P A I N M A N A G E M EN T

Resilience in families with a member with chronic pain: a mixed

methods study
Caryn West, Petra Buettner, Lee Stewart, Kim Foster and Kim Usher

Aims and objective. To measure and explore between 2007–2010 measure and explore the nature of family resilience in the
context of families with a member with chronic pain.
Background. Chronic pain impacts on the entire family. The literature suggests that it is possible to strengthen resilience in
individuals with chronic conditions, but little is known about the impact of chronic pain on family resilience.
Design. A explanatory sequential mixed method study was undertaken.
Methods. In the initial quantitative phase, assessment measures were administered using the Connor-Davidson Resilience Scale,
Family Impact of Pain Scale, Medical Outcomes Study Short Form 36 and Medical Outcomes Study Social Support Survey. Data
were collected and analysed from 31 family cases (n = 67 participants). In the second, qualitative phase, follow-up semi-
structured interviews were undertaken with 10 families to help explain the quantitative results.
Results. The impact of pain on the family was high overall, but the perceived impact was greater for the person with pain.
Resilience scores were above average for both the person with pain and other family members. However, the person with pain
scored lower on the resilience scale than other members of the family. The families scored high for social support overall, while
the person with pain perceived they had greater support than their family members.
Conclusions. Identifying the strengths or resilient properties inherent in families and using those strengths in the planning and
implementation of care, especially of chronic conditions such as chronic pain, is pivotal to quality health outcomes.
Relevance to clinical practice. It is important that nurses and healthcare professionals include family members when planning
and delivering care for persons with chronic pain. Identification of strengths within families can help tailor nursing interventions
to meet family needs.

Key words: chronic pain, family resilience, mixed methods, nursing

Accepted for publication: 12 May 2012

the individual should not be under estimated, having a

Introduction
family member with chronic pain creates many additional
Chronic pain poses a potentially life changing, ongoing stresses and problems for the entire family (Silver 2004). The
challenge to many people. While the impact of the pain on physical aspects of chronic pain are distressing for the

Authors: Caryn West, RN, GDip Res Methods, GCert Ed, Lecturer/
PhD Candidate, School of Nursing, Midwifery and Nutrition, James
Cook University, Cairns, Qld; Petra Buettner, MSc, PhD, Associate
Professor, Epidemiology and Biostatistics, School of Public Health,
Tropical Medicine and Rehabilitation Sciences, James Cook
University, Townsville, Qld; Lee Stewart, RN, RM, DipTch,
BHlthSc, MDispute Resolution, PhD, MRCNA, Senior Lecturer,
School of Nursing, Midwifery and Nutrition, James Cook University,
Townsville, Qld; Kim Foster, PhD, RN, Associate Professor, Mental
Health Nursing, Sydney Nursing School, University of Sydney,
Sydney, NSW; Kim Usher, BA, RN, MNSt, DipNEd, DipHSc, PhD,
FRCNA, FACMHN, Professor and Associate Dean of Graduate
Research Studies Cairns, School of Nursing, Midwifery and
Nutrition, James Cook University, Cairns, Qld, Australia
Correspondence: Caryn West, Lecturer/PhD Candidate, School of
Nursing, Midwifery and Nutrition, James Cook University, PO Box
6811, Cairns, Qld 4870, Australia. Telephone: +61 07 4042 1391.
E-mail: caryn.west@jcu.edu.au

