Pain Management as Triadic Interaction: Shifting Alliances in Nurse-Patient-Family-Member...

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Pain Management as Triadic Interaction:Shifting Alliances in Nurse-Patient-Family-Member CommunicationScott A. Eldredge a , Elizabeth D. Dalton a & Laura E. Miller aa School of Communication Studies , University of TennesseePublished online: 03 Nov 2014.

To cite this article: Scott A. Eldredge , Elizabeth D. Dalton & Laura E. Miller (2014) Pain Managementas Triadic Interaction: Shifting Alliances in Nurse-Patient-Family-Member Communication, SouthernCommunication Journal, 79:5, 448-467, DOI: 10.1080/1041794X.2014.928899

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Pain Management as TriadicInteraction: Shifting Alliances inNurse-Patient-Family-MemberCommunicationScott A. Eldredge, Elizabeth D. Dalton, &Laura E. Miller

Throughout an individual’s life, family exerts a major influence on his or her healthcare

choices and behavior. Families often act as surrogates for the patient by providing infor-

mation to nurses and other healthcare providers regarding a patient’s pain and illness

symptoms. Viewing the pain-management process as triadic interaction, researchers used

in-depth interviews with 21 nurses to investigate nurses’ perceptions of the role families

have in assessing and managing a patient’s pain. Participants in this study described

situations where patient-family member alliances formed in opposition to the attending

nurse. Attempts at providing social support to the patient resulted in interference

with nurse-patient communication, negative effects on the patient’s healthcare, and

damaging, or even life-threatening, impacts on the patient’s health.

Illness and hospital stays dramatically disrupt people’s daily lives and place significant

stress on individual patients. Compounding the stress associated with the illness

itself, patients must also cope with pain stemming from illness, required treatment

protocols, and surgical procedures. For example, women with advanced breast cancer

experience a cycle of pain; pain is a distressing reminder of the cancer diagnosis, and

the realization they have cancer contributes to greater pain (Koopman, Hermanson,

Scott A. Eldredge, School of Communication Studies, University of Tennessee. Elizabeth D. Dalton, School of

Communication Studies, University of Tennessee. Laura E. Miller, School of Communication Studies,

University of Tennessee. Scott A. Eldredge is now at the Department of Communication, Western Carolina

University. Correspondence to: Scott A. Eldredge, Department of Communication, Western Carolina University,

Old Student Union 109, 180 Joyner Road, Cullowhee, NC 28723. E-mail: [email protected]

Southern Communication Journal

Vol. 79, No. 5, November–December 2014, pp. 448–467

ISSN 1041-794X (print)/1930-3203 (online)

# 2014 Southern States Communication Association. DOI: 10.1080/1041794X.2014.928899

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Diamond, Angell, & Spiegel, 1998; Spiegel & Bloom, 1983). In hospital settings, pain

management is a collaborative process conducted via nurse-patient communication.

To alleviate pain, nurses must gather information from the patient to determine the

appropriate action. Within these interactions, it is important to note the difference

between pain measurement and pain assessment. While pain measurement is

concerned with quantifying pain in a bias-free manner, nurses are required to

conduct a more generalized pain assessment that is concerned with critically analyz-

ing a variety of factors associated with pain and developing on overall appraisal of the

patients’ pain experience (McGuire, 1992). Specifically, nurses must make judgments

on six dimensions of pain that include physiologic, sensory, affective, cognitive, beha-

vioral, and sociocultural factors (McGuire, 1992). In assessing pain related to these

dimensions, nurses gather information related to pain intensity, pain location, things

that increase and decrease pain, pain duration, verbal statements of pain, and use and

effects of pain medication (de Rond, de Wit, van Dam, & Muller, 2000). To further

complicate the pain assessment process, nurses are often required to use numeric

pain scales (de Rond et al., 2000), interpret the patient’s nonverbal expressions of

pain (Poole & Craig, 1992), and note their perceptions regarding the patient’s

emotional distress (Pasero & McCaffery, 2005).

With nurses being asked to appraise information across such a wide spectrum of

dimensions, pain assessments are fraughtwith problems. For example, numeric pain scales

have been found to be ineffective in assisting nurse-patient pain-management efforts

partly due to nurses’ perceiving patients’ facial expressions to be inconsistent with what

the patients report via the numeric scale (de Rond et al., 2000). Problems such as this have

led to nurses consistently underestimating a patient’s level of pain (McCaffrey, Ferrell, &

Pasero, 2000). Further complicating the process, nurses may also be required to gather

information regarding the patient’s pain via surrogate reporting (Herr et al., 2006).

In discussing pain-assessment techniques, clinical guidelines recommend

gathering information regarding a patient’s pain from family members (McCaffrey

& Pasero, 1999; McGuire, 1992). Often acting as the surrogate source of information,

the patient’s family and friends become part of the pain assessment and management

process, interacting with both the patient and healthcare providers, thereby influen-

cing the patient’s health and well-being. Nurses are then challenged to synthesize

the information gathered from these disparate sources and choose from an array

of solutions that vary from attending to the patient’s physical comfort, to providing

non-opioid analgesics (i.e., acetaminophen) or administering opioid-based pain-

killers such as OxyContin or Hydrocodone (McCaffrey & Pasero, 1999). Given that

clinical guidelines and actual nursing practice are not confined to just the interactions

between nurses and patients, this triad of patient, nurse, and family member

is a more realistic depiction of the interactions that occur within the pain-management

process; however, healthcare discussions and decision making as a three-way

interaction remains largely unexplored (Pecchioni & Keeley, 2011).

