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Testing a theory of chronic pain

Article  in  Journal of Advanced Nursing · August 2003

DOI: 10.1046/j.1365-2648.2003.02690.x · Source: PubMed

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 N U R S I N G T H E O R Y A N D C O N C E P T D E V E L O P M E N T O R A N A LY S I S

Testing a theory of chronic pain

Pao-Feng Tsai PhD RN
Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Sunghee Tak PhD RN

Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Carole Moore BSN RN

Staff Nurse, Critical Care, St Joseph’s Mercy Medical Center, Hot Springs, Arkansas; and HSC Medical Center, Malvern,
Arkansas, USA

6 and Iris Palencia

Research Assistant, College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

Submitted for publication 9 April 2002

Accepted for publication 13 December 2002

Correspondence: TSAI P., TAK S., MOORE C. & PALENCIA I. (2003) Journal of Advanced Nursing
Pao-Feng Tsai, 43(2), 158–169
College of Nursing, Testing a theory of chronic pain
University of Arkansas for Medical Sciences,
Background. Chronic pain is highly prevalent among older people with arthritis,
4301 W. Markham St.,
with depression as its major outcome. The psychopathological process of chronic
Slot 529,
Little Rock, pain and its outcomes in older people with arthritis have not been the subject of
AR 72205, extensive research. The purpose of this study was to test a middle-range theory of
USA. chronic pain derived from the Roy Adaptation Model, a nursing theory whose
E-mail: tsaipaofeng@uams.edu validity has not been tested in the context of chronic pain.
Methods. The study used a convenience sample of 71 older people with arthritis.
Two subscales of the Arthritis Impact Measurement Scales were used to measure
pain and physical disability. Social support was measured by Part II of the Personal
Resource Questionnaire, and the Elderly Daily Stress scale was used to measure
daily stress. Participants also completed the 10-item Center for Epidemiological
Studies of Depression scale. Univariate analysis, correlation, and path analysis were
used to analyse the data.
Results. Overall, the data supported the hypothesized model in which pain, dis-
ability, social support, age, and gender are predictors of daily stress and daily stress
further predicts depression. The direct effects of chronic pain, disability, and social
support accounted for 37% of the variance of daily stress, which in turn predicted
35% of the variance of depression. Age and gender had no influence on daily stress.
The chi-square index suggested a fit between the data and the model, and therefore
the current model is temporarily accepted. Other fit indices also showed a good fit of
the model to the data. To simplify the model, a revised version was developed.
Conclusions. This study validated a middle-range theory to explain the effects of
chronic pain in older people with arthritis and highlights the importance of chronic
pain in the development of depression.

Keywords: arthritis, chronic pain, daily stress, depression, disability, social support,
aging, Roy Adaptation Model, nursing

158
2003 Blackwell Publishing Ltd

Nursing theory and concept development or analysis
Background
Chronic pain is a very common experience for older people,
and how it results in so much suffering and adverse outcomes
needs to be clearly identified and described. The use of viable
nursing theories to explain nursing phenomena, serve as the
foundation of the discipline, and guide nursing practice has
been advocated for many years. Among these theories is the
Roy Adaptation Model (RAM) (Roy 1976), a widely used
theory that has been tested in various settings and popula-
tions. Its validity in the context of chronic pain, however, has
not been tested. Thus, the purpose of this study was to derive
a middle-range theory of chronic pain from the RAM and test
it with 71 older people with arthritis who suffered with
chronic pain.
Epidemiology of chronic pain and depression
It is estimated that 64–83% of older people suffer from
chronic pain (Roy & Michael 1986, Roy & Thomas 1987,
Ferrell et al. 1990), and the most commonly reported physical
source of pain is arthritis (Ferrell et al. 1995). Arthritis is
highly prevalent in older people, and osteoarthritis (OA) is
the most common form in this population. The OA is a
disabling condition among older adults, affecting 20 million
people in the United States of America (USA) (National
Academy on an Aging Society 2000) and accounting (in 1994
dollars) for $15Æ5 billion in expenditures each year (Yelin
1998). The social and financial burdens imposed by OA in
other countries are also enormous. For example, there are
6 million new diagnoses of OA reported each year in France,
and the cost of physician visits and drugs prescribed to treat
OA totaled 1Æ915 billion French francs (Levy et al. 1993).
The prevalence of OA increases with age (Hamerman
1995, Gunther et al. 1998): More than one-half (58–68%) of
all older people (Cicuttini & Spector 1995, Hochberg et al.
1995, Elders 2000) and 45–65% of older nursing home
residents (Ferrell et al. 1990, Marzinski 1991) suffer from
OA, which can cause severe pain and disability. Rheumatoid
arthritis (RA), on the other hand, is less prevalent in this
population. Its prevalence increases with age to 2% of men
and 5% of women older than 55 years, compared with that
of OA, which increases from 4% at age 55 years to 85% at
age 75 years and older (van Dieten et al. 2000). A study by
Laiho et al. (2001) found that the incidence of RA was
highest for people aged 65 and tended to decline with age.
Depression is the major outcome of chronic pain, and more
than half of chronic pain patients suffer from this (Dworkin
& Gitlin 1991). Depression is also a highly prevalent
condition among older people. In community-dwelling elders,