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3532 Journal of Clinical Nursing, 21, 3532–3545, doi: 10.1111/j.1365-2702.2012.04271.x
Pain management
individual with the pain. However, the family also experi-
ences many issues that are a direct result of having a family
member with chronic pain (Shapiro 2002). For example,
families are known to experience financial, emotional, social
and relationship issues as a result of chronic pain (Shapiro
2002). While it has been argued that strengthening resilience
in individuals with chronic conditions is possible (Greef
et al. 2006, Edward et al. 2008), there is little evidence to
support this argument. A family resilience approach to
managing pain and chronic pain has been proposed as an
effective intervention strategy for families in which a
member experiences chronic pain (Walsh 2006, West et al.
2011). Nurses and other healthcare professionals have a
valuable role to play in recognising the importance of
supporting positive attributes in people with chronic pain as
a way of enhancing their resilience. Therefore, the purpose
of this article is to describe the findings of a study
undertaken to measure and explore the nature of family
resilience in the context of families with a member with
chronic pain.
Chronic pain
Chronic pain is defined as persisting over time, for at least
6 months or more (Wall & Melzack 1999), with no easily
definable beginning, middle or end (Kralik 2002). In most
situations, while the symptoms may be treated or alleviated,
there is usually no cure for the condition. The definition of
chronic pain is thus similar to that of chronic illness
(Tollefson et al. 2008). For the individual, the impact of
chronic pain can lead to focus on their physical state such as
experiencing multiple vague symptoms and decreased activ-
ity. In addition, chronic pain can lead to decreased expecta-
tions; concerns about care provision and the future, an
increased sense of failure, frustration and dissatisfaction, as
well as sexual and emotional dysfunction (Weisberg & Clavel
1999, Silver 2004). However, like many chronic illnesses,
chronic pain impacts more widely than the individual with
the pain (Sturgeon & Zautra 2010). In fact, the impact of
chronic illness on families can affect finances, family roles,
emotional adjustment, social relationships and friendships,
occupation and leisure, intimacy and sexual relationships
(Harris et al. 2003). Furthermore, individuals with chronic
pain and their family or caregivers often differ in their ratings
of the pain and disability experienced by the person with pain
(Cano et al. 2005). Therefore, adaptation for families with
chronic pain is a complex process, which warrants further
attention. Finding ways to help the individual and their
family manage chronic pain more effectively can assist in
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Journal of Clinical Nursing, 21, 3532–3545
Resilience in families with a member with chronic pain
strengthening their ability to cope with the impacts chronic
pain can have.
Family resilience
Resilience is usually defined as a way of overcoming adversity
(Hegney et al. 2007), especially where people emerge from
adversity, or hardship, stronger and better equipped to deal
with future adverse events or crises (McCubbin et al. 1997,
Walsh 2006). Similar to individual resilience, family resil-
ience is not merely about surviving adverse events, trauma or
catastrophes. Family resilience includes the critical influence
of positive relationships between family members (Patterson
2002) and how these relational bonds assist families to not
only weather a crisis together, but lead them to emerge
stronger and more resourceful (McCubbin et al. 1997, Walsh
2006).
Common attributes found in resilient families are described
by McCubbin et al. (1997) as being either protective or
recovery focused. Protective factors facilitate adjustment,
while recovery factors promote adaptation. For example,
when confronted with a crisis, the family comes under
pressure, which results in the need for change; goals, rules or
boundaries may be adjusted. During the adaptation phase,
the family makes minor changes needed to restore their
family functioning (McCubbin et al. 1997).
Walsh (2006), a prominent researcher in the area of family
resilience, describes the notion of the family as a functional
unit. She claims that the family resilience approach supports
the notion that ‘…human beings survive and thrive best
through deep connections with those around us… Even
experiences of severe trauma and very troubled relationships
hold potential for healing and transformation…’ (Walsh
2006, p. xiii). Walsh’s framework of family resilience
incorporates three key processes: belief systems; organisa-
tional patterns; and communication processes (Walsh 2006).
Family belief systems are influenced by many factors
including culture and society. These beliefs have a strong
impact on how the family views crises, their management
and how they can be resolved. Resilience is fostered by
shared beliefs that increase the likelihood of positive
outcomes. Organisational patterns, or the ways in which
families organise and use their resources, involve flexibility,
connectedness and social support. Lastly, communication
processes are thought to facilitate resilience through clarity
in crisis situations, emotional expression and collaborative
problem solving (Walsh 2006). Walsh’s family resilience
framework was used as the conceptual framework to guide
this study.
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C West et al.
The study
Aim
The aim of this study, undertaken between 2007–2010, was
to measure and explore the nature of family resilience in the
context of families with a member with chronic pain. The
research questions were the following:
1 Phase 1: Quantitative
What is the impact of chronic pain on the family?
How does pain impact on family resilience?
What is the level of social support of individuals in the
family when a member has chronic pain?
What is the perceived health status of individuals in the
family when a member has chronic pain?
2 Phase 2: Qualitative
What is the experience of pain for the family when a
member has a chronic pain condition?
What are the qualities of a resilient family?
Design
The study is an explanatory sequential mixed method study.
In this type of design, the researcher first gathers and analyses
the quantitative data, which is followed by a qualitative
phase undertaken to help explain the quantitative results
(Creswell & Plano Clark 2011). In this study, the follow-up
qualitative phase helped to explain the findings from
measures administered in the initial quantitative phase. The
mixing of both sets of data in the final phase helped
strengthen the overall outcome of the study by offering a
more comprehensive integration of results (Creswell & Plano
Clark 2011).
Participants
The participants all lived in a regional area of Australia and
met the following inclusion criteria:
1 Had a chronic non-malignant pain condition diagnosed by
a medical practitioner and/or was a family member of a
person with chronic pain.
2 Lived in a family situation and/or household situation as
defined by the United States of America Census Bureau
(2005).
3 Were over the age of 18 years and willing to consent to the
study.
4 Were proficient in spoken and written English.
Exclusion criterion was as follows:
1 Concomitant debilitating disease or actively unwell with a
psychiatric illness.
3534
Chronic pain diagnosis varied in participants including
migraine, arachnoiditis, arthritis and chronic back pain. In a
small number of participants, the chronic pain condition was
caused by traumatic injury or accident.
For the purpose of the study, the term family was considered
any group of people related biologically, emotionally or
legally. Importantly, this definition includes anyone the indi-
vidual with pain believes is significant to his or her life and well-
being (McDaniel et al. 2005). In the study, while a person
living alone was not considered a family, multiple unrelated
individuals or families living together were.
Initially, the participants were recruited after a media
release and short media interview with the first author. Later,
participants were recruited via word of mouth where
participants who had volunteered for the study contacted
others in similar circumstances and referred them to the
researcher. A total of 31 families comprising 67 family
members agreed to participate.
Data collection
All participants completed a survey consisting of five parts: a
demographic section and four questionnaires chosen because
they indicate elements of family resilience according to the
Walsh (2006) framework, and one questionnaire that assessed
the impact of pain on the family. The Connor-Davidson
Resilience Scale (CD-RISC), useful for assessing resilience in
adult populations, comprises 25 items rated on a 5-point scale
(0–4). Higher scores indicate greater resilience (Connor &
Davidson 2003). The CD-RISC has been tested extensively,
found to have sound psychometric properties and capable of
distinguishing between people with greater and lesser resil-
ience (Connor & Davidson 2003, Ahern et al. 2006). Prior
testing showed good internal consistency and test–retest
reliability with a Cronbach’s alpha of 0Æ89 indicating adequate
consistency (Connor & Davidson 2003, Ahern et al. 2006).
The Medical Outcomes Study Short Form 36 (SF-36) was
constructed to measure health status (Ware & Gandeka 1998).
The questionnaire measures indicators of health including;
behavioural function and dysfunction, distress and well-being,
objective and subjective ratings and favourable and unfavour-
able self-evaluations of general health (Ware & Gandeka
1998). The SF-36 is a generic well-validated multipurpose
health measure (Turner-Bowker et al. 2002) with well-docu-
mented validity and reliability, and reliability estimates for
physical and mental scores exceeding 0Æ90 that indicate strong
consistency (Ware & Gandeka 1998).
The Medical Outcomes Study Social Support Survey
(MOS) is a 19-item questionnaire that measures perceived
availability of functional support (Sherbourne & Stewart
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Journal of Clinical Nursing, 21, 3532–3545
Pain management
1991). The scale is divided into five sections and each item is
scored on a 1–5 scale (Sherbourne & Stewart 1991). Scores
are transcribed into a linear scale of 0–100 and higher scores
indicate higher perceptions of social support (Sherbourne &
Stewart 1991). Psychometric evaluation of the MOS Social
Support Survey, conducted in almost 3000 patients with a
variety of chronic illnesses, found it to be a reliable measure
(Sherbourne & Stewart 1991) with a Cronbach’s alpha of
0Æ97 for the overall scale and 0Æ91–0Æ96 for the four subscales
(Sherbourne & Stewart 1991). The Family Impact of Pain
Scale (FIPS) is a 10-item self-report questionnaire. The FIPS
examines the effect of pain on domestic duties, social
functioning and communication within the family the higher
the score out of 10, the greater the perception of the impact of
pain on the family (Newton-John 2005). As the FIPS has not
been used in Australia or with people with chronic pain
before, the tool was tested prior to use. The results indicate
that the psychometric characteristics were consistent with
previous studies indicating that the tool is reliable for
predicting the impact of pain on the family and for use with
an Australian population (West et al. in press).
To gain further understanding of the results in the
quantitative phase of the study, interviews were also con-
ducted with a subset of participants. The ten families were
selected based on willingness to consent and having com-
pleted all quantitative data collection. A total of 10 families,
each comprising two family members (in all cases the person
with pain and their partner), consented to be interviewed.
Interviews ranged from 30–60 minutes in length and partners
were interviewed separately from the person with pain.
Interview questions included ‘What do you think resilience
means?’, ‘What do you think it is about your family that
helps manage the pain?’; ‘Can you think of a time when
things were very difficult with the pain? How did this affect
the family? How did you as a family deal with it?’; ‘What is it
about you as an individual and your family that have been
important for surviving and thriving?’ and ‘What would you
say you and your family have learnt from the pain, that might
help other families?’
Ethical considerations
Approval for the study was received from the relevant
University Human Research Ethics Review Committee
(H2821). Participants were provided with an information
sheet and if they agreed to participate, were asked to sign a
separate consent form for both phases of the study. The
participants were assured that they could withdraw at any
time and were also offered the telephone number of a
counsellor and/or pain specialist for follow-up support if
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Journal of Clinical Nursing, 21, 3532–3545
Resilience in families with a member with chronic pain
required. Pseudonyms were allocated to all transcripts to
ensure confidentiality. All data were stored securely during
the research process (West et al. 2012a).
Data analysis
Quantitative
Statistical analysis: Numerical data were described using
mean and standard deviation (SD) when approximately
normally distributed and using median and inter-quartile
range (IQR) when skewed. Categorical variables were
described by percentages. Standard deviations for all
participants and for family members without the patient
with pain were estimated and adjusted for the clustering
effect of family. Statistical analysis was conducted using
PASW (SPSS version 18; IBM SPSS, Chicago, IL, USA) and
STATA release 8 (StataCorp, College Station, TX, USA).
The Connor-Davidson Resilience Scale (CD-RISC) was
used as a measure for resilience. Comparisons between
demographic and other characteristics with respect to resil-
ience were conducted using independent t-tests, Analysis of
Variance, Pearson’s and Spearman’s correlation coefficients.
These analyses were conducted for all participants (n = 67)
and adjusted for the cluster sampling and for the participants
in pain (n = 31). Results of these analyses were adjusted for
multiple testing using Bonferroni. Multiple linear regression
analysis was conducted for the entire data set (n = 67) with
the Connor-Davidson Resilience Scale as the dependent
variable and all demographic characteristics as well as other
outcome measures were treated as independent variables. The
multivariable analysis was adjusted for the cluster sampling
approach by applying the survey commands of STATA
(StataCorp).
Qualitative
All qualitative data were subjected to content analysis, a
common approach to coding and identifying themes or pat-
terns (Hsieh & Shannon 2005). In this study, content analysis
was used to identify factors that helped the family in stressful
times as identified by the person with pain or their partner.
Interview transcripts were initially de-identified and coded for
the stressful factors using an iterative coding process. As the
last phase of the content analysis, the themes and subthemes
were counted or quantitised (Onwuegbuzie & Burke Johnson
2006), to identify the frequency each occurred (Ziegert et al.
2007). Using numbers in this way can help to strengthen
internal generalisability of conclusions, provide a check against
analytic bias, present evidence to support interpretations
(Maxwell 2005) and deepen understanding of the impact of
particular issues (Onwuegbuzie & Burke Johnson 2006). The
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C West et al.
analytic process was undertaken separately by two members of
the research team who later reached an agreement on relevant
codes (O’Reilly et al. 2009).
During qualitative data analysis, regular meetings between
author one and author five were held. Emergent themes were
discussed and agreed. Quotes from participant interviews
have been used to support the findings. Rigour was enhanced
by the purposeful inclusion of participants with experience of
chronic pain, or having a family member with chronic pain
(Giddings & Grant 2009). In keeping with good mixed
methods research, all data were then integrated (Creswell &
Plano Clark 2011).
Results
Quantitative data
A total of 31 families participated in the study (n = 67).
While the families had up to four members, the majority (25
of 31; 80Æ6%) consisted of the person with chronic pain and
his or her partner. A 21-year-old single male participant with
pain lived with his parents; two families comprised the person
with pain and one adult child; two families comprised the
person with and his or her partner living together with one
adult child; and one family comprised the person with pain
living with his son and daughter-in-law without a partner.
The mean family impact of pain score was rated as 5Æ25 by
the family members with chronic pain and 4Æ39 by other
family members, and resilience score was 64Æ9 for the family
members with chronic pain and 69Æ8 for the other family (see
Table 1). These results indicate a negative correlation
between perceived impact of pain and resilience in both
participants with pain and family members. In other words,
resilience decreased as perceived impact of pain increased
(Table 1).
The origin of pain was also investigated. Participants with
chronic pain were asked to rate their pain using a Visual
Analogue Scale (VAS) from 0–10 where zero indicates no
pain. The result indicated varied scores overall where pain
ranged from 2Æ75–10.
The impact of pain on the activities of daily living was also
assessed. The results indicate that sleep was interrupted for
the majority of participants (n = 29, 93Æ5%), and pain
interfered with the ability of many to participate in gardening
(n = 27, 87Æ1%), housework (n = 27, 87Æ1%), work (n = 26,
83Æ9%), standing (n = 25, 80Æ6%), walking (n = 24, 77Æ4%),
shopping (n = 24, 77Æ4%) and sexual activity (n = 23,
74Æ2%) (see Table 2).
Resilience scores were higher than average overall but as
expected, highest for family members without pain. Resil-
3536
ience was negatively correlated with the FIPS score in all
participants (r = 0Æ415, p = 0Æ001) as well as participants
with pain (r = 0Æ413; p = 0Æ029); indicating that the higher
the impact of pain the greater the perceived impact on
resilience. Resilience was positively correlated with SF36
mental health indicators in all participants (r = 0Æ462;
p < 0Æ001) as well as participants with pain (r = 0Æ513;
p = 0Æ004) (Tables 3 and 4). In other words, there was a
positive link between these outcomes, if resilience was low so
too was perceived mental health status; if resilience scores
where high, the mental health indicators were also high,
indicating greater mental health.
Multiple linear regression analysis based on all participants
(n = 67) confirmed the association between CD-RISC and
MOS (p = 0Æ003; data not shown). None of the other
characteristics investigated remained statistically significant.
Qualitative data
Qualitative content analysis identified a number of factors
considered helpful by the person with chronic pain during
difficult times. The one factor identified by all* participants
(*both the person with pain and other family members) was
the importance of commitment from and cohesion with a
partner or soul mate (n = 10) (Tables 5–7) (West et al.
2012a).
Transcripts of other family members were also analysed,
looking for factors that helped during stressful times. A
positive outlook, patience or tolerance, and commitment and
cohesion with a partner were regarded most highly by a
majority of the participants (n = 8) (Tables 6 and 7) (West
et al. 2012b).
Discussion
The aim of the study was to measure and explore resilience
in families with a member with chronic pain. The impact of
pain on the family was high overall, but the perceived
impact was greater for the person with pain when compared
to other family members. While this finding is consistent
with the notion that pain impacts on the family more
widely than simply the person experiencing pain (Harris
et al. 2003, Sturgeon & Zautra 2010), it is interesting that
the impact of the pain on the family is thought to be greater
by the person with pain than other family members.
Previous research has explored pain assessments by an
individual with pain and their family caregivers (Cano et al.
2005) and found that pain and disability estimates were
incongruent between the dyad of family and individual
with pain.
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Journal of Clinical Nursing, 21, 3532–3545
Pain management Resilience in families with a member with chronic pain