Pain assessment is a communicative process; as such, the effective management

of a patient’s pain is a function of communication. Nurses must have the ability

to strategically select and employ a myriad of communicative behaviors. However,

Families, Nurses, and Patients 449

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miscommunication regarding patients’ pain remains a problem. Nurses often do not

believe patients’ descriptions of pain (McCaffrey et al., 2000). Furthermore, pain-

assessment tools to support the communicative process are insufficient in their

thoroughness, the tools often do not address all of the dimensions associated with pain,

and the subjective nature of the process makes accurate assessment difficult (Martin,

Williams, Hadjistavropoulos, Hadjistavropoulos, & MacLean, 2005). These types of

miscommunication lead to inadequate documentation and treatment of a patient’s

pain. For example, nurses frequently do not increase a patient’s dose of pain medicine

when treatment guidelines and protocols allow for an increased dose (McCaffrey et al.,

2000). In this case, miscommunication leads to ineffective pain management. Clinical

guidelines that recommend involving family and friends to assist in the pain-assessment

process are designed to increase the effectiveness of the communication. However,

given so little research exists in this area, there is little evidence that suggests enlisting

surrogates contributes to an increase in effective pain management.

Taking the perspective that the pain-management process frequently involves triadic

interactions, the current study seeks to explore nurses’ perceptions of communicative

efforts to facilitate the pain-management process involving patients and at least one

other member of their family. In previous research about families in the healthcare

setting, family has been defined as those who are close to the patient (Hardwig,

1990). Family, then, can include relatives as well as close friends and companions.

Given the involvement of families in patient care, this study first conceptualizes triadic

communication and then situates triadic communication within the healthcare context.

Then, results regarding nurses’ perceptions of family involvement in the pain-

assessment and management process are discussed, along with both theoretical and

practical implications for nurse-patient communication and the nursing profession.

Triadic Communication

While dyadic communication explores the interaction of two people and small-group

research is typically centered on five or more individuals, triadic interactions, those

involving three people, remain an area of communication research receiving little

scholarly attention (Hill & McGrath, 2008). A triad exists when three individuals

participate in a social interaction on a consistent basis (Caplow, 1968; Thibaut &

Kelley, 1959; Wilmot, 1975). However, just the existence of social interaction among

three individuals is insufficient for the formation of a triad. Triads are present only

when each member of the triad is dependent upon both of the other individuals

(Thibault & Kelley, 1959). In framing the nurse-patient-family member interaction

as a triad, all three actors involved must be, at some level, dependent on the contin-

ued existence of the triad. With each member of the triad involved with and respon-

sible for the patient’s health and well-being, the nurse, patient, and family member

are all pulled into a situation where all are dependent upon their involvement and

interaction with the others.

The communication dynamics involved in triads are somewhat unique. The

addition of a third person to a dyad always brings change. Because a triad involves

450 The Southern Communication Journal

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three individuals, inherently, the triad offers a situation where a majority can form.

It is very rare for each member of a triad to exert equal influence on the group; more

typically, two members of the triad form a majority alliance, essentially becoming

a dyad plus one and suppressing or excluding the third member (Wilmot, 1975).

For example, in an examination of parent-child-stepparent triads, Baxter,

Braithwaite, and Bryant (2006) found limited evidence of truly complete triads where

each member exhibited positive, functional communication among all members;

instead, the triadic structure was characterized by various alliances between the

parent-child dyad and the parent-stepparent dyad. These dyadic alliances formed

within triadic relationships are not necessarily permanent. As interactions take place,

alliances tend to shift, forming and dissolving with each member of the triad at times

remaining part of the majority dyad, while at other times becoming the lone indivi-

dual outside of the majority alliance (Wilmot, 1975). Because of this dynamic, triads

are less stable than a dyad and have a tendency toward discord (Wilmot, 1975).

The shifting relational dynamics within triads may stem from a variety of sources.

For example, triadic interactions within an organizational setting are affected by

dynamics associated with the relative status and power possessed by the individual

members of the triad (Caplow, 1968). However, power distributions cannot fully

explain triadic relationships. Within a family setting, the relationships within triads

involving various family members are affected by the degree to which they exhibit

formal authority, competing interests, strict taboos, and conflicting loyalties (Caplow,

1968). Healthcare and illness offer a unique environment in which to consider the

dynamics associated with the interactions among the patient, the family, and health-

care providers. By operating within the context of healthcare and the institutions

required for delivering care, the nurse-patient-family-member triad is, arguably, sub-

ject to the influence of each triad member’s status and authority associated with the

role the person plays in the healthcare organization. In addition, the interdependent

nature of families means their reactions to and experiences with illness are also inter-

related. The origins of how individuals comprehend, understand, and think about

health are found in an individual’s family life (Geist-Martin, Ray, & Sharf, 2003).

Health behaviors and attitudes toward health are first learned within the family that,

in turn, influences how the individual chooses everyday behaviors. These choices ulti-

mately influence current and future health outcomes (Geist-Martin et al., 2003).

Family influence is certainly not left behind when a patient is in the hospital or inter-

acts with a healthcare provider. The nurse-patient-family-member triad must also

contend with dynamics introduced via the relational dynamic between the patient

and family member.

