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International Journal of Nursing Practice 2015; 21: 200–206

RESEARCH PAPER

‘We are nurses, they are doctors’: Barriers to

nurses’ roles in pain management following
surgery in Jordan
Noordeen Shoqirat RGN MSc PhD
Head, Fundamental and Adult Health Nursing, Faculty of Nursing, Mutah University, Karak, Jordan

Accepted for publication June 2013

Shoqirat N. International Journal of Nursing Practice 2015; 21: 200–206

‘We are nurses, they are doctors’: Barriers to nurses’ roles in pain management following surgery
in Jordan

This study explored barriers to nurses’ roles in pain management following surgery in Jordan. A qualitative approach using
four focus group discussions (n = 4) was used. The total convenience sample of surgical wards nurses included 25 nurses.
The analysis revealed two categories explaining the context and perceived barriers affecting nurses’ roles in pain
management. First were barriers within bedside nursing, comprising attention-seeking patients, ‘buzzer obsession’ and
family interferences. Second were barriers within nursing, comprising lack of staff and ‘nurses need pain relief before
patients’, and the perception of ‘we are nurses, they are doctors.’ Nurses’ roles in managing patients’ pain following
surgery is hindered by contextually complex barriers identified by this research. Multidisciplinary actions are therefore
urgently needed to address barriers to pain management at the nursing professional, ward culture and policy levels. Failure
to do so might lead to more pain sufferers following surgery, and thus poor recovery.
Key words: focus group discussions, Jordan, nurses’ roles, pain management.

INTRODUCTION Given that nurses worldwide spend much of their time

It has been generally acknowledged for years that nurses’
roles in pain management are crucial for patients’ care
following surgery. Growing evidence found that pain
impairs health and sleep patterns,1,2 and leads to a delayed
discharge.3 Unresolved pain therefore is costly both in
financial terms and in terms of patient comfort, and
greater research efforts are needed to identify the factors
that impede effective pain management.4,5
Correspondence: Noordeen Shoqirat, Fundamental and Adult Health
Nursing, Faculty of Nursing, Mutah University, Karak 61710, PO:
BOX: 7, Jordan. Email: noorshoq@yahoo.com; noordeen@
mutah.edu.jo
with patients, it is unsurprising that they are urged to have
a visible role in managing the pain of patients following
surgery.6,7 However, the reality is not like this, judging
from a review of international nursing literature. Numer-
ous studies found that many patients experience moderate
to severe pain following surgery.8–10 Pain in hospitals is
often poorly managed11,12 and underestimated by health-
care professionals, in particular nurses.13,14 Factors affect-
ing nurses’ roles in pain management were found to be
diverse, including the powerlessness of nurses, policies
and rules of hospitals, time constraints, and limited com-
munication with patients,5,7,15–18 in studies mainly carried
out in the UK, United States, Australia and Iran.
However, the applicability of existing data to other coun-
tries might be questioned.

