The job of a nurse is essential in today’s world. Gone are the times when a lone doctor could look after an entire community; instead, thanks to the dramatic changes in technology and record-keeping, as well as procedural modifications that mandate increased regular patient interaction, nurses have become an indispensable part of the medical practice. Yet due to their often second-class status as compared to doctors, nurses have had to wait quite some time before the significance of their profession was recognized as being a topic of interest to the academic world. This meant that a relative paucity of theories pervaded the work, leaving nurses without much to guide them in their daily work. Now, however, thinking has shifted such that nurses enjoy the full benefits of evidence-based practice that would have a nurse stay in a close, ongoing relationship with the literature, studies, and research on topics related to relevant specialties. Of these theories, it can at times be useful to select out one particular theory for focus. Given the degree to which pain governs treatment and the extent to which cancer remains one of the most frightening diseases in existence, it seems only fitting to select as that one specific theory Im’s theory on patients’ experiences of pain during cancer treatment. Before delving too deeply into that material, however, it is instructive to first justify the importance of primary nursing theories in general. Overall, it shall be seen that Im’s theory, though a practice-level theory, ties in well with many different nursing specialties and has components that make it suitable to interact with larger theories.
Nursing theory is what guides nurses to continue improving by providing a golden standard to which to compare themselves—or rather, given the veritable plethora of nursing theories in the world, a wide variety of such golden standards. Without a framework in which to perform nursing duties, the work can become routine and suboptimal habits can become entrenched. Fortunately, the era when nursing was treated as a series of rote actions mindlessly performed has passed. In the current day and age, nurses have many theories from which to choose, and indeed, often it is best to select multiple theories by which to guide one’s practice. Barnum (1998) would support this idea, having suggested that nurses become familiar with as many theories as possible. Of course, not all theories are created equal; the so-called “grand theories” of nursing, while they do have their upsides due to their universality, often fail to make explicit the connections to regular practice. Middle-range theories compromise, hedging their bets and carrying the best and worst of both worlds, but where nursing theory really shines is in the area of practice-level theories. One such theory of interest is found in the thinking of E. O. Im on pain and cancer.
Im’s theory regarding the pain experience during cancer added greatly to the field of nursing by investigating the relationship that ethnicity might play in the differing experiences patients underwent. This practice-level theory helps to draw nurses’ attention to the fact that seemingly unrelated factors may play a significant role both in the pain levels and in the degree of function a patient enjoys throughout treatment. The research that lies at the core of the theory can be found in Im (2007), in which Im stated that “The results indicated certain ethnic differences in types of pain and symptoms that patients experienced. Also, the results demonstrated significant ethnic differences in cancer pain and functional status” (p. 296). Proceeding from there, Im outlined these differences according to a variety of pain measurements, but what is instructive to note is that overall, the white patients seem to have reported the most pain. Without looking more deeply into this theory, a nursing student might not realize that the effects of racism as a problem interacts with nursing go beyond maltreatment of non-white patients and lack of access to care; it may true as well that the burdens of being non-white in the United States of America even manifest as a stoicism and discounting of one’s own pain, leading to inferior or inappropriate treatment. This idea can be blown out to interact with nursing theory as a whole.
In terms of the metaparadigm of nursing theory, even though Im’s theory is a practice-level theory, it is related to many other areas of nursing. Pain is inevitable when dealing with the ill, as most nurses do unless specifically involved in check-ups and other wellness exams. Its management overall could certainly be justified as a part of many middle-range theories and possibly even some grand theories. This is the strength of practice-level theories like Im’s; they can always be expanded outward. Larger-scale theories, on the other hand, do not exhibit the symmetrical version of this trait, for it is often hard to scale down their ideas to a level at which a nurse can feasibly use them on a day-to-day basis. Im’s theory fits neatly into a paradigm of increased awareness of pain management differences and difficulties as challenges arise naturally from the varying traits patients bring with them when they enter a nurse’s care. The ultimate test of any theory, however, is how well it can be applied to real life, and in this area, the literature abounds with many examples of specific work related to the concepts of Im’s theory.