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 158–169
Testing a theory of chronic pain
the prevalence of depressive symptoms is 15–20% (Mulsant
& Ganguli 1999, Steffens et al. 2000). Research has
suggested that depressive disorders are more prevalent among
people with RA than their counterparts (Brown 1990,
DeVellis 1995, Pincus et al. 1996). In addition, patients with
OA may be more than three times as likely as non-arthritic
patients to have depressed mood (Maisiak 1990).
There have been several attempts to explain the psycho-
pathological process of chronic pain. For example, a recent
meta-analysis confirmed that depression is the consequence of
chronic pain and not a disposing factor (Dworkin & Gitlin
1991). The psychopathological process of chronic pain that
results in depression is not fully understood (Parker & Wright
1995), and a theory to explain this process is needed. The
RAM (Roy 1976) has been used successfully to explain stress
and the adaptation process in other chronic illnesses
(Ducharme et al. 1998). Therefore, a middle range theory
derived from the RAM may offer an explanation of the
experience of older people with arthritis and chronic pain.
Theoretical model and related literature
Concepts in the RAM
The RAM, developed by Callista Roy, has continued to
evolve (Roy 1976, 1980, 1984, 1988, Roy & Roberts 1981,
Andrews & Roy 1991, Roy & Corliss 1993) and two
philosophical principles form the basis of the model. The
principle of veritivity asserts the existence of absolute truth,
while humanism proposes that the subjective experiences of
human beings are the most important bases for knowing and
valuing (Roy 1988). The scientific assumptions of the RAM
were drawn from general system theory (Bertalanffy 1968)
and adaptation level theory (Helson 1964).
In the model, three kinds of stimuli are included as inputs:
focal, contextual, and residual. A focal stimulus is an internal
or external factor that immediately confronts a person. A
contextual stimulus is any other identifiable factor that
contributes to the effect of the focal stimulus, and a residual
stimulus is a factor whose effect in the current situation is
unclear (Andrews & Roy 1991). The effects of contextual
and residual stimuli on the control process, and their
relationship with focal stimuli, need clarification in the
RAM, and we have discussed this need in detail elsewhere
(Tsai 1998, 2003). In short, contextual and residual stimuli
have additive, mediating or moderating effects on focal
stimuli in the adaptation process, according to the RAM (Roy
& McLeod 1981, Roy 1984, Andrews & Roy 1991). This
study reported below tested only the additive effects of
contextual and residual stimuli on focal stimuli in the
adaptation process.
159
P. Tsai et al.
CONCEPTS IN THE ROY ADAPTATION MODEL
Input Control process Output
(in four categories or adaptive modes)
Focal Contextual Residual Coping Physiological Self- Role
stimuli stimuli stimuli mechanisms: function concept function dependence
regulator &
cognator
Chronic Disability Age Perceived Depression
pain daily stress
Social Gender
support
CONCEPTS IN THE THEORY OF CHRONIC PAIN
A person’s coping mechanisms include regulator and
cognator subsystems. The regulator subsystem responds
through the neurological, chemical and endocrine systems,
whereas the cognator subsystem responds through the pro-
cesses of perception/information processing, learning, judge-
ment and emotion. Environmental inputs, such as stimuli, to
the regulator system activate the cognator system through a
perception process, and vice versa (Andrews & Roy 1991).
Depression is defined either as part of the control process or
output, As Roy (1984) stated that (a) a disruption in any
mode potentially leads to depression, (b) depression can be
assessed in each mode, and (c) depression might be viewed as
a coping mechanism.
This middle-range theory, depicted in Figure 1, differenti-
ates between the concepts in the RAM and those in the theory
of chronic pain based on the level of abstraction (Fawcett &
Downs 1992). Chronic pain, disability, social support, age
and gender are defined as inputs, while depression is defined
as the output portion of the theory. Perceived daily stress is
the control process that mediates the impact of chronic pain,
disability, social support, age and gender on depression.
Concepts in the theory of chronic pain
The major concepts in the Theory of Chronic Pain are
chronic pain, disability, social support, age, gender, daily
stress and depression. Chronic pain is the antecedent of
depression in older people with arthritis (Dworkin & Gitlin
1991). Avoidance of activity is a natural response to pain
(Wall 1979), and many people with chronic pain limit their
activities (Mullen & Suls 1982, Suls & Fletcher 1985,
Holmes & Stevenson 1990, van Lankveld et al. 1994).
However, if these patients adopt a sedentary lifestyle, this
may lead to further physical deconditioning (Minor 1991,