© 2014 Wiley Publishing Asia Pty Ltd doi:10.1111/ijn.12240

Barriers to pain management
Regardless of this, to date, the available studies are
largely descriptive, driven by quantitative data, inclusive
only of senior nurses, and focused exclusively on chronic
pain, cancer and critically ill patients.19–23 Overall, related
literature was generated as a result of theoretical debate
rather than empirical investigations.
This current situation poses dilemmas to nurse manag-
ers, educators and decision makers on how to train hos-
pital nurses to develop their role in pain management in a
complex setting where the scope and the impact of con-
tributing factors are largely unknown. Before addressing
such factors, it is logical to identify and understand them
first. A comprehensive understanding of how contextual
issues affect pain management is thus needed to better
care.24,25
To bridge this gap in the literature, the current quali-
tative study examined nurses’ perceived barriers to pain
management following surgery in Jordan. Once such bar-
riers have been identified, and the impact on patients’ pain
management is understood, a future strategy to address
them can be devised. It is hoped that the current findings
will stimulate further international debate in the area
of pain management and inform the development of
cross-cultural studies.
Aim
The study sought to explore barriers to nurses’ roles in
pain management following surgery in Jordan.
METHODS
Following a qualitative approach, a number of four focus
group discussions with registered nurses on surgical wards
were conducted. This approach was deemed appropriate
for exploring the complexity and overlapping issues sur-
rounding nursing pain management in a cultural and
postoperative context.5,17 In particular, focus group dis-
cussions yield insight into participants’ expressions and
concepts, allow group interactions, and enable research-
ers to learn more about the level of consensus on a topic.26
Accordingly, the focus group discussion was used in this
study as a method for arriving at a better understanding of
how participants feel about a certain situation by sharing
their experiences and views with each other in a group.27
Research Setting
The study was undertaken in a 250-bed Jordanian teaching
hospital. For cultural and religious reasons, the hospital
has two separate surgical wards for male and female
201
patients. Each ward has 25 beds and patients admitted
need minor to major surgeries.
To date, postoperative pain in general is controlled in
the surgical wards only through medications. Analgesia in
general are prescribed by the surgeons in the operating
room as p.r.n. (as required) or to be given regularly.
During medical and nursing rounds, patients’ recovery
and needs for pain management are monitored, discussed
and documented. Due to the lack of research, training
and funding, pain management teams have not yet been
established.
Sampling
The current researcher approached all registered nurses
on surgical wards and then they were conveniently
recruited. A total number of four focus group discussions
were undertaken with nurses. Two focus group discus-
sions were undertaken with surgical nurses in a male
ward, including five and six participants; and other two
discussions were held with surgical nurses in a female
ward, including six and eight participants. The number of
participants in each group was not too small to restrict the
dynamic interaction among participants, nor too large to
manage.28 The total sample included 25 nurses.
Ethics
The Research and Ethics Committee at Mutah University
approved the study, as the hospital management where
the data collection took place subsequently did. During
the period of study, ethical issues were concerned with
the participants’ autonomy, confidentiality and anonym-
ity. All participants were informed of the purpose of the
study and also the voluntary nature of their participation.
Informed consent was obtained from the participants in
writing and signed by them for all stages of the study.
Names in the transcripts were replaced by codes.
Data Collection
To enhance the consistency of data collected, the current
author conducted all of the focus group discussions. Given
the differences in hierarchy levels among nurses, the first
two discussions were arranged with junior nurses in sur-
gical wards and the other two discussions were arranged
with senior nurses. None of the participants in the study
had a leader position which could have an effect on the
group dynamics, and most had experience within the
discussed themes.27
© 2014 Wiley Publishing Asia Pty Ltd
202
The focus group discussion took a semi-structured
format but largely consisted of open-ended questions,
including the following: What are the barriers to your
role in pain management? How do they affect patients’
pain management? Any examples? These questions were
developed in the light of relevant international litera-
ture.7,19,29
The main questions for the third and fourth discussions
were developed from preliminary analysis of the first and
second discussions transcripts, respectively, and were
structured to uncover further issues raised in the previous
discussion, such as power imbalance between doctors and
nurses. Overall, the questions were exploratory in nature
and helped to keep the focus of the discussion related to
