Date of Award


Degree Type


Degree Name

Doctor of Philosophy



Major Professor

Martha R. Alligood

Committee Members

Norma J. Mertz, Sandra P. Thomas, Delina Cuallan


Under-treatment of pain by nurses continues to be a prevalent problem today. Many times pain management situations prove to be ethical in nature for nurses. Nurses are ethically obligated to alleviate pain as part of the profession's responsibilities to patients. The American Nurses' Association Code for Nurses, Joint Commission for Accreditation of Healthcare Organizations pain management standards, the American Pain Society, and other pain management standards express this commitment. Therefore, nurses must possess adequate moral judgment to effectively deal with moral dilemmas and provide adequate pain management. To date, no studies have been conducted to examine the relationship of nurses' moral judgment and perception and judgment of pain.

Other factors of the nurse have been examined in previous research studies. In response to the problem of under-treatment of pain, the National Institute of Nursing Research in 1 994 published a state of the science report on acute and episodic pain and its management . Nurse factors that could influence pain management decisions were identified: nurses' age, education level, personal pain experience, professional experience, nurses ' espoused goals of pain relief, fear of respiratory depression, and nurses' addiction attitudes. Many of these studies are now old and reexamination of these factors is indicated.

Imogene King's Interacting Systems Framework guided this study. Based on this framework, perception and judgment precedes and influences action. It was proposed that moral judgment is part of the nurse's personal system within the growth and development subsystem. The concept of moral judgment within this proposed framework was defined by James Rest, a noted moral development theorist and researcher, as a cognitive and develop mental process of reasoning about moral choice. It includes principled thinking, which is guided by principles of what is the right thing to do.

In addition, it was proposed that decision-making is part of the nurse's personal system as well . It was also proposed that moral judgment influences perception and judgment of pain, therefore impacting nurses' choices of pain intervention. Therefore, the purpose of this study was to examine the relationship of nurses' moral judgment and perception and judgment of pain. A secondary purpose was to examine selected nurse factors' relationship among moral judgment, perception, and judgment of pain.

The research design was a descriptive correlational design utilizing Pearson r and Spearman rho correlations, and descriptive statistics as appropriate. A convenience sample of 101 registered nurses that provide direct care to adult patients in acute pain on hospital units was used. Moral judgment was measured using the Defining Issues Test, version two designed by James Rest. Nurses' perception and judgment of pain was measured utilizing a pain vignette tool, designed by McCaffery and Ferrell, two well-known pain management nurse experts. The tool was adapted to reflect ethical situations in the patient vignettes. Perception was measured based on the subjects' rating of the vignette patient's pain using a one to ten scale. The subjects' selection of analgesic dosage or no selection of analgesics measured judgment for the patient in the vignette. The selected nurse factors were collected via the demographic questionnaire.

The findings of this study did not support the proposed middle-range theory. Moral judgment and perception and judgment of pain were not related for the total sample. Subsamples based on education, nursing experience, and unit worked did reveal significant correlations between moral judgment and perception of pain. Nurses who did not believe pain relief is possible revealed that their moral judgment was related to judgment of pain. Several relationships among the selected nurse factors, moral judgment, perception, and judgment of pain were also found.

Significance of this study points towards the need to gain further knowledge of the relationship of moral judgment and nurses' perception and judgment of pain. Knowing more about this relationship may indicate a new way to teach pain management. Reflective education and practice may be the path to take to help nurses enhance their moral decision making regarding pain.

Examination of the selected nurse factors' relationships among moral judgment, perception and judgment of pain will provide greater understanding of how personal attributes of the nurse affect pain management The most important implication of this study is that it moves us closer to a better approach in addressing under-treatment of pain.

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