Triadic Communication in Healthcare

Triadic interactions are a common occurrence within a health context, with the

actors involved often adopting the roles of passive patient, advocate, and antagonist

(Adelman, Greene, & Charon, 1987; Greene & Adelman, 1996; Ishikawa, Roter,

Yamazaki, & Takayama, 2005). Certainly within these triads, the power of the actors


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involved affects the interactions. For example, while healthcare providers would like

to see more involvement from the child-patient, they describe children as passive and

uninvolved, with parents acting as the main partners in the interaction (Van Staa,

2011). Other common triadic medical encounters include doctors, elderly patients,

and an adult companion of the patient (e.g., adult child, caregiver). Power distri-

butions also seem to be at play in these encounters, with older patients holding

a deferential view of physicians (Ishikawa et al., 2005), and communicating less, rais-

ing fewer questions, and focusing primarily on biomedical issues and less on other

psychosocial issues that also affect the health of the patient (Greene & Adelman,

1996; Ishikawa et al., 2005). In describing triadic encounters, healthcare workers

often feel they lack effective communication strategies to deal with the dynamics

present within the triad. For example, in dealing with parents and adolescents, many

healthcare workers feel incompetent to restrict parents’ involvement and increase

adolescents’ participation (Van Staa, 2011).

Arguably, there is a substantial difference between patients who are children and

patients who are elderly adults, and researchers suggest these encounters should be

studied as variants involving distinct subgroups (Adelman et al., 1987). With much

of the research exploring triadic communication within a healthcare context focused

on either young patients (children and adolescents) or elderly patients, a gap demon-

strating the need to investigate other types of triadic medical interactions exists.

Considering the nurse-patient-family-member triad occurs at the intersection of both

organizational and family relationships, and there is a dearth of studies investigating

triadic communication outside of those involving very young and very old patients,

the current study seeks to fill this literature gap and to investigate nurses’ perceptions

of triadic interactions involving nurses, patients, and the patients’ family member.

The following research questions are posed:

RQ1: What alliances form within the nurse-patient-family-member triad withinthe context of pain management?

RQ2: What communication strategies do nurses employ in an attempt to managetriadic interactions?

Method

Due to a lack of research exploring the pain assessment and management process as

a triadic interaction, this study employs the use of qualitative interviewing techniques

associated with a grounded theory approach. As exploratory research, qualitative

interviews are particularly useful to study complex behaviors in-depth where little

a priori knowledge exists (Charmaz, 2006).

Participants

Participants were recruited from a medium-sized Southeastern city. Purposive

sampling techniques were utilized to recruit participants via online listservs and flyer

distribution. Snowball sampling was also used to recruit additional participants. Due


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to the exploratory nature of this study, an effort was made to facilitate the inclusion

of a balanced sample (e.g., not a predominance of one nursing specialty).

This study consisted of individuals who were currently employed as a nurse

at the time the interview was conducted. All of the participants had earned a nursing

degree, such as an associate of science in nursing (ASN), bachelor of science in

nursing (BSN), or master of science in nursing (MSN), except for one participant

who was a certified nursing assistant (CNA). The final sample included 21 nurses

from a variety of specialties, including labor and delivery, anesthesia, intensive care,

hospice, pulmonary, and emergency room care. Each participant received $50 for his

or her participation. Two of the participants were male, and 19 were female. The

average age of the nurses was 38 (range 23 to 54) and, on average, the participants

had been working as a nurse for 10 years (range 1 to 32). All participants identified

as White. Pseudonyms are used to refer to study participants.

Interview Procedures

One-on-one interviews were scheduled with participants. All three authors conducted

interviews, and participants were asked to select a convenient time and location for

the interview. Interviews were held in university buildings, coffee shops, and restau-

rants. The interview guide consisted of approximately 20 questions designed to elicit

nurses’ descriptions of their experiences interacting with patients regarding pain and

pain management. Each participant was first asked brief demographic questions (e.g.,

education, nursing experience). Participants were then asked about their experiences

communicating with patients, eliciting information about patients’ pain levels,

and regulating patients’ requests for pain medication. In addition, participants were

asked about their experiences interacting with patients’ family members in the

hospital setting. Each interview lasted approximately 45 minutes, was audio recorded

with the participant’s permission, and was transcribed for analytic purposes. The

final sample yielded 334 transcript pages. Data collection continued until saturation

was reached. After interviewing 21 participants, no new insight was presented, and it

was believed that the data-collection process had reached completion.

Data Analysis

After interviews were transcribed verbatim, a constant comparative analytic

method was used to analyze the data (Glaser & Strauss, 1967; Strauss & Corbin,

2007). Constant comparison techniques allow salient themes to emerge from the data

and refining these themes assists in the development of conceptual categories. In the

current study, open and axial coding techniques were utilized to determine the

prominent themes in the data. In the first stage of analysis, each author read

and independently coded a subset of transcripts. Next, the researchers discussed

the prominent themes and constantly compared the prominent themes with the

previously coded transcripts. For example, the researchers found that the general


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theme of triadic interactions emerged, thus, they engaged in constant comparison

until themes and subcategories relating to triads were developed. In the second stage

of analysis, the authors refined the categorical scheme by reaching consensus about

the emergent themes and the relationships among each of the categories. In the cur-

rent analysis, for example, the researchers met to finalize the subcategories that best

represented the notion of triadic interactions. Specifically, the researchers found three

major themes: triad formation, alliance development, and strategies for managing

alliances. Once coding was finalized, the authors discussed and decided upon

appropriate exemplars to represent each category. The following section details the

prominent themes that emerged from the constant comparative analytic process.

Findings

Nuances of the nurse-patient-family communication triad are revealed by nurses

through their descriptions of everyday interactions in pain treatment. Results are

organized according to their descriptions of triad formation, the patient-family

alliance that occurs within the triad, and strategies for dealing with complications

caused by this two-against-one alliance.

