or lack of investigation of this subject
from the nurse’s perspective. A phenomenological in-depth
exploration of nurses’ experiences of pain management may
provide a more holistic approach, providing information
about the rationale behind nurses’ actions and information
about the challenges of caring for patients with pain from the
nurses’ perspective.
Aims and objectives
The aim of this study was to increase understanding of what
it is like for nurses to care for patients in pain. The research
question was ‘What are nurses’ experiences when caring for
patients in pain?’.
Methods
The methodological approach was phenomenology: the
Vancouver School of doing phenomenology (Halldorsdottir
2000). This is a phenomenological school strongly influenced
Nurse perspectives Caring for patients in pain

by constructivism and hermeneutics. The nature of dialogues Table 1 Overview of the participants’ demographics
and possibilities for repeated verification, which are distinc- Total number of participants 10
tive features of this school, were regarded as very useful for Number of nurses working on
collecting data for complicated and sensitive issues such as Medical wards 4
nurses’ pain management. Surgical wards 6
Sex of co-workers
Females 10
Sample Males 0
Nationality and race
The population consisted of 249 nurses with at least Icelandic All
two years of nursing experience, working within general White/Caucasian All
adult medical and surgical inpatient hospital wards in three Number of years in nursing 3–30 years
Number of years on the current ward Two years or more
different hospitals in Iceland. Ten participants were progres-
Hours of employment per week 24–40 h
sively selected from a group of 20 volunteers who responded Professional education
to an introductory letter. First five nurses from both medical Basic education University level and/or
and surgical wards were selected, then others were gradually diploma qualification
added after the interviewer had learnt more about their Specialized in pain management None
experiences and contexts. Table 1 portrays the participants’ Age
25–34 years 3
demographics.
35–44 years 4
45–55 years 3
Mean age 41Æ7
Data collection and analysis

In-depth (unstructured) interviews were used for data

collection. The interviews were seen as dialogues, denoting
the respectful and collaborative nature of such conversation
(Halldorsdottir 2000). Data collection and analysis fol-
lowed the research process of the Vancouver School
(Table 2).
Rigour
Many elements to ensure trustworthiness are inbuilt in the
research process of the Vancouver School. Firstly, repeated
reading of interview transcripts and checking of one theme
against others provide a check on the study’s ‘representative-
ness’ (Cutcliffe & McKenna 1999). Secondly, repeatedly
returning to the participants for validation (Table 2, steps 7
and 11) establishes the ‘credibility’ of the research (Lincoln &
Guba 1985). Furthermore, an effort was made to bring into
view and lay aside preconceived ideas before starting the
dialogues (Halldorsdottir 2000). A ‘reflective journal’ was
also kept as a contribution to ensuring the study’s ‘trustwor-
thiness’ (Lincoln & Guba 1985).

Table 2 The 12 basic steps of the Vancouver School as followed in this study

Steps Action

Step 1 Selecting dialogue partners (the sample), 10 experienced nurses

Step 2 Silence (before entering a dialogue). Reflection on preconceived ideas
Step 3 Participating in a dialogue (data collection), 20 dialogues in all
Step 4 Sharpened awareness of words (data analysis). Listening, reading, reflecting
Step 5 Beginning consideration of essences (coding). Trying repeatedly to answer the question:
What is the essence of what this nurse is saying?
Step 6 Constructing the essential structure of the phenomenon from each case. Two dialogues with each nurse
Step 7 Verifying case construction with the relevant co-researcher. This was done with all of the nurses
Step 8 Constructing the essential structure of the phenomenon from all the cases (meta-synthesis of all the
different case constructions)
Step 9 Comparing the essential structure of the phenomenon with the data. Reading all the transcripts again
Step 10 Identifying the overriding theme which describes the phenomenon: The challenging journey of caring
for patients in pain
Step 11 Verifying the essential structure with some research participants. This was only done with four of the nurses.
All were key-informants
Step 12 Writing up the findings (multivoiced)

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K Blondal and S Halldorsdottir