Table 1 Description of all participants,

Overall Participants Family members
participants with pain and family members
participants in pain without pain
Characteristics (n = 67) (%) (n = 31) (%) (n = 36) (%)

Gender
Male 32 (47Æ8) 13 (41Æ9) 19 (52Æ8)
Female 35 (52Æ2) 18 (58Æ1) 17 (47Æ2)
Mean age (SD) [years] 49Æ9 (19Æ7) 51Æ1 (13Æ8) 48Æ8 (16Æ4)
Marital status
Married 55 (82Æ1) 25 (80Æ6) 30 (83Æ3)
Cohabiting 6 (9Æ0) 3 (9Æ7) 3 (8Æ3)
Divorced 2 (3Æ0) 2 (6Æ5) 0
Single 4 (6Æ0) 1 (3Æ2) 3 (8Æ3)
Median time living in area (IQR) [years] 18 (8, 34) 19 (7Æ9, 34Æ25) 18 (8, 34)
Number of dependent children (under 18)
0 49 (73Æ1) 23 (74Æ2) 26 (72Æ2)
1 6 (9Æ0) 3 (9Æ7) 3 (8Æ3)
2 10 (14Æ9) 4 (12Æ9) 6 (16Æ7)
3 2 (3Æ0) 1 (3Æ2) 1 (2Æ8)
Number of independent children (18 years or older)
0 28 (41Æ8) 11 (35Æ5) 17 (47Æ2)
1 9 (13Æ4) 4 (12Æ9) 5 (13Æ9)
2 16 (23Æ9) 9 (29Æ0) 7 (19Æ4)
3 9 (13Æ4) 4 (12Æ9) 5 (13Æ9)
4 5 (7Æ5) 3 (9Æ7) 2 (5Æ6)
Level of highest education
High school not completed 20 (29Æ9) 9 (29Æ0) 11 (30Æ6)
High school completed 16 (23Æ9) 5 (16Æ1) 11 (30Æ6)
College/TAFE 15 (22Æ4) 9 (29Æ0) 6 (16Æ7)
University 8 (11Æ9) 4 (12Æ9) 4 (11Æ1)
Postgraduate degree 8 (11Æ9) 4 (12Æ9) 4 (11Æ1)
Paid employment
None 33 (49Æ3) 19 (61Æ3) 14 (38Æ9)
Part-time 15 (22Æ4) 6 (19Æ4) 9 (25Æ0)
Full-time 19 (28Æ4) 6 (19Æ4) 13 (36Æ1)
Unpaid employment 29 (44Æ6) 14 (48Æ3) 15 (41Æ7)
On social benefit 31 (47Æ0) 19 (61Æ3) 12 (34Æ3)
Part of social and/or sport group 22 (32Æ8) 10 (32Æ3) 12 (33Æ3)
Religious or spiritual 13 (19Æ7) 6 (20Æ0) 7 (19Æ4)
Mean FIPS (SD) 4Æ77 (2Æ81) 5Æ25 (2Æ22) 4Æ39 (2Æ25)
Mean CD-RISC (SD) 67Æ5 (18Æ5) 64Æ9 (15Æ4) 69Æ8 (16Æ3)
Mean MOS (SD) 66Æ0 (27Æ4) 71Æ5 (24Æ5) 61Æ3 (23Æ1)
Mean SF36_P (SD) 38Æ6 (12Æ7) 26Æ9 (9Æ6) 48Æ3 (9Æ3)
Mean SF36_M (SD) 44Æ7 (12Æ9) 41Æ2 (10Æ3) 47Æ5 (10Æ7)