The Triad and Its Complexities in the Healthcare Setting

Participants described how the very presence of family members creates a three-way

dynamic that can complicate their roles. For instance, families often directly interfere

with nurses’ attempts to treat the patient’s pain. Both Kendra and Morgan, for

instance, complained about family members critiquing their work. According to

Morgan, a critical care specialist: ‘‘Whenever they [family members] try to tell me

what to do or how to do it, or critique the way you do it, then I would just as soon

try to do it when they weren’t in the room.’’ Many participants described the influ-

ence families have on the attention directed toward patients. Family members often

divert attention away from patients, even in the most critical situations, creating

a complicated three-way interaction. For instance, Rachel described a circumstance

in which she and her patient had to interact about helping a family member:

I had a kid [patient] whose mom was staying with him, passed out, I couldn’t evenwake her up and we ended up having to take her to the emergency room andlooked in her purse and it was like, a pharmacy of pain pills and muscle relaxersand she had taken all of these meds together and [the patient] called out for usto come help her because she was falling down in the room because she couldn’tstand. He is the patient, who can’t get out of bed because he’s had his leg ampu-tated and his mother is so high that she’s falling on the floor, she can’t even standup. We had to come and help her into a wheel chair to take her to the emergencyroom because she couldn’t even function.

Rachel’s difficulty stems from having to care for an inebriated family member—a third party—using time and resources that would otherwise be dedicated to her

patients.


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Next, family members often weigh in on and try to influence the administration of

pain medication to the patient. While some try to advocate for increased dosages, others

are fearful of the potential fallout from narcotic addiction. According to Georgia,

Yes, they [families] do have a big effect on the patient. I have had several familymembers that take the approach, ‘‘Well, you shouldn’t need all those pain pills.’’‘‘Mom’s got debilitating arthritis and it’s hard for her to get out of bed, but I don’twant her hooked on those pills.’’

Robin also mentioned needing to convince family members that medications are,

in fact, necessary and safe:

The guy had esophageal cancer, and he couldn’t swallow. And I went to see him forthe first time. His wife was very reluctant to give him his pain medicines becauseshe just knew he was going to become addicted. I said, ‘‘He’s not going to becomeaddicted. He needs the pain medicine. You need to give it.’’

Some family members circumvent both the nurse and patient by directly

interfering with patient-controlled anesthesia. In doing so, nurses reported that the

family members are unwittingly putting patients at risk out of concern for their level

of pain. Both Leslie and Lorraine reported problems with family members pushing

the patient-controlled anesthesia button. According to Lorraine, ‘‘We have a lot

of problems with families pushing that because if [the patients] squirm around

in the bed just a little bit [the family members] think they’re in pain, so they will give

them more and more.’’ Leslie describes a ‘‘very loving’’ husband who slept next to his

sick wife in the hospital. The man

didn’t want her to hurt or anything, and every so often, he’d wake up and push thatbutton for her. He didn’t want her to wake up in pain. Well, she almost didn’t wakeup, because she was fine. Her pain was fine . . . he nearly killed her.

In these instances, nurses felt that verbal input and behaviors by family members

negatively impacted the pain-treatment process, and interfered with the nurses’

job. Participants’ descriptions indicated that they found these interferences by a third

party annoying, unnecessary, and often dangerous.

Finally, several participants described the impact of family members on patients’

presentation of pain. Kendra described how the very presence of a family member

often brings out the ‘‘needy’’ side of patients: ‘‘The patient may be in the room alone,

they are fine and asleep. The family comes in and wakes them up, they are all of

a sudden hurting more. They want more pain medicine. They become more needy

in general.’’ Lorraine says that patients often start ‘‘moaning and groaning and acting

like they’re really hurting’’ when the family arrives, which she attributes to attention

seeking on the part of the patient. In spite of how much pain the patient is actually

experiencing, nurses felt that complaints increase in the presence of family members.

Therefore, more is required of the nurse in terms of assessment and increased dosages

of medication, of which he or she often questions the necessity.

Overall, it is evident that the treatment of pain by nurses is not a two-way

interaction. Instead, nurses find themselves part of a complex triad that demands


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careful navigation. The participants describe these triadic interactions as problematic,

with family members directly interfering with treatment and influencing patients’

pain presentation.

Alliance Formation and Influence

Based on nurses’ descriptions, it appears that a patient-family alliance occurs

as a natural outcome of the nurse-patient-family-member triad. As described

previously, a two-person coalition often emerges when there are three voices present

in an interaction. Nurses, then, are left feeling as though patients and their families are

teaming up against them, often thwarting their best efforts to treat the patient’s pain

in a caring and effective way.

As ER nurse Jeremy explains, nurses often feel as though families and patients

strategically coalesce against healthcare providers to obtain pain pills. Whether to

share amongst themselves or to sell on the street, the purposeful elicitation of surplus

pain medication by patients and family members is described by nurses as hugely

problematic. Jeremy describes how he assesses not only the patient but the family

members as well:

You look and you see. When a family comes in and a family has a certain look, just asmuch of a drug addict as the patient, you kind of roll your eyes, especially when theywill escort you out of the room and grab your hand and say, ‘‘They are just hurtingso bad. You just, we just need to do something for the pain . . .’’ Are you saying thatbecause you want them to get pain medicine and get a prescription so you can sharein that? These are just the thoughts that everybody has that works there.

Lauren, a trauma nurse, describes how patients themselves will hoard medication

in the hospital, often with the intention of sharing it with family members later:

I definitely, um, had patients who, um, you know, will say they’re hurting and needtheir valium or whatever they can have, and will not take it but . . . either give it totheir loved one or save it for later. I can’t tell you how many times I’ve ripped backthe sheets on someone and they’ve got pills in the bed with them. It’s a big thing.That makes me really mad . . . nothing makes me more mad than someone whothinks I’m stupid.