II The four main challenges nurses face regarding pain

Ethical considerations
Study approval was obtained from the Office of Human
Resources at the Icelandic National University Hospital and
the Ethical Committee of the FSA University Hospital. The
Icelandic Data Protection Commission was notified about the
study as required. To ensure anonymity, each participant
selected a pseudonym from a list of names.
Under Icelandic law only doctors have permission to
prescribe medication and hence a nurse administering un-
prescribed medication or changing medication may lose their
registration status. We were prepared for the possibility that
we might be told of some practice inconsistent with hospital
regulations and, therefore, questioned whether we could still
safeguard the participants’ confidentiality, or could possibly
be forced to identify individuals if the hospitals’ administra-
tors insisted. In Iceland nurses have not been obliged to
report such activity, but this issue was also discussed with a
lawyer and addressed by informing the Nursing Directors of
these concerns; they assured us that there would be no such
expectation.
Results
The results reveal that caring for a patient with pain is indeed
a ‘challenge’ where nurses encounter and react to multiple
demanding assignments which they continually meet on their
mission towards pain relief. Their experience may, therefore,
be understood by viewing their role within a goal-directed
mission aiming towards pain relief, a challenging journey
with the following landmarks: the beginning, the motiva-
tional factors which trigger advocacy, the main challenges the
nurses meet on their journey and lastly the end (positive or
negative outcome).
This challenging and complex ‘journey’ therefore has three
main aspects (Table 3):
I The four main factors motivating nurses as patient advo-
cates: moral obligation, knowledge, personal experience
and self-confidence and conviction.
management: reading the patient; dealing with inner con-
flict and moral dilemmas; dealing with the ‘gatekeepers’
and dealing with organisational hindrances in pain
management.
III Finally, there are the positive and negative patient
outcomes of pain management and their effects on nurse
and patient.
Main factors motivating nurses as the patient’s
advocate in pain management
On their goal-oriented mission aimed at relieving patients’
pain, the nurses instantly and without hesitation assumed the
role of the patients’ advocates. Fulfilment of this mission
involves responses to certain challenges where four important
motivating factors appear to prevail: moral obligation and
nurses’ formal and tacit knowledge along with personal
experience and their self-confidence and conviction. In this
respect, a strong sense of duty or moral obligation was
evident as a fundamental factor for taking action. For some,
this was ‘something inside you’, for others it was ‘inculcated’
during nursing training and at work. Julie asserted: ‘If the
patients report pain, then they’re in pain … and of course you
must do something about it’.
Some experienced a theory–practice gap in pain manage-
ment and many stated that the foundation of their knowledge
of pain management was their education, but experience
weighed more. Many claimed that their experience makes
them stronger professionally, as they have developed ‘self-
confidence’ and conviction which helps them to ‘stick up for
themselves’ and their patients.
The main challenges of caring for patients in pain
Four main challenges of caring for patients in pain were
constructed from the dialogues: reading the patient, dealing
with inner conflict and moral dilemmas and dealing with
‘gatekeepers’ and organisational hindrances.

Table 3 The challenges of caring for patients in pain from the nurse’s perspective: overview of the study findings

The nurses’ motivational Positive and negative outcome and its

factors The challenges of caring for patients in pain effects on nurse and patient

Moral obligation
Knowledge
Personal experience
Self confidence and
conviction
Challenge one: Reading the patient
Challenge two: Dealing with inner
conflict and moral dilemmas
Challenge three: Dealing with the ‘gatekeepers’
Challenge four: Dealing with organisational
hindrances in pain management
Positive outcome and its positive effects on the nurse
Negative outcome and its negative effects on the nurse
Positive outcome and its positive effects on the patient
Negative outcome and its negative effects on the patient