nursing pain management and contributing barriers while
still enabling the participants to exchange their clinical and
individual experiences.
An observation of the groups’ interaction and contri-
bution was recorded by the current researcher at the time
of each discussion to aid in the data analysis. Debriefing
notes helped the researcher to recall the overall atmos-
phere of the group. Each focus group discussion lasted for
between 25 and 90 min.
Data analysis
All focus group discussions were undertaken using the
Arabic language. Thus, all transcripts were translated into
English by two bilingual professionals. The transcripts
were coded and grouped into categories to explore the
initial themes using N-vivo (9). Transcripts were read
several times and coded, and emergent themes were iden-
tified. An independent researcher checked the plausibility
of the data interpretation and ensured that the qualitative
data analysis was systematic and verifiable. Disagreements
between the researchers were resolved by face-to-face
discussions. A brief narrative summary was generated for
each interview.
Trustworthiness
The trustworthiness of qualitative data was considered by
taking a number of measures. Validity was accomplished
through member checking, and in particular when partici-
pants confirmed that the formalized description repre-
sented their experience and responses as a whole.29 The
involvement of a bilingual professional contributed to the
validity of translation and thus of the data obtained.
The credibility of data was enhanced by involving an
independent researcher who carried out some coding.30
© 2014 Wiley Publishing Asia Pty Ltd
N Shoqirat
Finally, the transferability was addressed by providing a
detailed description of the research procedures, setting,
participants and results to enable readers to judge the
applicability of the results in other settings.
RESULTS
General characteristics of
the participants
The participants’ age ranged from 24 to 45, with an
average of 32.1 years. The experience of nurses in surgical
wards ranged from 2 to 16 years, with a mean of 10.6. All
participants had BS degree in nursing. Fifteen participants
were women and 10 were men. Two categories emerged
that explain the context and perceived barriers affecting
nurses’ roles in pain management.
Category one: Barriers within bedside
This category illuminates barriers to pain management
within patients and their environment. It is made up of two
closely related barriers, comprising: attention-seeking
patients and ‘buzzer obsession’ and family interferences.
Attention-seeking patients and ‘buzzer obsession’
When participants were asked about the common barriers
to pain management, all of them (n = 25) cited that many
patients overseek attention from nurses despite their pain
being well managed. Using N-Vivo qualitative data analy-
sis software (version 9; QSR International Pty. Ltd., Don-
caster, VIC, Australia) to check the frequency of a certain
statement or concept, ‘buzzer obsession’ was mentioned
23 times.
Participants felt that the overuse of the buzzer was a
key barrier to nursing pain management. This is because
in addition to being noisy, it distracts nurses while they
are looking after other patients. In some situations, par-
ticipants expressed their concerns that the ward supervi-
sor might believe that nurses do not work hard and ignore
patients’ needs when buzzers are on:
I gave a pain killer for a patient following appendectomy . . .
she kept buzzing for more pain killers and this was annoying
. . . sometimes I ignored the buzzers . . . it is just a buzzer
obsession problem . . . and seeking attention I had others
patients to look after them (RGN9).
That is right . . . the supervisor assumes that we do not work
hard as there are a lot of buzzing for pain killers . . . we are
blamed (RGN6).
Barriers to pain management
These findings seem to indicate how the perceived
unnecessary use of buzzers might affect nurses’ roles in
pain management. Participants felt that they might be
blamed by supervisors for not answering the buzzer
when it goes off several times. What is striking in these
data is that nurses often assume that patients use the
buzzers to exclusively seek painkillers following surgery,
which might not be always the case. Buzzers were often
seen by nurses as a source of stress and noise rather
than a nurse call system to draw attention to patients’
needs. This in its own right might contribute to poor
pain management and follow-up. Although it is recog-
nized that nurses were busy with others patients, a state-
ment such as ‘sometimes I ignored the buzzers’ would
imply that patients’ pain is not only poorly monitored,
but also that patients’ lives could be at risk, in particular
following surgery, where deterioration might swiftly
occur.
Family interferences
According to the participants, one of the perceived
barriers to pain management was family interferences.
Related elements to this barrier included ‘chasing
nurses’ for pain injections and acting on behalf of
patients, and verbal abuse of nurses. Although partici-
pants recognized the importance of updating the family
about pain management, in some cases it was found that
dealing with families was more difficult than with
patients:
Some families do not understand that overdose of pain killers