Ettinger & Afable 1994, Ries et al. 1995, Keefe et al. 1996, 2 population with arthritis, Zautra and Smith (2001) also found
160
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 158–169
Inter-
Figure 1 Major conceptual-theoretical
structure.
Evers et al. 1998) and thus disable their daily functioning.
Inability to handle their daily life creates stress and eventually
leads to depression. Therefore, chronic pain will be concep-
tualized as a focal stimulus. Disability and social support also
contribute to depressed mood, and thus are conceptualized as
contextual stimuli. As the effects of age and gender on
depression in this specific population are unclear, they will be
conceptualized as residual stimuli, as defined by the RAM
(Roy 1976, 1984).
Chronic pain, a focal stimulus in the hypothesized model,
is the major factor that results in the output, depression,
through daily stress. Studies consistently show that pain is the
most significant predictor of depression (Mindham et al.
1981, Hawley & Wolfe 1988, Peck et al. 1989, Fifield et al.
1991), and chronic pain has a great impact on depression in
patients with RA (Brown 1990, Sharpe et al. 2001). Pain
explained 24% of the variance of depression in patients with
RA in a study by Buchi et al. (1998), and a weekly increase in
pain was significantly associated with depressive symptoms in
women with OA according to Zautra and Smith (2001).
Chronic illnesses, such as arthritis, involve continuous low-
grade stress. Daily stress is conceptualized as the control
process mediating the impact of chronic pain on depression.
Chronic pain can interfere with an individual’s normal daily
functioning and constitutes inescapable stress (Blackburn-
Munro & Blackburn-Munro 2001). On the other hand,
stress by itself has a marked effect on the immune and
sympathetic nervous systems, as well as the hypothalamo–
pituitary–adrenal axis, thus contributing to chronic stress
(Van Houdenhove 2000). A study by Logan et al. (1996)
explored the relationship between stress and pain in chronic
pain, acute pain, and pain-free patients. Chronic pain patients
anticipated more stress than the other two groups. In a
Nursing theory and concept development or analysis
that chronic pain was significantly associated with perceived
stress. Patients with OA, however, did not demonstrate the
same relationship among depression, stress and pain as did
those with RA. People with RA with depression may
experience higher disease activity after exposure to interper-
sonal stressors (Zautra et al. 1996). In addition, major
stressors, including pain and disability in women with OA,
evoke stressful emotions, including anger, frustration, discour-
agement, fear and helplessness (Romer 2000). Daily stress, as
shown by several studies, explains a significant amount of the
variance of depression in people with RA (Murphy et al.
1988, Wright et al. 1996, Arango & Cano 1998).
Disability is defined as a contextual stimulus. Arthritis is
among the leading causes of disability (Tuomi et al. 1991,
Callahan et al. 1996, Potter & Zauszniewski 2000), and the
severity of disability correlates with daily stress in RA
patients (Turner Cobb et al. 1998); increased disability is
also associated with exposure to stressors (Weinberger 1990).
No information about the relationship between disability and
stress is available for people with OA.
Social support is also defined as a contextual stimulus, and
is viewed as emotional and instrumental resources from
social relationships that are used to cope with stress.
Although the mechanism of social support regarding stress
and health outcomes is not well understood, there is evidence
that it has a beneficial effect on the well-being of older
people. Levels of psychological distress in older adults have
been linked both to the quality and quantity of their social
networks (Kahn & Antonucci 1981), social isolation
(Chappell & Badger 1989), and involvement in social activity
(Thomas & Chambers 1989).
Social support can protect people in crisis from a wide
variety of pathological states, including arthritis (Cobb
1976). Professional support that provides knowledge about
the disease process and joint protection affects how people
view their physical capacities and interpret their pain (Parker
et al. 1984). Social support seems to relate only to psycho-
logical well-being, and not physical functioning (Barry 2000).
Others argue that progression of RA affects social function-
ing (Waltz et al. 1998). Personal resources, such as self-
control, enhance the impact of social support on stress
(Spitzer et al. 1995). Assessing for the lack of social support is
essential in the rehabilitation of disabled people with RA
(Murphy et al. 1988).
Age and gender are conceptualized as residual stimuli. A
growing interest among psychologists and health care provid-
ers is the influence of age on stress and how this differs in old
and young adults (Folkman et al. 1987). Little, however, is
known about this relationship. One study showed that
stressful events change with age and that, for young adults