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Nurse perspectives
The first challenge: ‘Reading the patient’
The nurses’ first challenge is the assessment of pain. They
often referred to patients’ verbal and nonverbal expressions,
which Eve called ‘reading the patient.’ This means ‘to see
how the patient really feels’ and ‘know how to ask’, as it can
often be difficult to elicit accurate information since patients
may ‘grin and bear it’, even though nurses ask to be informed
if they are in pain. Three nurses mentioned specifically
‘relating to the patients’ pain’. They thus ‘experienced’ it
differently, were able to ‘put themselves in their place’ and
were ‘more attuned to how they felt’.
Nurses’ views on the use of pain scales varied. Some
regarded such scales as ‘very important’ and used them
routinely. Many, however, claimed that pain assessment was
too personal to be reflected on a pain scale. Four concluded
that older people and those with severe pain, could not use a
pain scale effectively as it seemed to ‘irritate’ some of them:
‘They just say, I’m in intolerable pain, or just a lot of pain’
(Helen). About half the nurses felt that the role of enrolled
nurses in pain assessment was very important and often an
‘enormous support’.
The second challenge: ¢Dealing with inner conflict and
moral dilemmas’
All the dialogues were characterised by the nurses’ inner
conflict and moral dilemmas. These feelings became
particularly apparent in the nurses’ descriptions of caring
for addicts in pain, which was evidently the nurses’ most
stressful experience. They found it very hard to assess
‘whether’ these patients needed medication and ‘how
much’. They had ‘no frame of reference’ to help them and
‘lacked expertise’ to care for them. Some found these
patients ‘difficult’, ‘demanding’ and ‘frustrating’ and some
were actually ‘afraid’ of them. Helen commented: ‘then all
you get is ingratitude and rage if you won’t give them
painkillers’. For some, tension existed between the nurses’
duty and beliefs: ‘you try to care for everyone without
prejudice, but we aren’t unprejudiced... maybe you want
them to give it up, maybe you think that if you don’t give
it to them, they’ll simply stop’ (Claire).
Very few felt that the fear that ‘the average patient might
become addicted’ caused nurses to withhold analgesia. More
prominent was the fear of giving too much analgesia because
of the risk of respiratory depression, mainly with reference to
older patients who are unaccustomed to analgesics and in
cases where patients need an unusually large amount of
medication. In many cases the nurses found that they ‘dared
not give too much,’ because of their biggest fear: ‘You can go
on and on giving medication and you can easily kill someone
that way’ (Julie).
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Caring for patients in pain
Nurses began to doubt the honesty of the patient and their
own judgement when the aetiology of the pain was unclear or
when patients who received ‘normal’ doses ‘constantly asked
for more’. They also found it very difficult when patients
were inconsistent: ‘Then you put the brakes on and think
‘what’s going on?’... People asking for loads of some pain
medication and then they jump out of bed to go for a smoke
with a big smile on their face... it’s problematic…’ (Mary).
Andrea described how the doubt touched her deeply: ‘I felt it
was a strain, really on human nature — are you doing
something wrong? Or are you doing right? Or are you just
cruel to refuse to give it to him? – really, what should you
do?’.
Dealing with inner conflict and moral dilemmas also
became apparent within palliative care when a patient’s
decision to refuse analgesia conflicted with the nurses’ duties
and values. Paradoxical situations sometimes also arose
where pain relief had to be balanced against other goals of
treatment and the nurses felt they were ‘being cruel’ by
inflicting pain. Julie, for instance, had to turn her patient to
prevent pressure sores: ‘we know that every movement causes
pain, but we can’t simply leave them lying there’.
The third challenge: ‘Dealing with gatekeepers’
As in every story, when the travellers reach the gate to the
‘Promised Land’ they meet the gatekeepers: in this case the
physicians who decide who will be allowed through. A cru-
cial attribute at the ‘gate’ is having a voice: ‘We don’t have
any final authority – perhaps that’s what’s most diffi-
cult…and we have to put up with that, naturally, but it’s very
important, of course, that we feel we are listened to, that our
voice is heard’ (Rachel). Importantly, the majority of nurses
was fairly satisfied, as they felt they had a voice.
Many said that knowing the physician, particularly
specialists, was crucial: ‘We know each other and they have
absolute confidence in us and listen to us’ (Julie). There were
cases of the opposite. Eve, for instance, wanted to give an
injection for pain relief before a physician, whom she did not
know, treated a painful wound. The physician did not listen,
however and started ‘hacking at the wound,’ much to the
distress of Eve who concluded: ‘maybe it’s just part of
working with people you don’t know; they don’t listen’.
When a change is required in drug prescription, most of the
nurses mentioned such factors as ‘exerting influence’ or
‘pressure,’ and stressed the importance of being ‘unhesitant,’
and ‘convincing’ to achieve the best solution: ‘It’s not a
question of making a great fuss and argument, but more of
being very determined’ (Elisabeth). Sometimes they had to go
further; ‘argue’ and ‘make a fuss’, or even ‘fight for the