Adapted from West et al. (in press), p. 13.

SD, standard deviation; MOS, Medical Outcomes Study social support scale; IQR, inter-quartile
range; SF36_P, SF-36 health survey physical health component; TAFE, training and further
education; SF36_M, SF-36 health survey mental health component; FIPS, family impact of pain
scale; CD-RISC, Connor-Davidson Resilience Scale.

Overestimation of pain and disability can lead to negative
consequences for the person with pain, as it reinforces the
sick role and overprotection by the spouse or family.
However, underestimation of pain can give the individual
the feeling they are not being taken seriously, which may be
seen as unhelpful by the person with pain and lead to
criticism by the partner or family member (Reimsma et al.
2000). In our case, the family members rated the impact of
pain lower than the person with pain. This may lead to
individuals with pain viewing their partner and/or family
members as unhelpful, as they perceive family members do
not realise the seriousness of their condition and thus its full

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Journal of Clinical Nursing, 21, 3532–3545 3537
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Table 2 Effects of pain on activities of daily living as reported by 31

Table 3 Resilience as measured by the Connor-Davidson Resilience
participants with chronic pain
Scale (CD-RISC) and its association with demographic and other
Activity of Affected participants characteristics: all participants (n = 67). Results are adjusted for the
daily living (n = 31) (%) cluster sampling approach

Sleep 29 (93Æ5) Overall participants

Housework 27 (87Æ1) (n = 67)
Gardening 27 (87Æ1) Mean CD-RISC
Work 26 (83Æ9) (SD) or correlation
Standing 25 (80Æ6) Characteristics coefficient p-value*
Walking 24 (77Æ4)
Gender
Shopping 24 (77Æ4)
Male (n = 32) 68Æ0 (16Æ1) 0Æ792
Sex 23 (74Æ2)
Female (n = 35) 67Æ0 (15Æ5)
Sitting 22 (71Æ0)
Age R (Pearson) = 0Æ061 0Æ629
Dressing 21 (67Æ7)
Marital status
Hobbies 21 (67Æ7)
Married (n = 55) 66Æ8 (20Æ0) 0Æ189
Driving 19 (61Æ3)
Cohabiting (n = 6) 76Æ0 (10Æ0)
Family relations 19 (61Æ3)
Divorced (n = 2) 61Æ5 (7Æ6)
Bathing 17 (54Æ8)
Single (n = 4) 67Æ0 (6Æ4)
Bowels and/or bladder 16 (51Æ6)
Time living in area R (Spearman) = 0Æ094 0Æ333
Toileting 13 (41Æ9)
Number of dependent children (under 18)
Eating 13 (41Æ9)
0 (n = 49) 69Æ1 (15Æ0) <0Æ001
Childcare 12 (38Æ7)
1 (n = 6) 55Æ2 (14Æ8)
Grooming 12 (38Æ7)
2 (n = 10) 65Æ2 (27Æ9)
3 (n = 2) 77Æ0 (17Æ0)
impact on the family. However, Sturgeon and Zautra (2010) Number of independent children (18 years or older)
claim resilient individuals adopt more adaptive coping 0 (n = 28) 68Æ3 (19Æ0) 0Æ627
strategies to manage their pain, possess a greater belief that 1 (n = 9) 63Æ8 (13Æ6)
2 (n = 16) 71Æ4 (14Æ2)
they can effectively control their pain and possess greater
3 (n = 9) 60Æ1 (19Æ1)
emotional knowledge and direct more attention inwards as a 4 (n = 5) 68Æ2 (15Æ3)
means of evaluating their current emotional state. In this Level of highest education
way, they seek to bolster their own positive affect as a means High school not 64Æ4 (13Æ6) 0Æ238
of reducing the control that their pain has over their emotions completed (n = 20)
High school completed 70Æ0 (8Æ4)
and lives. In addition, Sturgeon and Zautra (2010) contend
(n = 16)
that resilient individuals with pain often demonstrate a more
College/TAFE (n = 15) 63Æ3 (18Æ7)
optimistic outlook on their lives, express a greater belief that University (n = 8) 72Æ8 (10Æ2)
their lives have meaning and demonstrate a willingness to Postgraduate degree 73Æ4 (20Æ1)
accept pain and its consequences as a part of their lives. (n = 8)
Perhaps it is resilient qualities such as these that led to the Paid employment
None (n = 33) 64Æ0 (13Æ3) 0Æ105
participants in this study recognising the potential impact
Part-time (n = 15) 71Æ3 (15Æ7)
their pain has on their family, even though the other family Full-time (n = 19) 70Æ4 (16Æ3)
members did not have the same opinion. It is also possible Unpaid employment
that the participants used adaptive coping mechanisms to No (n = 36) 69Æ8 (18Æ8) 0Æ229
ensure they viewed the impact of their condition on the Yes (n = 29) 65Æ4 (13Æ2)
On social benefit
family in a realistic way.
No (n = 35) 69Æ1 (19Æ2) 0Æ325
Resilience scores were above average for both the person
Yes (n = 31) 65Æ6 (13Æ3)
with pain and other family members. As the first study to Part of social and/or sport group
explore the link between family resilience and chronic pain, No (n = 45) 66Æ8 (18Æ7) 0Æ605
this is an important finding. However, the person with pain Yes (n = 22) 69Æ0 (15Æ9)
scored lower on the resilience scale than other members of Religious or spiritual
No (n = 53) 69Æ4 (19Æ1) 0Æ074
the family. As resilient people are more likely to be able to
Yes (n = 13) 60Æ7 (14Æ0)
see the positive aspects and potential benefits of a situation FIPS R (Pearson) = 0Æ415 0Æ001
(Jackson et al. 2007) and resilient families view and

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3538 Journal of Clinical Nursing, 21, 3532–3545
Pain management Resilience in families with a member with chronic pain

Table 3 (Continued) Table 4 Resilience as measured by the Connor-Davidson Resilience