Areas related to Im’s theory have been touched upon multiple times in the literature, sometimes even before Im’s theory itself was in common circulation. These real-world examples bear out Im’s ideas on the subjective nature of pain and the degree to which it can be correlated with seemingly unrelated factors. For example, Bernabei et al. (1998) described the purpose of their study and went on to summarize their results, stating the purpose as, “To evaluate the adequacy of pain management in elderly and minority cancer patients admitted to nursing homes” and the results as, “Age, gender, race, marital status, physical function, depression, and cognitive status were all independently associated with the presence of pain” (p. 1877). This is exactly the type of study that ties directly in with Im’s work, though of course, it predates the bulk of that writing. Those who study pain in cancer must continue to keep in mind what a multifaceted thing pain can be. Going forward, there is greater support for future studies in this area now that Im has established a framework for thinking about these topics. Of particular interest are Im’s own projects that tie into the theory.
How a theorist applies a theory penned by that theorist is particularly instructive because the real-world examples thus created suffer the least amount of dilution between theory and practice possible. Even before Im’s (2007) work on directly measuring patients’ pain levels and comparing their ethnicities, Im was already working on trying to solve this same problem not through theory but through technology. Im and Chee (2003) proposed a computer system to aid nurses in evaluating pain given the confounding factors: “The findings indicated ethnic, gender, geographic, and age differences in cancer pain descriptions. Based on the collected data, a decision support computer program for cancer pain management, including [three components] was developed” (p. 12). This is an interesting application to the theory, for it implies that when nurses are faced with complex issues such as the interactions of ethnicity and pain levels, it might be best to simply turn the problem over to a computer. Going about the problem in a different way, Im et al. (2009) also suggested creating a national database with information comparing various variables including but not limited to ethnicity and pain. As a competing real-world attempt to conquer some of the concerns raised by Im’s theory, this is possibly less practice-based than the computerized approach, but it does have the merit of gathering larger quantities of data than might be possible in a single, lone study by starting and maintaining a database. Overall, Im’s theory has lots of implications for real-world studies and for any specialty of nursing that deals with pain—which is to say, essentially every branch of nursing—alike.
Im’s theory shows the fascinating ways in which the pain experience of patients with cancer is constructed not only from those patients’ medical factors but also from something as superficially disconnected as pain. Whether the differences between various ethnic or racial groups are the result of culture or whether there is something to the nature of the medical setting that induces stoicism remains to be uncovered, yet even without this data, Im’s theory has already drawn well-needed attention to the topic of the relationship between ethnicity and pain. Simply because the topic of the theory at first appears narrow, as has been shown, does not mean it is indeed a theory that is limited only to cancer or only to pain. Given the overall importance of nursing theory to the nursing profession and academic field alike, in fact, it is vital to ensure that theories are consistently checked for the ways in which their various components might cross-link with one another. This activity is one that here has been performed exhaustively, such that now it is apparent that all nurses ought to be made aware of Im’s conclusions, and not merely those nurses who work with patients of multiple ethnicities who happen to have cancer. From practice-level theories such as Im’s theory, up through middle-range theories, and then up to grand range theories, every aspect of nursing theory has something to contribute. If nurses continue to take responsibility for acquainting themselves with nursing theories of all levels and integrating the various components of these theories, in the end, better outcomes for patients will result in a better world.
Barnum, B. S. (1998). Nursing theory: Analysis, application, evaluation. New York: Lippincott.
Bernabei, R., Gambassi, G., Lapane, K., Landi, F., Gatsonis, C., Dunlop, R., . . . & SAGE Study Group. (1998). Management of pain in elderly patients with cancer. JAMA, 279(23), 1877-1882.
Im, E. O. (2007). Ethnic differences in cancer pain experience. Nursing Research, 56(5), 296.
Im, E. O., & Chee, W. (2003). Decision support computer program for cancer pain management. Computers Informatics Nursing, 21(1), 12-21.
Im, E. O., Lee, S. H., Liu, Y., Lim, H. J., Guevara, E., & Chee, W. (2009). A national online forum on ethnic differences in cancer pain experience. Nursing Research, 58(2), 86.