patient with fists flying…’ (Rachel). Mary added: ‘I don’t
2901
K Blondal and S Halldorsdottir
stand by and watch the patients and do nothing if I think they
are crazed with pain’…‘I keep on pushing until something is
done’.
Many nurses choose at times to bypass the ‘gatekeeper’ by
changing the dose of analgesia on their own initiative. This
common activity seldom caused any negative reactions.
Another way to bypass the ‘gatekeeper’ was to use non-
pharmacological methods. Over half the nurses mentioned
this, referring to certain nursing interventions. Some felt that
these skills were lacking in their training, as the emphasis was
on medication; others suggested that there was a tendency to
wait too long before applying such methods.
The fourth challenge: ‘Dealing with organisational
hindrances to pain management’
Diverse organisational structures affect nurses’ ability to
provide successful pain relief. Some felt that time constraints
made pain treatment more difficult, as those whose condition
was worst received more care, at the expense of other
patients. Often, appropriate prescriptions were lacking and
unclear division of tasks and lack of continuity of care may
also hinder good pain management, as Claire pointed out:
‘it’s not that one can’t cope with those tasks, it’s more that
people do not quite agree on what needs to be done and who
should do it’. Sometimes limited access to physicians led to
‘insecurity’, while inexperienced physicians could not always
provide a solution and often the main purpose of consulting
them was to seek formal permission to give what the nurses
already knew the patient needed.
Pain relief for dying patients is a prominent issue and a
source of considerable distress. Almost all of the nurses who
took care of such patients stated that a decision by doctors on
palliative care was fundamental for satisfactory pain relief.
Many felt that the time prior to such a decision was ‘difficult
and bad’ and ‘too long’, at the expense of good pain relief.
Some complained about physicians’ reluctance to initiate
such treatment and said that their emphasis was always on
cure. The decision to provide palliative care brought a certain
‘relief’: ‘then you finally feel there’s some sense in what you’re
doing’ and that ‘everything is being done’ (Mary).
Positive and negative patient outcome of pain
management and its effects on the nurse
The nurses’ journey can have different outcomes, based on
how well they are able to fulfil their mission. Sara described
the mutual contentment of successful pain relief for both
nurse and patient: ‘He was so satisfied, he just glowed and he
was so happy to be rid of the pain… observing how well it
[the pain medication] worked gave me a fantastic feeling’.
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Many others mentioned the positive aspects of pain manage-
ment: ‘It’s enjoyable to consider what works well, what
works better and see that there is generally a response’ (Eve).
However, profound distress and frustration existed in cases
of unrelieved pain as well, such as when nurses’ voices were
silenced and the best solution was not provided. They
reported feelings of ‘defencelessness’, ‘powerlessness’ and
‘frustration’ when witnessing pain inflicted and feelings of
‘hopelessness’ and ‘sadness’ when a dying patient refused
pain medication. Andrea referred to an episode when her
patient suffered from continuous extreme pain: ‘I think,
really, it’s one of the more difficult things you experience… I
was so upset inside… so angry inside, not being able to help
and not really knowing where to turn, because the doctors
said just that [dose of medication] and it didn’t work at all, so
I was somehow defenceless about what to do’.
Sometimes, nurses’ distress over unsuccessful pain relief led
to their seeking further help. They used various coping
mechanisms to seek better solutions for those patients. They
agreed unanimously on the value of support and most
received good support from their co-workers. In more
demanding cases they sought assistance from palliative care
and pain service teams, anaesthesiologists or psychiatrists.
Where lack of backup could cause professional isolation and
defencelessness, this support provided ‘safety’, a sense of
‘shared responsibility’, increased ‘self-confidence’, necessary
‘limits’ and ‘plans for further treatment.’ Consulting special-
ists could, however, be a double-edged sword, since they
sometimes took over the nursing care, when nurses wanted to
‘continue to be responsible and be included’ (Claire).
All the nurses also had private methods of coping with
demanding cases, which seem to keep them and their patients
satisfied, even when the outcome is otherwise unsatisfactory.
Many affirmed that ‘involvement’ and ‘telling the truth’ were
important. Some said that as long as you ‘kept on trying’ the
situation was satisfactory. Helen took care of a patient who
suffered from chronic unmanageable pain: ‘you didn’t feel
too bad about it because… you were always doing your best’.
For some, knowing the patients and concentrating on their
strengths was a critical factor. However, not all coping
mechanisms were constructive, as one nurse mentioned
‘avoiding contact’ with patients who constantly asked for
more pain medication.
Discussion
This study focussed on the nurse’s experience of taking care
of patients in pain. We suggest that, perhaps, the most
important contribution of the study is that it provides a new
and more holistic view of the complicated and challenging
Nurse perspectives
journey of nurses taking care of patients with pain, since it