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 158–169
Testing a theory of chronic pain
such events are more often one-time incidents, whereas older
adults have stressors of a chronic nature (Aldwin & Coyne
1996). Age has been shown to have indirect effects on
depression through its influence on perceived stress, the coping
process and perceived efficacy (Aldwin 1991). Because men use
different coping skills and receive different support, they react
to stressors differently from women (Abel 1998, Glynn 1999).
The study
Aim
The aim of this study was to test a middle-range theory of
chronic pain derived from the RAM, a nursing theory whose
validity has not been tested in the context of chronic pain.
Design
A secondary data analysis strategy was used. The original study
was a descriptive, correlational design examining the relation-
ships among functional disability, chronic daily stress, social
support and depressive mood in older adults with arthritis.
Sample
A convenience sample of 71 older people was obtained from
participants in Arthritis Foundation programmes and visitors
of local grocery stores in Virginia, USA. To be included, a
person had to be (a) age 60 or older, (b) diagnosed by a
physician as having arthritis for more than 1 year, and
(c) community-dwelling (i.e. non-institutionalized).
The sample size of 71 was chosen to achieve enough
statistical power for further path model analysis. The sample
size was large enough for regression and correlational
procedures as calculated by the Statistical Power Analysis
computer program (Borenstein & Cohen 1988). The recom-
mended sample size according to the power analysis was 65
when a power of 0Æ80, effect size of 0Æ20, and alpha level of
0Æ05 were set for regression and correlational procedures
(Cohen 1985).
Instruments
Pain was measured by a subscale of the Arthritis Impact
Measurement Scales (AIMS) (Meenan et al. 1980, Meenan
1990), whose validity has been reported and internal consis-
tency is between 0Æ70 and 0Æ85 (Meenan et al. 1980, 1982).
We used only the four-item pain subscale to measure pain.
Questionnaire items are arranged in a five-point Likert-type
scale ranging from ‘all days, always, or severe’ to ‘no days,
161
P. Tsai et al.
never, or none’. Higher scores reflect higher levels of pain.
Internal consistency for this study was 0Æ76.
Physical disability was measured by three subscales of
physical function of the AIMS (Meenan et al. 1980, Meenan
1990). These three subscales measure mobility, walking,
bending, and hand and finger function. Questionnaire items
are arranged in a five-point Likert-type scale ranging from ‘all
days, always, or severe’ to ‘no days, never, or none’. Higher
scores reflect higher levels of physical disability. Internal
consistency for this study was 0Æ81.
Social support was measured by Part II of the Personal
Resource Questionnaire (PRQ85). The PRQ85 was formula-
ted to measure perceived levels of social support. It is based on
a model of relational functions of social support (Weiss 1969):
(a) provision of attachment/intimacy, (b) social integration,
(c) opportunity for nurturant behaviour, (d) reassurance of
worth, and (e) availability of informational, emotional, and
material help (Brandt & Weinert 1981, Weinert 1987). The
PRQ85-Part II is a 25-item, seven-point Likert-type scale.
Higher scores indicate higher levels of perceived social
support. Its validity has been reported (Weinert 1987, Weinert
& Tilden 1990). Internal consistency is between 0Æ91 and 0Æ93
(Weinert & Brandt 1987) and was 0Æ90 for this study.
The Elderly Daily Stress (EDS) scale was used to measure
chronic daily stress. The EDS scale is a 40-item questionnaire