Nurses claim that family members also encourage the patient to exaggerate or lie

about pain symptoms to acquire more pills. According to Robin, when patients ask

for more pain medicine than seems necessary, ‘‘nine times out of ten, they’ve

got a family member feeding into that . . . they may be wanting the medicine

for themselves and they think this person can get it. And then they can have it or sell

it. Whatever.’’ In these cases, patients and family members are motivated to team up

in an effort to influence the nurse and to gain surplus medication.

At other times, nurses sensed that family members saw their own types

of ‘‘remedies’’ and products from home to be necessary or even superior to what

is administered in the hospital. Circumventing the sanction of the nurse, family

members will bring the patient medications and other substances from outside the


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hospital. Nurses told numerous stories of this occurring. Mary, for instance, describes

the sister of one of her regular nursing home patients: ‘‘Her sister brings in her

remedy. Sometimes at night she brings in ‘chamomile tea.’ And what’s in that tea,

I have no idea. But after [the patient] drinks that tea, she gets loopy.’’ Overall, nurses

expressed feelings of frustration and inefficacy at the coercive actions of the

patient-family-member alliance. When this dyad conspired to elicit additional

medication or to sneak outside substances into the treatment scenario, the nurse is often

forced into a hypervigilant state as both practitioner and wary third-party outsider.

Strategies Employed to Navigate Alliances

Tomanage such challenges and the formation of alliances, nurses reported engaging in

a variety of strategies to overcome the problems associated with the triadic nature

of healthcare. Specifically, nurses described using family members as a resource in

treatment, bringing in a fourth entity to correct the triadic power imbalance and

exercising strategic communication practices to diffuse the aforementioned problems.

Using family as a resource

Some participants highlighted the positive aspects of family involvement in

treatment. They acknowledged the impact that social support can have on health out-

comes. According to Allison, ‘‘They have, patients have much better outcomes when

they have support.’’ She also felt that a patient’s ability to deal with pain is directly

related to the amount of family support available to that patient. In addition to

providing social support, a few nurses reported being able to strategically use family

members as a resource during a healthcare encounter. For instance, Ken, a critical

care nurse, will often ‘‘put [family members] to work’’ as a way to facilitate patient

care; in addition, doing so ‘‘builds a good rapport with the families.’’ In essence, he

takes steps to build a nurse-family alliance that will help to balance out an existing

patient-family alliance. Families can also serve as a source of information. Ken

describes one of his patients: ‘‘A couple of weeks ago, this stroke patient, it was an

older stroke patient, and he was non-verbal. He didn’t communicate in any way,

shape or form, but his wife said, ‘every time he rubs his head like this, he’s in pain.’ ’’

Similarly, Joan describes how families can provide helpful information: ‘‘Like

they’ll say, ‘This is their normal routine. This is how they normally act. He never

complains of this. This is out of the norm for him’ . . . families will volunteer a lot

of information for you without even having to ask.’’ Family members may even

encourage the patient to divulge important behavioral health information. Heather,

for instance, describes overhearing a wife tell her husband:

‘‘Well, shouldn’t you tell them you took my hydrocodone the other day becauseyou were hurting so bad and you didn’t have something?’’ Well, it’s not prescribedto them but I mean, I’ll list it as something they’ve taken because it will be intheir system.

In these instances, nurses utilized the knowledge of family members to more quickly

and effectively treat the patients’ pain.


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Utilizing external entities to manage family members

The nurse must often reach beyond the triad for help neutralizing the coalition that

he or she feels has formed against him or her. Citing the law, calling security,

and using sitters are three ways that nurses bring in outside help. In these cases,

nurses utilized outside sources to diffuse alliances and to terminate potentially

unhealthy dynamics.

Kate described strategically referencing a higher authority when discussing pain

medication with a patient’s family members. As she noted:

I was waiting to give them their medication and they [family] were like, ‘‘Just leaveit on the table, I’ll give it to ‘em.’’ I said, ‘‘No, I can’t do that.’’ ‘‘Oh yeah,you can trust me.’’ And I said, ‘‘No, I can’t do that. By law, I cannot do that.’’

Melanie described the problems stemming from family members who bring

in prescription pills from outside the hospital: ‘‘We have to call security, and then

you’ve got people hoarding their pills when you give it to ‘em, or, bringing their

own in, chopping it up, stealing syringes to inject it or snort it.’’ Claire, a pulmonary

nurse, describes a mentally disabled man in his mid-forties whose parents continued

to secretly administer prescription pain medicine to him while he was under Claire’s

care. The patient’s symptoms included unexplainable seizures, and when Claire

discovered a stash of pain pills that his parents had hidden under his hospital

mattress, she utilized hospital security staff to intervene:

[A]fter weeks of having him, family visiting him, um, we had to send his parentsout, like ban them from the hospital with security because they were giving himVicodin. They’d been medicating this man to control him because they couldnot control his actions and activities but they needed [him for] the social securitycheck, or wanted the social security check, whatever it be.

By citing legal obligations and calling on hospital security, nurses not only manage

problematic patient-family alliances but they relieve themselves of full responsibility

by asking for help from a fourth party.

Other nurses dealt with problematic patients by stationing sitters in patients’

rooms. For example, citing the problem of drug abuse within the hospital, Courtney

noted:

[W]e have to put sitters with them to watch everything that they do because we’vecaught them with drugs in the room. Just recently, we had somebody, the CNApicked up her pillow and all this stuff fell out of the pillowcase, and we had to havea sitter round the clock to make sure somebody didn’t bring her drugs in.