Scale (CD-RISC) and its association with demographic and other
Overall participants characteristics: participants with pain (n = 31)
(n = 67)
Mean CD-RISC Participants with
(SD) or correlation pain (n = 31)
Characteristics coefficient p-value* Mean CD-RISC
(SD) or correlation
MOS R (Pearson) = 0Æ359 0Æ003
Characteristics coefficient p-value*
SF36_P R (Pearson) = 0Æ157 0Æ220
SF36_M R (Pearson) = 0Æ462 <0Æ001 Gender
Male (n = 13) 62Æ8 (16Æ3) 0Æ520
All significant results in Table 4 remain statistically significant when Female (n = 18) 66Æ4 (15Æ0)
adjusted for multiple testing (Bonferroni adjustment a = 0Æ003125). Age R (Pearson) = 0Æ162 0Æ384
*p-value is the result of a t-test in case of a comparison of CD-RISC Marital status
involving a categorical variable with two categories; is the result of Married (n = 25) 64Æ6 (16Æ7) 0Æ829
ANOVA in case of a comparison of CD-RISC involving a categorical
De-facto (n = 3) 72Æ0 (6Æ6)
variable with more than two categories; and is the result of testing Divorced (n = 2) 61Æ5 (10Æ6)
Pearson’s or Spearman’s correlation coefficient against zero. Single (n = 1) –
SF36_M, SF-36 health survey mental health component; TAFE, Time living in area R (Spearman) = 0Æ092 0Æ628
training and further education; FIPS, family impact of pain scale; Number of dependent children (under 18)
MOS, Medical Outcomes Study social support scale; SF36_P, SF-36 0 (n = 23) 67Æ5 (14Æ4) 0Æ424
health survey physical health component. 1 (n = 3) 54Æ0 (12Æ0)
2 (n = 4) 58Æ3 (22Æ9)
3 (n = 1) –
Number of independent children (18 years or older)
manage crises in different ways (Walsh 2006), this finding 0 (n = 11) 62Æ1 (13Æ5) 0Æ655
helps improve our understanding of how some people 1 (n = 4) 61Æ8 (20Æ4)
thrive in the face of a chronic illness such as chronic pain. 2 (n = 9) 71Æ4 (14Æ1)
Furthermore, this may help explain that the family mem- 3 (n = 4) 60Æ0 (17Æ2)
4 (n = 3) 66Æ3 (21Æ5)
bers who scored higher on resilience perceived the family
Level of highest education
member’s chronic pain in a more positive way than the
High school not 57Æ6 (14Æ0) 0Æ059
person with the pain. In that case, including family completed (n = 9)
members in the treatment plan may have positive influences High school 67Æ4 (7Æ6)
on the person with the chronic pain and the family as a completed (n = 5)
whole. College/TAFE (n = 9) 60Æ7 (18Æ6)
University (n = 4) 70Æ3 (8Æ3)
In this study, we found that resilience was negatively
Postgraduate 82Æ5 (9Æ9)
correlated with the FIPS score for individuals with pain and degree (n = 4)
other family members. Further, resilience was positively Paid employment
correlated with the SF36 mental health score and with social None (n = 19) 61Æ8 (15Æ1) 0Æ347
support in all participants as well as the individuals with Part-time (n = 6) 71Æ7 (10Æ0)
Full-time (n = 6) 68Æ0 (19Æ7)
pain, although the results were no longer signifcant for the
Unpaid employment
individuals with pain after Bonferroni adjustment. These
No (n = 15) 66Æ9 (15Æ2) 0Æ587
results highlight that pain impacted less on more resilient Yes (n = 14) 63Æ7 (16Æ4)
families, resonating with Walsh’s Family Resilience Model On social benefit
(2006) and the framework of McCubbin et al. (1997). In No (n = 12) 69Æ3 (16Æ4) 0Æ208
addition, this finding also shows that support is an important Yes (n = 19) 62Æ1 (14Æ5)
Part of social and/or sport group
contributor to the sense of family coherence (Greef et al.
No (n = 21) 63Æ6 (15Æ5) 0Æ494
2006). Yes (n = 10) 67Æ7 (15Æ5)
Interestingly, while the families in this study scored high Religious or spiritual
for social support overall, the person with pain appeared to No (n = 24) 67Æ4 (15Æ3) 0Æ117
perceive themselves as having greater support than their Yes (n = 6) 56Æ2 (14Æ4)
Time in pain R (Spearman) = 0Æ345 0Æ067
family members. Social support is an important characteristic
In current treatment with psychologist or psychiatrist
of Walsh’s family resilience model and is especially vital to
No (n = 26) 68Æ2 (13Æ8) 0Æ005
families during times of distress helping buffer the negative

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Journal of Clinical Nursing, 21, 3532–3545 3539
C West et al.

Table 4 (Continued) Table 5 Factors that help the family through stressful times
according to the person with chronic pain (n = 10)
Participants with
pain (n = 31) Resilience factors Frequency
Mean CD-RISC
Commitment and cohesion – soul mate 10
(SD) or correlation
‘I draw strength with the love I have for my partner,
Characteristics coefficient p-value*
the love I get from my partner.’ (Beth, p. 24)
Yes (n = 5) 48Æ0 (12Æ5) Positive outlook, hope 8
Pain status ‘I believe things will be better. And if not, I will try
Worse (n = 10) 62Æ0 (17Æ4) 0Æ153 and make it better.’ (Cameron, p. 54)
Same (n = 14) 65Æ9 (14Æ3) Determination and fight 8
Better (n = 2) 86Æ0 (7Æ1) ‘you have to be that type of person who can face up
Per cent of time in pain R (Spearman) = 0Æ138 0Æ468 to anything, you’re lost in the jungle, are you going
Pain score R (Spearman) = 0Æ086 0Æ651 die, are you going to get, get out of there? (some)
FIPS R (Pearson) = 0Æ413 0Æ029 will wait to be rescued or curl up and die and I’m
MOS R (Pearson) = 0Æ302 0Æ099 not that kind of person.’ (Julie, p. 17)
SF36_P R (Pearson) = 0Æ176 0Æ361 Acknowledging/Accepting pain as being part of your 8
SF36_M R (Pearson) = 0Æ513 0Æ004 life
‘..you get an acceptance whereby you, you say well
None of the significant results in Table 5 remain statistically signifi- this is part of who I am…’ (Beth, p. 28)
cant when adjusted for multiple testing (Bonferroni adjustment Support from friends 7
a = 0Æ00238). ‘I’ve got a lot of friends that I would consider family
*p-value is the result of a t-test in case of a comparison of CD-RISC too... I was never short of anyone to help out.’
involving a categorical variable with two categories; is the result of (Susan, p. 11)
ANOVA in case of a comparison of CD-RISC involving a categorical
Patience/Tolerance 7
variable with more than two categories; and is the result of testing ‘…all I can say is that she’s got bucket loads of, of
Pearson’s or Spearman’s correlation coefficient against zero. patience.’ (Gary, p. 27)
SF36_M, SF-36 health survey mental health component; TAFE, Communication 7
training and further education; FIPS, family impact of pain scale; ‘…you’ve got to be able to communicate with each
MOS, Medical Outcomes Study social support scale; SF36_P, SF-36 other, that’s probably the biggest thing.’ (Cameron,
health survey physical health component. p. 22)
Getting on with it/Not giving in 7
‘I am fairly stubborn um, stubborn, persistent um,
impacts of distress on family well-being (Orthner et al. yeah, determined not to give up, not to give up on
2004). Involvement in the wider community also provides my life.’ (Craig, p. 32)
the family with larger social networks that help to bolster Literature/Education/Knowledge 6
‘…educate your children, educates their partner so
their sense of support (Benzies & Mychasiuk 2009). As
their partner does completely understand, make
family members indicated they perceived themselves to be less sure that everyone knows what’s going on and
supported than the individual with pain, nurses and other what’s the best way to handle things…’ (Teresa,
healthcare workers need to identify ways to ensure family p. 17)
members are better supported in the future. Adapting 6
‘…you have to learn to quickly adapt.’ (Cameron,
Overall, the families indicated that their physical and
p. 30)
mental health was well below average. Low scores in physical
Support from family 6
health were expected by the family member with chronic pain, ‘I suppose for me it’s having family, it’s having
due largely to their pain conditions. However, the mean score the support.’ (Gary, p. 4)
in physical health for family members without chronic pain Having a purpose 5
indicated they also perceived their physical health as below ‘I want a life, that’s it, I’m trying to get a life and
live life, not live an existence.’ (Craig, p. 33)
average, which may be related to the additional demands
Hobbies 5
placed upon them in the household. We are not the first to find ‘I can’t just survive I need to do something else to
that people in carer roles have poorer health levels than their get out of life and that’s where the, my hobbies,
counterparts. In at-risk groups such as people with chronic the birds and all that come into place.’ (Gary, p. 11)
pain, who may have concomitant illnesses or limited mobility, Working together as a family 5
‘…everyone’s just got to work together and that
poor physical health can increase susceptibility to disease
includes the person that’s in pain.’ (Susan, p. 11)
(Thomas & Frankenberg 2002). Improving physical health,
however, has numerous associated beneficial effects, especially