measuring the degree to which older persons experience daily
stress from irritating, frustrating, or repeated occurrences in
their lives (Tak 1998). Responses are scored on a five-point
Likert-type scale from ‘not at all’ to ‘extremely’; higher scores
reflect a higher degree of stress. Internal reliability has been
reported between 0Æ94 and 0Æ96 (Tak 1998) and was 0Æ94 for
this study.
To measure levels of depressive symptoms, an abbreviated
version of the Center for Epidemiological Studies of Depres-
sion (CESD) scale was used (Andresen et al. 1994). The
10-item version of the CESD scale uses a four-point scale
ranging from 0 (none of the time) to 3 (most of the time).
Respondents were asked to indicate how often in ‘the past
week’ they experienced each of the 10 descriptions of
depressed mood. Higher scores reflect a higher level of
depression. The possible range of scores is 0–30, with cutoff
scores for depression at ‡10. Alpha coefficient was 0Æ86 in
past studies (Andresen et al. 1994) and 0Æ69 for this study.
The scale’s validity has been reported as adequate (Andresen
et al. 1994).
In addition, a personal data form was used to collect
information on demographic and illness-related variables.
Demographic information included age, ethnicity, financial
status, educational level, and marital status. Illness-related
information consisted of duration of illness and comorbidity.
162
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 158–169
Data collection
Participants were recruited from local chapter programmes of
the Arthritis Foundation and via local grocery stores. The
research team distributed a cover letter to potential partici-
pants and explained the study when they expressed an interest.
A research assistant was available to answer questions and to
assist participants when they needed help to complete the
questionnaire. The voluntary nature of participation was
emphasized during recruitment procedures and participants
received $10 when they completed the questionnaires. The
completed questionnaires were placed in a sealed envelope and
returned to the research team either by mail or in person.
Ethical considerations
Data collection was initiated after review and approval of the
study by the Virginia Commonwealth University Committee
on the Conduct of Human Research. If a potential participant
met the inclusion criteria and agreed to participate in this study,
they were asked to participate and consent was obtained.
Statistical analysis
Univariate analysis was used to describe the sample. The
initial relationship among variables was examined by
correlation. Path analysis employing LISREL8W software
(Joreskog & Sorbom 1993) was used to test the initial
hypothesized model. A revised, simplified model was
created that eliminated non-significant paths from the
hypothesized model. Path analysis is a procedure for giving
a quantitative interpretation to a hypothesized theory that
assumes a causal relationship among variables. We used the
method of multiple regression to create the path model.
Chi-square and other goodness-of-fit indices [Comparative
Fit Index (CFI) and Normed Fit Index (NFI)] were
reported. Values of CFI and NFI between 0Æ90 and 1Æ00
were considered as indicating a good fit between the model
and the data.
Results
Descriptive findings
Characteristics of the sample are summarized in Table 1.
Mean age of participants was 71Æ63. The great majority was
female (76Æ1%) and white (94Æ4%), and a member of a
Protestant religious denomination (77Æ5%). Slightly more
than half of participants were married, and 36Æ6% widowed.
Mean number of medical problems was 1Æ38. Participants
Nursing theory and concept development or analysis Testing a theory of chronic pain