Again, the nurse must often ask for help from someone outside the triad in order

to manage the situation.

Utilizing strategic communication to manage family members

In addition to their regular healthcare duties, nurses must utilize strategic communi-

cation to recognize when exclusion of the family member is in the best interest

of the patient’s health. Often the first step involves observational strategies, such


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as analyzing verbal and nonverbal cues from family members in the treatment setting.

Similar to Jeremy’s aforementioned evaluation of family members in the ER, Lauren

explains:

I’m watching their families very closely. I have to learn to feel out what kind ofpeople they are, um, if the family’s asking a lot of questions about their pain med-icine . . . sometimes they’re kind of passed out in the chair themselves from theirown issues.

Strategic communication often involves coalescing with the patient in a way that

may exclude the family. According to Lorraine, patients often do not want family

members knowing what pain medications are being prescribed for them. They will

therefore request that the nurse wait until it can be discussed in private, away from

the family. Georgia, a home health and hospice nurse, also strategically educated

patients to use lock boxes and even to lie to family members about what kinds of

medicine they have been prescribed. As she described,

I lock boxes and all that kind of business. Especially, cuz, you know, [families] seehospice and it’s like, ‘‘Oh, there’s the drug fairy.’’ You know. And then, like when Igo into a home, especially older clients, I’ll tell them, ‘‘Do not tell anybody you’retaking pain medication.’’ . . . I just have to be real with them, people rob people forpain medicine. They knock on your door and you open your door and boom, theyare in your house. So don’t tell them. And if they do ask you, just tell them, youknow, ‘‘I don’t really need anything. They told me to take ibuprofen and Tylenol.’’

In another example, Kendra mentioned that nurses and patients may collaborate

and utilize a ‘‘patient code’’ specific to that alliance if the patient wanted the family

to leave the room. As she noted, ‘‘We used to have a system, actually, that they would

teach in prenatal classes, that if you wanted your room cleared, you would ask

the nurse for a green popsicle. Because we don’t have green popsicles.’’ For these

participants, families diverted attention away from the patient, and some even had

specific communication strategies that assisted in developing a coalition with the

patient and ensuring that the patient was still at the center of care.

On the other hand, some nurses used communication as an opportunity

to include and educate family members about their loved one’s health situation.

This has a way of mitigating any isolation the family may feel as a third party

to the treatment scenario. According to the participants, making families feel

involved in patient care can be—but is not always—beneficial for the triad.

If it appears that family members do not understand, or are not ready to grasp

information about the patient’s health status, Julie explains that nurses mark ‘‘needs

reinforcement’’ on the patient’s chart. She describes how she recognizes the need for

educational reinforcement:

Like if, a lot of times if they’re really, really quiet and don’t ask a lot of questions,they’re not ready to hear everything. They’re just overwhelmed with everythingand, um, you know, you say, ‘‘do you have any other questions,’’ and they say,‘‘no’’ but you’ve given them a lot then you know they’re going to need more.It’s just they don’t know what to ask yet or they’re, you know, still stuckon the fact that mom is here with all these tubes and, um, you just say, ‘‘needs


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reinforcement’’ so the next nurse will know, she started the conversation but I needto go in and, you know, reinforce this.

Nurses also take advantage of opportunities to educate families about pain

medication and its related side effects. Robin, for example, described her communi-

cative strategies for educating family members on the necessity of pain medication.

As she mentioned,

You know, you are not going to become addicted to pain medicine for legitimatepain. It’s going to work like it’s supposed to on that pain. I’ve told people, also,‘‘You know, for right now, what difference does it make if they become addicted?If that’s what happens, they’ve got legitimate pain. You can deal with the addictionpart or weaning them off the medication later. Let’s get their pain under control.’’

In this instance, Robin is educating the patient’s family member in an attempt

to break the patient-family-member alliance and diffuse the opposition the nurse

is feeling from that alliance.

Claire, a pulmonary nurse, describes how she decided to strategically disclose

information about her patient’s deviant behavior as a way of including the patient’s

mother in the management of her patient. She was having difficulty with a patient

who was stealing needles out of the sharps box in her room and decided to tell

the patient’s mother about her problematic behavior. In an effort to manage the

patient’s behavior, Claire says:

And I told her mom what happened because her mom wanted to know. And shewas very mad at me for telling her mom. I did not feel like I was violating HIPAA[Health Insurance Portability and Accountability Act] because the momtold . . . even though she is an adult, we have been dealing with this for a long time -. . .But she [the patient] was getting upset with me. And it’s awkward taking careof someone after being in a situation like that with them.

Through observational analysis, specialized language codes, education, and strategic

disclosures, nurses use communication as a way to manage the complexities of the

nurse-patient-family triad. These communicative efforts on the part of the nurse

demonstrate an attempt to effectively deal with the shifting nature of alliances in

triadic interactions. In these instances, nurses are using communication strategies

to diffuse alliances they find adversarial and to build beneficial coalitions to navigate

the interactions required to effectively manage a patient’s pain. These particular

descriptions provide the basis for possible educational interventions for nurses

in the pain-treatment context.

Discussion

The current study examines nurses’ perceptions of families and their impact on

the pain-assessment and management process and extends current research on

nurse-patient communication by illuminating the difficulties and dilemmas nurses face

when administering pain medication. In particular, viewing the pain-management pro-

cess from a triadic perspective provides a more realistic picture of the communication


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challenges that nurses face, while also allowing for a deeper understanding of the

unique dynamics involved in managing pain. When pain-management efforts are con-

ceptualized as an interaction only between nurses and patients, these insights are lost.