does not concentrate on isolated aspects of pain management.
It brings to light how nurses’ reactions toward patients in
pain are constantly moulded by interpersonal relations and
the immediate environment and how nurses’ clinical deci-
sions also are stimulated by multiple patterns of knowledge.
Nurses’ motivational factors
The findings demonstrate how motivating factors – moral
obligation and nurses’ knowledge, both formal and tacit,
along with personal experience, self confidence and convic-
tion – act as their drives. The nurses clearly assume the role of
patients’ advocates within a goal-directed mission aimed
towards relieving patients’ pain. This role correlates with
Mallik’s (1997) triadic model of advocacy where ‘moral
justification’ enhances advocacy. Furthermore, nurses’
emphasis on knowledge, experience and self-confidence is
consistent with ‘intervening conditions’ facilitating advocacy
(Mallik’s 1997). Our findings are at odds with statements
proposing that pain relief is not a priority for nurses
(Brockopp et al. 1998), or not their responsibility (Twycross
2002).
Nurses’ challenges when caring for patients in pain
The nurses embark on this mission’s journey by reading the
patient, which is the first challenge and predicts further
decisions and reactions. In agreement with Liaschenko
(1997), knowing the patient as a person strongly facilitates
the assessment of patients’ needs and clinical decision-
making. The second main challenge is dealing with one’s
own inner conflict and moral dilemmas. Here, in agreement
with Howell et al. (2000), the most prevailing feature is the
fear of giving too much medication because of respiratory
depression. Interestingly, in contrast to some other studies,
the nurses’ main worries were not the addictive properties of
narcotics for the average patient (as suggested e.g. by
Brockopp et al. 1998), but rather taking care of pain relief
for individuals with addiction.
An important turning point on the nurses’ journey is when
they participate in mutual decision-making with the ‘gate-
keeper’—the physician. The physician decides what medica-
tion the patient can or cannot have; i.e. whether the nurse
passes through the gate. At this point, having a voice is
pivotal, because here the nurses represent the patient and, by
using their influence, they strive to fulfil their mission.
Features influencing their success are: nurses’ own actions
and, as also pointed out by Jenks (1993), knowing the doctor.
Although, in general, using their influence or pressure is
 2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 2897–2906
Caring for patients in pain
sufficient for them to be granted what is needed, they
sometimes find they must insist and persist and/or consult
another gatekeeper for help. Hence nurses may not be
capable of reacting to patients’ pain without first entering
upon the relations mentioned above. Our interpretation of
the physicians’ position as gatekeepers in this respect has not,
to our knowledge, been described before. Furthermore, such
assertive behaviour as is described above contrasts with the
‘nurse–doctor game’ (Stein et al. 1990) and, therefore,
deserves much more attention; we believe that the implica-
tions of these relations may have been underestimated.
Interestingly, many nurses chose to bypass the ‘gatekeeper’
by altering the medication dose on their own initiative and/or
using independent nursing interventions. Altering medication
doses on their own initiative is consistent with ‘responsible
subversion’: consciously bending the rules for the patient’s
benefit (Hutchinson 1990). However, this could have serious
consequences, as nurses risk losing their registration status.
The fourth main challenge is dealing with multiple organ-
isational hindrances that influence nurses’ decision-making,
performance and wellbeing. The organisational barriers
observed in this study are in many ways consistent with
those reported in earlier studies (Kuuppelomäki 2002,
Manias et al. 2005). Because support from specialists is often
critical for providing successful pain relief in difficult situa-
tions and thus for nurses’ wellbeing, another vital support
that organisations must offer is specialised pain services.
However, if specialists are dominant, nurses may become
passive sub-servants, deprived of the possibilities to learn and
grow and therefore be disempowered, as Kramer and
Schmalenberg (1993) have also noted.
Positive and negative outcome of pain management and
its effects on nurse and patient
As reported, this journey has two potential outcomes and
from the findings we suggest that pain management is not
only a burden but also a challenge. When patients’ sufferings
are not relieved or the nurses are silenced, with consequent
dissatisfaction and often overwhelming distress, as Nagy
(1998) and Söderhamn and Idvall (2003) also point out, pain
management is unsuccessful and burdensome. Conversely,
effective pain relief may provide satisfaction, both by means
of professional achievements and benefits for the patient; yet
such positive outcomes are, surprisingly, rarely identified.
The findings indicate that successful pain relief may enhance
nurses’ autonomy and sense of empowerment, relevant to
both quality of pain management and job satisfaction and it
is therefore important for nurses’ overall wellbeing.
Furthermore, interventions that increase feelings of personal
2903
K Blondal and S Halldorsdottir
achievements may reduce risk of burnout (Garrosa et al.
2008). Moreover, it must not be overlooked that distress
related to unsuccessful pain relief can be a potent motivator
for advocacy, if dealt with in a constructive manner. It can