Table 1 Characteristics of the sample of elderly persons (n ¼ 71) Table 2 Correlation coefficients among the major research variables

Characteristics n % Mean SD 1 2 3 4 5 6

Age (years) 71Æ63 7Æ03 Age 1Æ00

Gender Gender 0Æ16 1Æ00
Male 17 23Æ9 Pain 0Æ12 0Æ11 1Æ00
Female 54 76Æ1 Disability 0Æ22 0Æ10 0Æ35** 1Æ00
Race Social support 0Æ11 0Æ04 0Æ11 0Æ42** 1Æ00
White 67 94Æ4 Daily stress 0Æ05 0Æ18 0Æ42** 0Æ47** 0Æ41** 1Æ00
Non-white 4 5Æ6 Depression 0Æ01 0Æ09 0Æ29* 0Æ40** 0Æ43** 0Æ59**
Education (years) 13Æ39 2Æ86
Marital status *P < 0Æ05; **P < 0Æ01.
Married 37 52Æ1
Divorce 6 8Æ5
Widow 26 36Æ6 Table 3 Regression equations used to test the hypothesized and
Other 2 2Æ8 revised models
Religion Hypothesized model
Protestant 55 77Æ5 Daily stress ¼ (b)* pain þ (b) disability þ (b) social support þ
Catholic 7 9Æ9 (b) age þ (b) gender þ e
Other 9 12Æ6 Depression ¼ (b) daily stress þ e
Medical problems (n) 1Æ38 1Æ27
Diagnosed with arthritis (years) 11Æ43 9Æ85 Revised model
Pain 12Æ11 3Æ60 Daily Stress ¼ (b) pain þ (b) disability þ (b) social support þ e
Disability 29Æ03 8Æ59 Depression ¼ (b) daily stress þ e
Social support 140Æ18 24Æ83
*b, Standard coefficient.
Daily stress 75Æ94 22Æ23 
e, Error variance.
Depression 8Æ44 4Æ90

the hypothesized model, a second path analysis was conduc-

had been diagnosed with arthritis for a mean of 11Æ43 years.
Mean pain scale score was 12Æ11. Respondents scored
means of 29Æ03 ± 8Æ59 on the disability instrument and
140Æ18 ± 24Æ83 on the social support scale. Mean daily
stress score was 75Æ94 ± 22Æ23, and mean depression scale
score 8Æ44 ± 4Æ9. The criteria for depression, as measured by
the CESD, were met by 43Æ7% of the sample.
Bivariate analysis
The relationships among depression, pain, social support,
daily stress and disability are shown in Table 2. Elders with
higher pain scores tended to be more disabled (r ¼ 0Æ35,
P < 0Æ01), had higher daily stress (r ¼ 0Æ42, P < 0Æ01), and
were more depressed (r ¼ 0Æ29, P < 0Æ05). Stressed elders
were more disabled (r ¼ 0Æ47, P < 0Æ01), had less social
support (r ¼ 0Æ41, P < 0Æ01), and were more depressed
(r ¼ 0Æ59, P < 0Æ01).
Path analysis
Two path analyses were conducted to test the hypothesized
model and a revised model. The hypothesized model was
tested first to see how well the data fitted the model that
represented the proposed middle-range theory. To simplify
ted to create a revised model, in which insignificant paths
were eliminated.
Regression equations used to test the hypothesized model
are shown in Table 3. Figure 2 shows the path coefficients
and the levels of significance associated with them. Chronic
pain and disability positively predicted daily stress, while
social support had a reverse impact on daily stress. Age and
gender had no influence on daily stress.
The direct effects of chronic pain, disability, social support,
age, and gender accounted for 37% of the variance in daily
stress. Daily stress strongly predicted depression, with a
significant path coefficient (b ¼ 0Æ59, P < 0Æ01) that
accounted for 35% of the variance. The chi-square index
(v2 ¼ 5Æ15, P ¼ 0Æ40) suggested that it failed to reject the fit
between data and the model. Therefore, the hypothesized
model will be accepted until further evidence is found for
rejecting it. Other fit indices (CFI ¼ 1Æ00 and NFI ¼ 0Æ95)
also showed a good fit of the model to the data. Overall, the
data supported the hypothesized model, although two hypo-
thesized paths (age to daily stress and gender to daily stress)
were not supported.
Age and gender were then eliminated from the hypothes-
ized model to simplify it; thus only significant paths remained
in the model. The results were similar to those of the
hypothesized model, with 35% of the variance explaining

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 158–169 163
P. Tsai et al.

Pain

0·27*
Disability 0·28*

–0·26* 0·59**
Social support Daily Stress Depression
–0·10 2
R = 0·37 R 2 = 0·35
Age
0·10

*P < 0·05 **P < 0·01 Figure 2 Path coefficients for hypothesized
Gender
model.