One important aspect of these triadic interactions is social support. Specifically, the

nurses participating in this study described the ways in which families, through seem-

ing acts of social support, interfere with the care of the patient, often with damaging

and potentially life-threatening consequences. This research goes beyond just a dis-

cussion of poor outcomes associated with social support; instead, it begins to describe

the communication processes that explain why certain efforts at advocacy and social

support often fail in dramatic fashion. The current study, therefore, has important

theoretical and practical implications for the nursing profession and further highlights

the need to fully explore the triadic nature of healthcare interactions.

Theoretical Implications

In describing how nurses experience their roles within the field of healthcare, this

research has important theoretical implications for understanding the role families

play in providing social support to hospitalized patients.

Social support

At a theoretical level, social support has been alternately conceptualized according

to integration within a social network or based on perceptions of the availability of

support (MacGeorge, Feng, & Burleson, 2011). Regardless of the scholarly tradition,

communication is central to the concept of social support, making the involvement

of a third party providing some form of assistance, be it emotional or instrumental,

a communicative act (MacGeorge et al., 2011). Because social support often involves

a third actor actively participating in the patient’s healthcare experience with

providers, social support, in these instances, is inherently a triadic interaction subject

to the dynamics involved with alliance and coalition formation. At the conceptual

level, this study calls attention to previous research on social support in the health-

care setting. Goldsmith (2004), for instance, points out that emotional and instru-

mental support from families tend to enhance health outcomes. Nurses in this

study acknowledge that family social support in the medical setting can be beneficial;

however, nurses also perceive ulterior motives on the part of family members, who

often use the patient to acquire prescription pain medication for themselves or for

the patient to hoard for later use or to be sold. This often occurs under the guise

of advocacy, as family members request additional pain medication on behalf of

the patient. Clearly, in such circumstances, the presence and involvement of family

members does not enhance health outcomes for the patient. Although family

members may care about the patient’s pain level, and patients may benefit from

the involvement of loved ones in their healthcare, perhaps a ‘‘dark side’’ of these

types of supportive acts lies in what the family members hope to gain for themselves.


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While the dark side of communication encompasses a variety of aspects and

dimensions of communicative behaviors, Spitzberg and Cupach (2007) have ident-

ified seven themes associated with the dark side of communication. In particular,

the direct and indirect exploitation of others is a theme associated with the dark side

of communication (Spitzberg & Cupach, 2007), and data from the current study

suggest nurses often see family members’ supportive communication as a guise

for exploiting patients for their own gain. Seeing family members use the patient’s

medical situation as a path to obtain drugs for themselves or to hoard for illegal sale,

nurses perceive family members’ social support as a communicative act that, while

typically perceived as moral and productive, is now deceptive and dysfunctional.

In this way, family members’ supportive communication lives within the ‘‘what once

was bright is now dark’’ conceptualization of the dark side of communication

(Spitzberg & Cupach, 2007, p. 6).

Vangelisti’s (2009) research highlights some additional potential downsides to

social support in the health context. Of particular interest within this study is that

receiving support may remind the patient of his or her negative circumstances and

may encourage the patient to become overly dependent on the support provider.

In taking a triadic view, this example demonstrates a coalition being formed between

the dependent patient and his or her family member. The current data confirm this

as a downside of social support, one that has a negative effect on nurse-patient

communication about pain. Several participants in this study pointed out patients’

increased neediness in the presence of family. It is possible that this downside

of social support is the mechanism by which families draw out the ‘‘needy’’ side

of patients. They may cause patients to feel sorry for themselves or encourage

the elicitation of pity from visitors and hospital staff. Nurses see this increased

neediness as clouding the lines of communication between themselves and

the patient. In taking a triadic view, the current study seeks to explain the

dependency of the patient on a family member as an alliance that positions the family

member and patient in opposition to the nurse and negatively affecting the health

outcomes for the patient.

Applied Implications

Although not every participant was currently working in a hospital setting, the vast

majority had experience on multiple floors and with a variety of different types of

patients. Their experiences point to important implications for hospital policy,

especially when it comes to the ‘‘who’’ and ‘‘when’’ of patient visitation. Less restric-

tive visitation policies are based on the idea that the presence of families and support

network members has an inherently positive influence on patient outcomes

(Berti, Ferdinande, & Moons, 2006; Clarke, 2000; Fumagalli et al., 2006; Whitis,

1994). Visitors to the patient are considered a valuable asset when it comes to

interpreting medical information for the patient and patient communication for

the nurse or doctor (Gonzalez, Carroll, Elliott, Fitzgerald, & Vallent, 2004); however,

little evidence exists to back up such claims. Instead, nurses in the current study


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continually point out the many ways in which families complicate communication

efforts and interfere with patient treatment.

In many cases in this study, nurses do not see family members as effective

interpreters of medical information; instead, nurses must spend time explaining

procedures, treatments, and diagnoses to both the patient and the families. It is

important to note, however, the cultural context in which the study takes place.

Nurses confirmed that many of the people served by hospitals in this region are very

poor and uneducated, and families are therefore no better at understanding medical

information than the patient. Nurses also described how ‘‘remedies’’ from home,

which may constitute belief in a kind of folk medicine, often dominate families’

worldviews. Therefore, much of the nurses’ energy is spent countering not only

the information and opinions family members bring to the patients but also moni-

toring for and undoing the harm caused by outside substances being brought into

the hospital. These environmental factors are important to consider when attempting

to explain the nurse-patient-family-member interactions. While the current study

is limited to nurses’ perceptions of these factors, certainly education levels, poverty,

and cultural traditions shape family members’ motivations and goals, while also

influencing how alliances form in triadic interactions.