is harmful, they just do not believe you and keep chasing you
in the corridor . . . you cannot do your work with other
patients . . . if you refuse to offer extra pain medications . . .
you will be verbally abused (RGN6).
These findings suggest that nurses fulfilling their role in
pain management might be subject to abuse from patients’
relatives. Some families demand that more attention be
given to their relatives (patients), which in turn com-
pounds the heavy workload borne by nurses on duty. The
researcher personally witnessed many arguments related
to pain management between families and nurses during
the data collection process, which often led to a formal
complaint being made to the hospital manager, thus
undermining the trust relationship between nurses and
patients.
203
Category two: Barriers within nursing
Lack of staff and ‘nurses need pain relief
before patients’
During some discussions about factors affecting their role
in pain management, informants were upset because their
workload is too high to cope with. In fact, some partici-
pants stated that they take pain relief at the end of each
shift. The analysis found that a single registered nurse
typically had to look after 15–20 patients who needed
close monitoring. As a result of the shortage in nursing
staff, some participants felt too exhausted to manage
patients’ pain:
I look after 15 to 20 patients following surgery . . . we do not
have enough nurses . . . I carry pain pills in my bag! [laugh-
ing] . . . you know at the end of shift my legs and knees
become so sore. I feel disempowered . . . so I need pain man-
agement before patients . . . [smiling] (RGN10).
The above evidence indicates that nurses are unable to
manage patients’ pain effectively unless they feel physi-
cally capable to do so; nurses’ ability to address patients’
needs for pain management is inhibited by the limited
number of nurses on duty together with a feeling of
disempowerment, which can be reduced to the factor of
overwork (and consequently, understaffing).
‘We are nurses, they are doctors’
Participants emphasized the problem with power imbal-
ance between doctors and nurses. This barrier and a
related cluster of meanings are reflected in the frequently
reported statement ‘we are nurses, they are doctors’. The
analysis of data revealed that due to nurses’ limited power
and involvement in pain management decision-making
compared with doctors, participants felt helplessness.
Others stressed that many patients follow doctors’
instructions carefully about pain management but they
ignore nursing advice. According to participants, nurses’
roles in pain management often revolve around carrying
out doctors’ orders as opposed to being involved in the
whole decision process:
Doctors expect us to carry out what they order . . . arguing
with them about a certain pain pill is not fruitful as we are
looked at as just nurses and nobody will listen to us (RGN, 5).
Some patients note that doctors do all the decisions about pain
management and thus it is not surprising that they ignore
© 2014 Wiley Publishing Asia Pty Ltd
204
nursing advice . . . they [patients] ignore the pain manage-
ment plan . . . because we are nurses they are doctors
(RGN, 12).
In light of above evidence, it seems that power imbal-
ance between doctors and nurses not only made nurses
feel helpless, but also negatively shaped patients’ recep-
tivity to the nursing role in pain management. This might
create resistance to nurses’ instructions and therefore
compliance with a prescribed pain management plan.
DISCUSSION
Study limitations
This is one of the few studies to focus on, and exclusively
describe, the barriers that affect nurses’ roles in the pain
management of patients following surgery. This study,
however, has certain limitations. The sample was selected
from only one hospital and two surgical wards, and given
the differences in terms of nursing training and pain man-
agement protocols, these findings might not be generaliz-
able to other clinical areas. A larger or more diverse
sample in this study would have increased the probability
of different or more distinct findings.
However, although qualitative research does not aim to
generalize findings to a wider population,31 the study pro-
vided sufficient descriptive detail to enable the reader to
judge whether or not the findings apply in other settings.
It is our hope that these findings will spur further efforts to
develop and evaluate strategies to adequately address bar-
riers to effective pain management in the postoperative
context.
Discussion of findings
The current study contributes significantly to the pain
management literature by exploring understanding quali-
tatively barriers to nurse’s roles in managing the pain of
those patients following surgery. The findings echo those
international studies stressing the complexity and diver-
sity of factors affecting pain management in the postop-
erative context, in particular the lack of time in and the
‘business’ of the ward.7,23,24 However, while patients’
fears of addiction to pain medications and the fear of
disturbing health-care professionals were confirmed by
many studies as key barriers to pain management, evi-
dence from this study does not support this concept.19,25,32
Instead, nurses felt that over-demand for pain relief and