stimulate further actions of advocacy and seeking support
from co-workers and teams, which is another aspect which
has barely been dealt with in the literature, along with nurses’
use of various other coping mechanisms.
Nurses’ preparedness to deal with the challenges of pain
relief is crystallised in the themes earlier described. It is vital
that nurses have good theoretical knowledge, but they must
also possess knowledge of moral origin: otherwise they may
not be motivated to use their knowledge in practice.
Furthermore, personal knowledge that nurses use in relation-
ships with patients and doctors is also of great importance,
because theoretical knowledge may become useless if it
cannot be used because of lack of communication skills or
because the nurse’s voice is silenced. Organisations involved
must also provide the optimal environment for pain man-
agement so that nurses can use their potentials. It may
therefore be seen that the themes described above interact
and that deficit in one aspect may have significant conse-
quences for both patients and nurses.
Study limitations
This study offers a more holistic approach than many other
studies which concentrate on single factors of pain manage-
ment. However, this element could lead to a somewhat
superficial view of some of the aspects of this complex matter.
This study requires that nurses express their actions and
feelings about (sometimes) sensitive issues. They may, how-
ever, be reluctant to describe activities that are not consistent
with best practice. Furthermore, these findings may be
affected by the sampling, which predominantly consisted of
volunteers who may have been more interested or knowl-
edgeable than other nurses about pain relief. These findings
may therefore not be applicable to situations involving novice
nurses.
Relevance to clinical practice
The findings of this study can stimulate nurses to reflect
critically upon their current pain management and may also
enable them to realise what factors facilitate or obstruct their
achievements. By identifying their strengths as well as their
limitations, they can improve their knowledge and perfor-
mance on their own, or else request more education, training
and support. Although the nurses in this study seem to be
very straightforward in their requests for pain relief and,
2904  2009 The Authors. Journal compilation  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 2897–2906
contrary to other studies (see e.g. De Schepper et al. 1997,
Willson 2000), more willing to encroach on the physicians’
domain, there were critical examples of unsuccessful outcome
of advocacy. Since such experiences caused severe distress
and suffering for the patients and for the nurses involved, it
seems vital that nurses’ personal knowledge be improved. In a
wider context, the findings add to the knowledge base of
nursing and point to a need for change in nurses’ education
and support at work regarding pain management. Nurses and
nursing students should be prepared for identifying feelings of
distress and constructively employing their ‘voices’ in work-
relations within health organisations. This should be done by
teaching the skills of communication, negotiation and asser-
tiveness, since conveying ideas in a forceful and even
confrontational manner seems to increase the likelihood of
successful collaboration (Keenan et al. 1998) and nurses who
feel adequately consulted by physicians are more likely to
initiate the consultation process (Van Niekerk & Martin
2002).
Furthermore, as non-professional and professional moral
values that motivate and direct individuals’ choices can be
inculcated through education or socialisation (Omery 1989),
more discussion should be devoted to the moral responsibility
and ethical dilemmas of pain management in nursing
education, as well as addressing the need for multiple
patterns of knowing (Carper 1978). It seems to us that
nurses’ pain management has at least rarely been investigated
from the perspective of Carper’s patterns of knowledge and
that their education has therefore not met the various needs
involved.
Conclusions
Relieving patients’ pain involves several challenges for
nurses. It is vital that they be adequately prepared for their
important role by multidimensional knowledge about pain
management. Nurses ‘knowledge’ in this respect may have
been too narrowly defined and more attention must be given
to other patterns of knowledge. A favourable organisational
environment may enable nurses to grow through their
experiences, thereby providing opportunities to enhance
quality of care. Improvements in pain management should
adopt a more holistic perspective, since the findings demon-
strate that not only theoretical but also personal and ethical
knowledge are the essential prerequisites for pain manage-
ment. Previous studies in this field have often been limited to
isolated aspects of pain management and have been rather
negative towards nurses and not appreciated the complexity
of the nurse’s challenging journey of caring for patients in
pain.
Nurse perspectives
Acknowledgements
Sincere thanks to the participants for their contribution; for
finding time to share their experience and for the courage to
express their deep concerns.
Contributions
Study design: KB, SH; data collection and analysis: KB and
manuscript preparation: KB, SH.
Funding
This study was funded by grants from the Icelandic
Nurses’ Association, National Hospital Research Fund
and RANNIS – the Icelandic Centre for Research which
is gratefully acknowledged.
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