This study calls into question the idea that family members and other third-party

caregivers should be enlisted to actively participate in the pain-assessment process

(McCaffrey & Pasero, 1999), the clinical guidelines that are in part used to support

the idea of more liberal visitation policies. While a few nurses in this study were

able to utilize family insight into patients’ needs, participants overwhelmingly

agreed that family involvement in pain assessment is counterproductive. As the

current study postulates, perhaps an unintended consequence of a more open

hospital environment is more opportunities for nurse-patient-family-member

interactions—interactions centered on shifting alliances that the nurses in the

current study seem ill equipped to effectively navigate. Instead, the culture in which

the individual hospitals exist and the individual populations they serve must be

taken into account when determining such policies. Policies should be developed

considering the implications they have for all actors involved in communication

efforts focused on patient care. As previously noted, participants for the current

study were recruited in the Southeastern United States. Of note for this study,

the region suffers from a growing trend in the misuse of prescription drugs. Perhaps

against a cultural backdrop of misusing prescription drugs, more steps should

be taken to limit the presence of families and caregivers whose presence may be

problematic for both providers and patients. Results of this study indicate that

such regional or local cultural factors should be taken into account, and nurses

should be trained in communication strategies intended to identify and build

coalitions with family members toward positive patient health outcomes. The stra-

tegies of those nurses who have been able to do this successfully should be the basis

for education of other practitioners. For instance, observational analysis, specialized

language codes, family education, and strategic disclosures could all be codified

as teachable skills in the healthcare setting.


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Future Research

The findings in this study point to several future research opportunities around the

topic of social support. Most of the current research about the negative outcomes

of social support (i.e., Vangelisti, 2009) relates to behaviors that are intended to be

supportive, yet inadvertently fail to do so. But nurses in the current study bring

up a different aspect of social support, one that is colored by the ulterior motives

of patients’ family members. These are people who enact social support in the

hospital setting—with their presence, their actions, and their communication—yet

their concurrent attempts to acquire something for themselves (namely, prescription

pain medications) are barely concealed. Because the current study only explored

nurses’ perceptions of others’ motives, future research will need to include speaking

directly to the patients and their family members. In this way, we can understand

more about how they construct their roles, and what constitutes support in the

healthcare setting. For instance, if families are present, emotionally supportive,

and hoping to acquire pain medication for themselves, is this still perceived as social

support by the patients and families? Does the patient’s knowledge of ulterior

motives on the part of the family erode any potentially positive effects of social

support? Future scholars will want to continue to explore these important questions

relating to the nurse-patient-family communication triad.

Advocacy also needs to be examined, especially as it occurs in healthcare

communication. Previous research has characterized advocacy as an attribute of

social support (Finfgeld-Connett, 2005). Advocates are traditionally conceived of

in a professional sense, having something that the ‘‘client’’ lacks, such as training,

education, certification, or experience. Typical advocates may include attorneys,

nurses (Chafey, Rhea, Shannon, & Spencer, 1998), or experienced peers (Whittemore,

Rankin, Callahan, Leder, & Carroll, 2000). Advocacy, then, by its very nature, is

inherently a triadic interaction facilitating the natural formation of an alliance

between the family member and the patient in opposition to the nurse. Families of

patients, although not advocates in the traditional sense, still seek to ‘‘intervene with

the system on the client’s behalf’’ (Chafey et al., 1998, p. 48) when they make requests

related to the patient’s pain treatment. Yet, they do not have any special skills or

knowledge that set them apart from the patient. Is this not still advocacy? Further-

more, providers of social support are thought to serve as advocates in part by

empowering recipients to act on their own behalf (Chafey et al., 1998; Coffman &

Ray, 1999; Whittemore et al., 2000) and to maintain control over their situation

(Chang & Schaller, 2000; Coffman & Ray, 1999). This does not seem to fit with

nurses’ portrayals of what family members are attempting to do for patients. Future

research will need to revisit the concept of advocacy as it occurs in the medical setting

and to speak directly to family members of patients to see if the empowerment aspect

of advocacy holds true.

Finally, future research should explore the macrolevel discourse regarding

prescription drug abuse at the societal, communal, and organizational levels to

determine any influence on the microlevel discourse occurring among providers,


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patients, and the patients’ families. For example, do the effects of more broadly based

messages about prescription drug abuse affect healthcare providers’ attitudes

and beliefs regarding pain management? Understanding this macrolevel influence

may point to an increase in certain predilections providers may have toward patients’

subjective assessment of their pain levels.

In conclusion, the role that families play in the assessment and management of

patients’ pain is an active one that is inherently triadic in nature. While there is

potential for positive influence, the negative implications of family involvement are

quite serious in terms of nurse-patient-family-member communication and health

outcomes for the patient. The current study is limited in its ability to assess the inten-

tions, goals, and motivations of patients and their families, because the data come

solely from the perspectives of the nurses who interact with them. However, the

observations of these nurses have given us important future research directions

in previously underexamined areas within family health communication and social

support and highlight the need to study the triadic dynamics of communication in

the medical setting. The results of the current study have important implications

for nurses, patients, and families, and healthcare providers will want to apply and

extend this work to improve patient outcomes and the overall healthcare experience.

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Pain Management as Triadic Interaction: Shifting Alliances in Nurse-Patient-Family-Member...

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