the ‘buzzer obsession’ issues contributed negatively to
pain management.
© 2014 Wiley Publishing Asia Pty Ltd
N Shoqirat
Although the differences in the sample, type of patients
(e.g. patients with cancer) and methods are recognized,
this inconstancy might be explained by the current find-
ings, whereby nurses did not have enough time to assess
patients and carry out follow-up. In other words, the
possibility that patients did not receive sufficient pain
relief and thus develop concerns about addiction cannot
be ruled out.
What is striking in this study is not only judging
patients as ‘attention seekers’—despite the possibility
that patients might be in pain—but also how nurses
ignored buzzers and assumed that patients were soliciting
more pain killers. Aside from the potential for poor pain
management this suggests, general health-care provision is
compromised by nurses ignoring buzzers, thus increasing
the risk of postoperative complications. Generally,
‘illness talk’ is associated with the potential for the indi-
vidual to be described as a complainer or malingerer, and
nurses believe that good patients are those who do not
complain.33
In light of current evidence, it can be argued that
much research and educational attention need to be
given not only to those barriers affecting pain manage-
ment but also on how nurses cope and change their behav-
iours accordingly. Although it is obvious that more nurses
on duty are needed for better pain management, ulti-
mately the unreasonable failure to treat pain is viewed as
professionally unethical and as a breach of basic human
rights,25 and labelling patients as demanding might hinder
patients from requesting pain relief34 and thus lead to poor
recovery.
An interesting barrier to nurses’ roles in pain man-
agement was patients’ family-related interferences. To
date, a large volume of research urges nurses to focus
on patients’ pain management education and to offer
them information when needed.35–37 Although this is
valued, evidence from this study implies that such
actions need to be expanded and include patients’ fami-
lies. In many cultures, patients’ families are involved in
the decision-making process regarding overall treat-
ment,38 and excluding them and not updating them
might create mistrust with health-care professionals and
lead to possible verbal abuse, as occurred in this study.
On this basis, the future of pain management lies in
better education of patients’ families as well as patients
themselves.39
Finally, perhaps the most complex inhibiting factor that
affects the nurses’ roles in pain management following
Barriers to pain management
surgery is related to the power imbalance between
doctors and nurses. Consistent with the current findings,
nurses view themselves as powerless in practical pain
management, which is purely led by doctors,5 who often
do not trust the nursing assessment of pain.23 To add to
the problem, as validated by this study, the literature
demonstrates that ward policies place too much emphasis
on medication prescription rather than on individuals’
comfort needs.40,41 This poses an important question: how
can powerless nurses play a vital role in pain management
where the philosophy of care is dominated by medicine
and is underpinned by a mechanistic process?
Therefore, it seems that nurses need to be educated and
trained in how to develop and use communication and
negotiation skills that would enable them to establish rela-
tionships with doctors, to better meet patients’ needs.39
However, education alone is not enough if decision
makers at the hospital level are unaware of the importance
of nurses’ roles in pain management and their impact on
patients’ recovery. Simply, it would be unreasonable to
expect patients to value nurses’ roles in pain management
while these roles are underestimated by other health-care
professionals, particularly doctors. Future research on
improving pain management should directly examine
the impact of the doctor–nurse relationship on barriers
to effective pain management in the postoperative
context.
Conclusions
Although the study limitations are recognized, it provides
us with contextualized insights into the complex world of
pain management following surgery. Nurses perceived
that barriers to pain management are diverse, ranging
from bedside factors and ‘buzzer obsession’ to barriers
within nursing itself and power imbalance with doctors.
Therefore, multidisciplinary actions to address barriers to
pain management at the level of nursing as a profession
ward culture and policies are urgently needed if pain
following surgery is to be well managed.
Successful initiatives to overcome barriers to pain man-
agement following surgery need to be multifaceted in
their approach. As part of this, continued and concerned
efforts are required to overcome the barriers to effective
pain management found by this study. Failure to do so
might lead to more pain sufferers following surgery, and
thus poorer recovery and satisfaction with the overall
nursing care.
205
ACKNOWLEDGEMENTS
The authors are grateful to all participants who took part
in this study. The project was funded by Abdul Hameed
Shoman Foundation. The funder was not involved in the
conduct of the study or development of the submission.
The author declares no conflicts of interest.
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