Pain
0·30**

0·26* 0·59*
Disability Daily stress Depression
2
R = 0·35 R 2 = 0·35
–0·26* Figure 3 Path coefficients for revised
Social Support
*P < 0·05 **P < 0·01 model.

both daily stress and depression. Estimation for the revised
model did not change significantly from that of the
hypothesized model (Dv2 ¼ 0Æ46; Dd.f. ¼ 2; P > 0Æ05).
Goodness-of-fit indices were adequate (CFI ¼ 0Æ97 and
NFI ¼ 0Æ94). The revised model is shown in Figure 3.
Discussion
The hypothesized model was supported by data showing that
pain, disability, and social support resulted in perceived daily
stress that in turn predicted depression. Pain, disability and
social support, however, explained only 35% of the variance
of perceived daily stress. It is possible that some variables that
affect daily stress were not included in the model. For
example, older people confront many problems other than
chronic pain, and the impact of chronic pain may be diluted
by other competing daily stressors or stressful life events.
Thus, the relationship between chronic pain and perceived
daily stress may not be as clear as in an acute pain situation.
It can also be argued that chronic pain enables elders to adapt
to its persistent needs and re-establish a balanced life over a
period of suffering. Viewed from this perspective, chronic
pain should not be expected to have a major effect on
perceived daily stress.
Many studies have found that stressful life events were
associated with psychological well-being (Byrne 1984,
Crandall et al. 1992, Dekkers 2001) and physical symptoms
(Crandall et al. 1992). However, Lennon et al. (1990)
reported that patients with chronic facial pain coped with
pain differently from how they coped with other stressful life
events. Also, the acute stress produced by stressful life events
might have a greater impact on perceived daily stress than
persistent chronic pain. Zautra and Smith (2001) further
investigated two types of life events – positive and negative –
and their association with stress. Their results showed that
only more negative events significantly increased stress in
both RA (r ¼ 0Æ38, P < 0Æ01) and OA (r ¼ 0Æ43, P < 0Æ01)
patients, while positive life events did not show an associa-
tion with stress. Therefore, future study may include only
negative life events as predictors of stress.
Other possible variables that were not included in this
study were negative affect, coping strategies, pre-existing
depression and financial hardship. Negative affect was found
to have a median impact on both OA and RA patients’
outcomes. A higher level of negative affect was associated
with a higher level of perceived stress in those with RA
(r ¼ 0Æ48, P < 0Æ01) and with OA (r ¼ 0Æ42, P < 0Æ01)
(Zautra & Smith 2001).
Similarly, coping skills had an impact on the health status
of older people (Dekkers 2001). Only problem-focused
coping skills moderated the relationship between daily
hassles and health status (P < 0Æ05), while emotion-focused
coping did not show an effect on elders’ health status. Keefe
et al. (1987) also found that patients with arthritis who had a
higher coping score related to pain control and rational
thinking had a lower level of pain, better health and a lower
level of perceived stress. Sharpe et al. (2001) found that
arthritic elders’ coping skills added additional variance in

164
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 158–169
Nursing theory and concept development or analysis
predicting depression. The same study also found that coping
strategy was more important in the early stage of the disease.
Further, research has showed that depressive mood before
diagnosis of the illness strongly predicted depression over
time. For example, Sharpe et al. (2001) showed that patients
with arthritis became more depressed over time. The initial
level of depression predicted about 37–58% of depression at
six time points during a 21-month period, independently of
the variance explained by pain, disability, beliefs and coping
skills. Unfortunately, our data set did not allow us to
investigate the effect of depression longitudinally. Further
study should include the effect of the initial level of
depression on depression over time.
Competing demands and difficulties other than chronic
pain include financial hardship. Conceivably, elders’ wealth
will subsequently decline because of their limited income
and the need to spend continually for daily living and
medical expenses. The situation is even worse for older
people with arthritis than their counterparts without arth-
ritis. Research has showed that median household wealth of
older people with arthritis aged 51–61 years in the USA is
$77 000, while their counterparts without arthritis have
household wealth averaging $111 000. Older people with
arthritis of advanced age (‡70) face even greater financial
difficulty than elders without arthritis. Their median house-
hold wealth in the USA is only $54 000, which is $47 000
less than for elders without arthritis (National Academy on
an Aging Society 2000).
Age did not predict daily stress in our study, as had been
expected. It is possible that the age range of the sample was
too restricted. Older adults, as opposed to younger adults,
share similar daily stresses. Alternatively, younger and older
elders may have similar perceptions of the stressfulness of a
problem, as well as appraisals of harm, loss and helplessness
(Aldwin & Coyne 1996). Thus, age did not play an important
role in predicting daily stress in older people with arthritis.
Gender also failed to predict daily stress. Fifield et al. (1996)
found that differences in emotional stress were predicted by
pain, functional ability and work characteristics, but not by
gender. Even after controlling for disease and work variables,
gender still had no effect on depression. Skirka’s (2000) study
supports this finding, revealing that college athletes showed
no differences in stress when compared by gender. It is
possible that daily stress does not mediate the relationship
between gender and depression.
Study limitations
Although this study provides a theory to explain the effects
of chronic pain in older people with arthritis, it should be