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3540 Journal of Clinical Nursing, 21, 3532–3545
Pain management
Table 5 (Continued)
Resilience factors
Participating in family events/activities
‘…you go to functions and – like I can’t go out and
kick the footy around you know, I have to sit – sit –
sit in the chair.’ (Cameron, p. 24)
Spiritual belief
‘(Buddhist’s way of thinking)...everyday life is about
fulfilling their inner quality and in getting, pursuing
a better life for themselves, for oneself.’ (Beth, p. 22)
Employment
‘…if I only went to work when I wasn’t in pain,
I wouldn’t go to work a lot.’ (Kate, p. 5)
‘Creating’ an understanding family that are not
biological
‘…being part of the family as I said to you, family
doesn’t have to necessarily be a blood relative to
be um, part of the family.’ (Craig, p. 39)
Support from non-medical therapies (complimentary
therapies)
‘…a relaxation type thing, the deep therapy and a
little bit of hypnotherapy …a guided imagery...’
(John, p. 5)
Being valued as a family member
‘…they need me, my husband needs me around for
the support, all three kids need mum just there,
whether it be emotional or physical support, or
whether it’s just for them to know that mum cares.’
(Julie, p. 4)
Laughter
‘…what we share everyday anyway is laughing, we
always, we, there’s not a day goes by we don’t
laugh.’ (Beth, p. 8)
Coping strategies
‘I … smoked a lot of pot, it did work if you had
enough, anything to make you laugh for
5-seconds.’ (John, p. 4)
Support from medical community
I keep spinning out the doctors and the nurses
because quite often I know more about what’s
going on than they do.’ (Craig, p. 34)
West et al. (2012a).
on mental health (Black & Ford-Gilboe 2004). The mental
health scores of families in this study were slightly higher than
the physical health score, but remained below average. This
could indicate that familiy members may have difficulty with
effectively resolving conflict or managing emotions (Papero
2005). Further, the known link of depression and chronic pain
(Silver 2004) may limit family members’ social interactions
and connections and willingness to explore opportunities and
treatment options (van Doesum et al. 2005).
Analysis of the qualitative data revealed the most widely
reported factor for reducing distress in the family was having
a committed, cohesive relationship with a partner. This
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Journal of Clinical Nursing, 21, 3532–3545
Resilience in families with a member with chronic pain
Table 6 Factors that help the family through stressful times
according to the family members where a family member has chronic
Frequency pain (n = 9)
4
Resilience factors Frequency
Commitment and cohesion – Soul mate 8
‘I love my man with all my heart, I don’t see that as a
3 quality, it just is.’ (Meg, p. 24)
Patience/Tolerance 8
‘…your tolerance levels will change, you’ve got to
take somebody else’s limitation on, things into
3 account and to do that you have to limit sometimes
your own things, and sometimes a bit of sacrifice.’
(Mark, p. 11)
3 Positive outlook, hope 8
‘…realising that your life is just taking a horrendous
change, treat it as a change and see it as okay I can’t
maybe do this and this, the way I would have liked
to have done this and this, but treat it like the next
3 page is turned and now your life is going to be
different, it doesn’t have to be bad, it’s just going to
be different.’ (Mark, p. 13)
Getting on with it/Not giving in 7
‘I will not give in, I will not fail, with everything,
3 pain, life, work, if I can’t do it one way, I’ll do it
another way.’ (Mike, p. 2)
Asking for help 7
‘…you need to be able to pick up the phone and say
can you come over, you just need to know that it
doesn’t matter what time of the day or night it is
2 you can ring them and say hey, I need help.’ (Karen,
p. 17)
Allow yourself your own time 6
‘…my therapy might be have a pedicure, sit in a
2 massage chair for an hour and have my feet
played with or go to the beautician or just go to the
shops. I don’t have to talk to anyone, I don’t have
to feel anything, it’s just what I want to do.’ (Karen,
2 p. 12)
Acknowledging/Accepting pain as being part of life 6
and adapting
‘…there’s a million things, you just adapt, it’s all
about adaptation, you can’t put the blinkers on, oh,
well this means I can only do this now, that’s
wrong, you’ve got to, oh, well this means I have to
do this to make this happen.’ (Mark, p. 10)
Remembering what is good/Things could always be 6
worse attitude
‘I said darling we will get there, I said that, there’s
always someone worse off, a little girl died while
she was down there, now that parent is worse off
than us.’ (Mike, p. 3)
Support from family 5
‘…my mum comes up and helps out, she does
what she can and that’s nice, ‘cause I go home
and I don’t have to do those extra things, I can
just come home and I do get a bit of sit down time.’
(Debbie, p. 20)
3541
C West et al.
Table 6 (Continued)
Resilience factors
Communication
‘We talk a lot. We are respectful. I mean, she’s well
aware of how it affects me, as much as it affects
her.’ (Debbie, p. 15)
Being able to compartmentalise (step by step, day
by day)
‘…sometimes down to you can get through a
minute, you can get through an hour, so I learnt to
deal with it on a day-type compartment, thinking
well today is shit, but tomorrow will be a better
day.’ (Meg, p. 11)
Understanding the pain
‘…like when this all first started I used to react a lot
differently ‘cause I’d be frightened and thinking oh,
shit what are we gonna do. You know? What’s
gonna happen here. But then learning cues and
realising that because there’s a lot of muscle
involvement and stuff that the muscles are all tense.
So being aware of those things, you know,
pre-empting it.’ (Debbie, p. 10)
Working together as a family
‘…we just get on with it, you just do what we’ve
got to do, I mean, the girls sort of know what
has to be done around the place, so they just
get in and help, they all know that everything’s
still got to move to keep the house going.’
(Thomas, p. 19)
Coping strategies
‘…the big brick wall that I put up, I suppose
probably drunk a bit too much, smoked a bit too
much, fall into bed you know at some silly hour of
the morning.’ (Karen, p. 7)
Support from friends
‘…it’s been such a long time, we’ve had a few good
friends that have sort of hung in there the whole
way.’ (Maree, p. 27)
Determination and fight
‘…no matter what, you stick with it, you improvise
at that time and overcome, and when it keeps
coming at you, you keep taking it, pushing back.’
(Mark, p. 1)
Moving forward together/as a team
‘…we’re on this road together so we may as well do
it together.’ (Karen, p. 13)
Not taking it personally
‘Try very hard not to take it personally, cause
again realistically it’s not personal, I appreciate
how tiring twenty-four seven pain can be.’
(Meg, p. 23)
Not blaming the person with pain
‘…when somebody is suffering chronic pain,
they have very little to give in a sense, except
their love, because they’re fighting so hard
just to survive and battle the pain. So be kind.’
(Meg, p. 27)
3542
Table 6 (Continued)
Frequency Resilience factors Frequency
5 Laughter/Humour 3
‘I say ‘I wish you’d do stupid things in the morning,
because then it’d all be done and dusted’ and then
she’ll pull a funny face and then we just laugh
5 more. Because what do you do?
if you don’t laugh you’d be bawling.’ (Debbie, p. 9)
Support from medical community 3
‘…we had a wonderful doctor, so he was always
trying to help us with you know new things.’
(Karen, p. 5)
Spiritual belief 3
5 ‘…a lot of my strength has come from my faith in
God that everything happens for a reason.’
(Meg, p. 12)
Having ‘normal’ conversations without reference 2
to pain
I don’t want to talk about him every time go
somewhere, because it’s not about him, it’s our life
you know. I would always make the ruling, no
talking about him, no talking about his condition,
5 if we want to talk about it we will otherwise we’re
here to have a good time.’ (Karen, p. 12)
Support from non-medical therapies 2
(complementary therapies)
‘…you know psychologists, hypnotherapy, anyone
that could maybe help, you know new things,
maybe medication or therapy.’ (Karen, p. 6)
4 Employment 2
‘.. my family are the world to me and if I’ve got to
crawl to work to work I will, I will not let ‘the pain’
have my family out in the street.’ (Mike, p. 4)
Literature/Education/Knowledge 2
4 ‘I will spend hours researching around the world for
something, anyone, people to talk to, information.’
(Karen, p. 10)
4 West et al. (2012b).
supports prior studies that have found that a supportive and
loving dyadic relationship provides a positive environment
4
for other family members (Place et al. 2002) and that the
most important social support is that which comes from a
3 partner (van Doesum et al. 2005). Other qualities such as
remaining determined, having a positive outlook, and getting
on with life were all important to both the individual with
pain and other family members. These findings are similar to
3 those of previous research (Evans & de Souza 2008,
Sturgeon & Zautra 2010) and are consistent with Walsh’s
(2006) family resilience model, which emphasises the
importance of warm connections and positive outlooks in
resilient families, and McCubbin et al. (1997) qualities of
resilient families.
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Journal of Clinical Nursing, 21, 3532–3545
Pain management Resilience in families with a member with chronic pain