2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 158–169
Testing a theory of chronic pain
noted that most of the study patients had OA. RA patients
have greater stress than those with OA (Latman 1996).
Because OA is far more common among elders, further
effort will be needed to cross-validate the path relations in
a sample comprising only OA sufferers in order to
contribute to the scientific understanding of older adults
with arthritis.
As we used a secondary data approach, the variables in the
original study limited our choices of operationalizing con-
cepts. In addition, use of a convenience sample limited the
generalizability of the findings. Further, although an associ-
ation was shown, causality among variables in the model
remains an assumption because the study was cross-sectional
and was consequently limited in its ability to test the causal
relationships depicted in the model. Better examination of
causality will require longitudinal data.
Conclusions
This study was the first step in validating a middle-range
theory of chronic pain derived from the RAM in a sample of
older people with arthritis, and we found that daily stress is a
very important factor leading to depression in older people
with arthritis. To treat depression properly, health care
providers need not only to use antidepressants for symptom
control but also to understand the influence of daily stress for
individuals and develop a strategy to minimize its impact.
The nursing discipline struggles to be professional and
distinct from that of medicine. The medical model has been
criticized because it neglects psychosocial-behavioural influ-
ences on health. On the other hand, nursing emphasizes the
influence of environment, both internal and external, on
health, as evidenced in the work of Roy (1976) and other
theorists. This study supports the above proposition about
the nursing discipline and provides evidence of the import-
ance of psychosocial-behavioral issues for personal health.
This middle-range theory also yields more specific hypo-
theses in relation to stress and adaptation processes in older
people with arthritis than the RAM. Thus, the findings of this
study will be more appropriate to explaining stress and
adaptation processes in older people with arthritis. They
advance our knowledge in using the RAM in clinical practice
to deal with older people with arthritis experiencing pain,
stress and depression. Similarly, the specific focus of this
middle-range theory on older people with arthritis makes it
more applicable in clinical practice.
The findings are particularly significant for nursing prac-
tice. Elders tend to be in a poorer overall condition, including
having gastro-intestinal disturbances and poor nutrition, than
younger adults. In turn, they are considered to be in poorer
165
P. Tsai et al.
What is already known about this topic
• The Roy Adaptation Model has been tested in various
settings and with various populations but its validity in
the context of chronic pain has not been investigated.
What this paper adds
• This study developed and validated a middle-range
theory derived from the Roy Adaptation Model to
explain the effects of chronic pain in older people with
arthritis.
• The results show that pain, disability and social support
were predictors of daily stress in arthritic elders, and
daily stress was predictive of depression.
• To treat depression properly, it is argued, health care
providers need not only to use antidepressants for
symptom control but also to understand the influence of
daily stress for individuals and develop a strategy to
minimize its impact.
health than elders without arthritis. The side effects of
pharmacological interventions, which are more likely to be
proposed by the discipline of medicine, tend to exacerbate
elders’ already frail physical condition. Finding psychosocial-
behavioural interventions for depression that deal with daily
stress resulting from chronic pain, disability and poor social
support will lead to fewer adverse effects for older people
than pharmacological interventions and thus be more bene-
ficial to those with arthritis.
Acknowledgments
This research study was funded in part by the A.D. Williams
Research Grant at the Virginia Commonwealth University.
The first author was supported by the Hartford Center of
Geriatric Nursing Excellence, College of Nursing, University
of Arkansas for Medical Sciences while this research was
being conducted. We also thank the University of Arkansas
for Medical Sciences Office of Grants and Scientific Publica-
tions for editorial assistance during the preparation of this
manuscript.
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