Table 7 Comparative table; Factors that help the family through underestimation of the strength of associations. However,
stressful times where a family member has chronic pain (n = 19) sometimes it is possible for generalisations to be made in the
Frequency Frequency absence of statistical sampling methods (Onwuegbuzie &
person with family Burke Johnson 2006), so a smaller sample size is possible in
Resilience factors pain members quantitative variable studies, especially when the quantitative
Commitment and cohesion – soul 10 8 and qualitative phases of the study are well integrated. In this
mate mixed methods study, the data from the first phase was used to
Positive outlook, hope 8 8 develop the questions for the second phase and to identify
Acknowledging/Accepting pain as 8 6 potential participants and the final integration of both data sets
being part of life & adapting
strengthened the study outcomes. In addition, investigating a
Determination and fight 8 4
Patience/Tolerance 7 8
concept such as family resilience continues to be problematic.
Getting on with it/Not giving in 7 7 Often, perceptions of individuals are individually assessed
Communication 7 5 rather than assessing the family unit as a whole. In this study,
Support from friends 7 4 we also assessed the family individually thus recommend the
Support from family 6 5 need for further investigation into the concepts of resilience and
Literature/Education/Knowledge 6 2
family, especially their connectedness. More resilient individ-
Working together as a family 5 5
Spiritual belief 3 3 uals may have volunteered to participate in the study, which
Support from non-medical 3 2 may also have affected the outcomes.
therapies (complementary
therapies)
Employment 3 2 Conclusion
Laughter/Humour 2 3
Support from medical community 2 3
This study revealed that family resilience is closely linked to
Coping strategies 2 4 adverse conditions such as chronic pain. As the results clearly
demonstrates family resilience decreases as perceived impact
While the experience of living with chronic pain is often of pain increases. The study also highlights the importance of
challenging, some people do manage to lead relatively normal previously identified strengths-based approaches to family
and fulfilling lives (Sturgeon & Zautra 2010). The families in resilience such as cohesive and supportive relationships,
this study were faced with adversity because a member had having a positive attitude, determination and communica-
an ongoing chronic condition, however they appeared to be tion. The understanding of resilience uncovered in this study
dealing with the adversity from a positive perspective. While offers a starting point for the development of interventions
it is difficult to identify exactly which factors contributed that may benefit families where a member has chronic pain.
more towards the family remaining resilient, perhaps it is For healthcare providers, especially nurses, this opens the
more effective in the end to determine how they are resilient door for the development of strengths-based interventions
(Simon et al. 2005). that may be applicable in a number of chronic conditions and
which will be the subject of a forthcoming article. Identifying
the strengths inherent in families and using those strengths in
Limitations of the study
the planning and implementation of care, especially of
The major limitations of this study are related to the hetero- chronic conditions such as chronic pain, is pivotal to quality
geneous nature of the pain experienced by the participants with health outcomes.
pain, the length of time they had experienced the pain and the
method of sampling. Larger sample sets are required in order to
Contributions
gain the necessary statistical power to examine the trajectory
effectively and participants selected using a random sampling Study design: CW, KU, KF; data collection and analysis: CW,
technique rather than a convenience approach would strength- KU, PB and manuscript preparation: CW, PB, LS, KF, KU.
en the study findings. In addition, the convenience and
snowball sampling approach might have further introduced
Funding
selection bias to the study with participants and their charac-
teristics being more homogenous then results from a random The research received no specific grant from any funding
sample. Such selection biases might have made it more difficult agency in public, commercial or not-for-profit sectors.
for the study to detect associations and might have led to an However, the first author received a 1-year scholarship

 2012 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 3532–3545 3543
C West et al.
and special study leave from the School of Nursing,
Midwifery and Nutrition at James Cook University,
Queensland.
References
Ahern NR, Kiehl EM, Sole ML & Byers J
(2006) A review of instruments mea-
suring resilience. Issues in Comprehen-
sive Pediatric Nursing 29, 103–125.
Available at: http://dx.doi.org/10.1080/
01460860600677643
Benzies K & Mychasiuk R (2009) Fostering
family resiliency: a review of the key
protective factors. Child and Family
Social Work 14, 130–114.
Black C & Ford-Gilboe M (2004) Adoles-
cent mothers: resilience, family health
work and promoting practices. Journal
of Advanced Nursing 48, 351–360.
Cano A, Johansen A & Franz A (2005)
Multilevel analysis of couple congru-
ence on pain interference and disability.
Pain 118, 369–379.
Connor K & Davidson J (2003) Develop-
ment of a new resilience scale: the
Connor-Davidson Resilience Scale (CD-
RISC). Depression and Anxiety 18, 76–
82. Available at: http://www.ncbi.nlm.
nih.gov/sites/entrez?cmd=Retrieve&db=
PubMed&list_uids=12964174&dopt=
Citation.
Creswell J & Plano Clark V (2011).
Designing and Conducting Mixed
Methods Research, 2nd edn. Sage Pub-
lications Inc, Thousand Oaks, CA.
van Doesum K, Hosman C & Riksen-Wal-
raven J (2005) A model-based inter-
vention for depressed mothers and their
infants. Infant Mental Health Journal
26, 157–176.
Edward K, Welch A & Chater K (2008) The
phenomenon of resilience as described
by adults who have experienced mental
illness. Journal of Advanced Nursing
65, 587–595.
Evans S & de Souza L (2008) Dealing with
chronic pain: giving voice to the expe-
rience of mothers with chronic pain
and their children. Qualitative Health
Research 18, 489–500.
Giddings L & Grant B (2009) From rigour
to trustworthiness: validating mixed
methods. In Research for Nursing and
the Health Sciences (Andrew S & Hal-
comb E eds). Wiley-Blackwell, Oxford,
pp. 119–134.
3544
Conflict of interest
No conflict of interest is declared by the authors.
Greef A, Vansteenwegen A & Ide M (2006)
Resiliency in families with a member
with a psychologiocal disorder. Ameri-
can Journal of Family Therapy 34, 285–
300.
Harris S, Morley S & Barton S (2003) Role
loss and emotional adjustment in pain.
Pain 105, 363–370.
Hegney D, Buikstra E, Baker P, Rogers-
Clark C, Pearce S, Ross H & Watson-
Luke A (2007) Individual resilience in
rural people: a Queensland study,
Australia. The International Electronic
Journal of Rural and Remote Health
Research, Education, Practice and
Policy 7, 1–13. Available at: http://
www.rrh.org.au.
Hsieh HF & Shannon SE (2005) Three
approaches to qualitative content anal-
ysis. Qualitative Health Research 15,
1277–1288.
Jackson D, Firtko A & Edenborough M
(2007) Personal resilienceas a strategy
for surviving and thriving in the face
of workplace adversity: a literature
review. Journal of Advanced Nursing
60, 1–9.
Kralik D (2002) The quest for ordinariness:
transition experienced by midlife wo-
men living with chronic illness. Journal
of Advanced Nursing 39, 146–154.
Maxwell JA (2005) Qualitative Research
Design: An Interactive Approach, 2nd
edn. Sage Publications, Inc, Thousand
Oaks, CA.
McCubbin H, McCubbin M, Thompson A,
Han S & Allen C (1997) Families under
stress: what makes them resilient.
Journal of Family and Consumer Sci-
ences 89, 2–11.
McDaniel S, Campbell T, Hepworth J &
Lorenz A (2005) Family-Orientated
Primary Care, 2nd edn. Springer, New
York, NY.
Newton-John T (2005) The family impact of
pain scale: preliminary validation.
Journal of Clinical Pschology in Medi-
cal Settings 12, 349–358.
Onwuegbuzie A & Burke Johnson R (2006)
The validity issue in mixed research.
Research in the Schools 13, 48–63.
O’Reilly R, Peters K, Beale B & Jackson D
(2009) Women’s experiences of recov-
ery from childbirth: focus on pelvis
problems that extend beyond the puer-
perium. Journal of Clinical Nursing 18,
2013–2019.
Orthner D, Jones-Sanpei H & Williamson S
(2004) The resilience and strengths of
low-income families. Family Relations
53, 159–167.
Papero A (2005) Is early, high-quality
daycare an asset for the children of
low-income, depressed mothers?
Developmental Review 25, 181–211.
Patterson J (2002) Understanding family
resilience. Journal of Clinical Psychol-
ogy 58, 233–246.
Place M, Reynolds J, Cousins A & O’Neill
S (2002) Developing a resilience
package for vunerable children. Child
and Adolescent Mental Health 7, 162–
167.
Reimsma R, Taal E & Rasker J (2000)
Perceptions about perceived functional
disabilities and pain of people with
rheumatoid arthritis: differences be-
tween patients and their spouses and
correlates with well-being. Arthritis
Care and Research 13, 255–261.
Shapiro E (2002) Chronic illness as a
family process: a social-developmental
approach to promoting resilience.
Journal of Clinical Psychology 58,
1375–1384.
Sherbourne C & Stewart A (1991) The
MOS social support survey. Social Sci-
ence and Medicine 32, 705–714.
Silver J (2004) Chronic Pain and the Family.
Harvard University Press, London.
Simon J, Murphy J & Smith S (2005)
Understanding and fostering family
resilience. The Family Journal 13, 427–
436.
Sturgeon A & Zautra A (2010) Resilience: a
new paradigm for adaptation to chronic
pain. Current Pain and Headache Re-
ports 14, 105–112.
Thomas D & Frankenberg E (2002) Health,
nutrition, and prosperity; a microeco-
nomic perspective. Bulletin of the World
Health Organisation 80, 106–111.
 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 3532–3545
Pain management Resilience in families with a member with chronic pain

Tollefson J, Piggot K & FitzGerald M
(2008) Management of chronic pain. In
Chronic Illness & Disability (Chang E
& Johnson A eds). Elsevier, Sydney, pp.
110–125.
Turner-Bowker D, Bartley P & Ware J
(2002) SF-36 Health Survey & ‘SF’
Bibliography, 3rd edn. Quality Metric
Incorporated, Lincoln.
United States of America Census Bureau
(2005) Definitions of Household and
Family: Question and Answer Centre.
Available at: https://ask.census.gov/cgi-
bin/askcensus.cfg/php/enduser/std_adp.
php?p_faqid=614&p_created=109164
1666&p_sid=YVkcl3Mi&p_accessibil-
ity=0&p_redirect=&p_lva=&p_sp=cF9
zcmNoPTEmcF9zb3J0X2J5PSZwX2d-
yaWRzb3J0PSZwX3Jvd19jbnQ9MTA
3JnBfcHJvZHM9JnBfY2F0cz0mcF9w-
dj0mcF9jdj0mcF9wYWdlPTEmcF9zZ
WFyY2hfdGV4dD1mYW1pbHk*&p_
li=&p_topview=1 (accessed 15 May
2007).
Wall P & Melzack R (1999) Textbook of
Pain. Churchill Livingstone, London.
Walsh F (2006) Strengthening Family
Resilience, 2nd edn. The Guilford Press,
New York, NY.
Ware J & Gandeka B (1998) Overview of
the SF-36 Health Survey and the
International Quality of Life Assess-
ment (IQOLA) project. Journal of
Clinical Epidemiology 51, 903–912
Weisberg M & Clavel A (1999) Why is
chronic pain so difficult to treat?: psy-
chological considerations from simple
to comple care. Postgraduate Medicine
106, 141–164.
West C, Usher K & Foster K (2011) Family
resilience: toward a new model of chronic
pain management. Collegian 18, 3–10.
West C, Stewart L, Foster K & Usher K
(2012a) The meaning of resilience to
persons living with chronic pain: an
interpretive qualitative inquiry. Journal
of Clinical Nursing 21, 1284–1292.
West C, Usher K, Foster K & Stewart L
(2012b) Chronic pain and the family:
the experience of the partners of people
living with chronic pain in a regional
Australian setting. Journal of Clinical
Nursing, in press.
West C, Buettner P, Foster K & Usher K
(in press) Psychometric testing of the
family impact of pain scale in a sample
of Australian families in which a
member experiences chronic pain.
Nurse Researcher, in press.
Ziegert K, Fridlund B & Lidell E (2007)
Professional support for next of kin of
patients receiving chronic haemodialy-
sis treatment: a content analysis study
of nursing documentation. Journal of
Clinical Nursing 16, 353–361.

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