Pain Acceptance in Chronic Postoperative Pain: Concept Analysis

Walker and Avant’s methodology is the preferred choice for analyzing the concept of CPOP due to its structured and systematic approach, which ensures clarity, consistency, and practicality throughout the analysis process ( Gunawan et al., 2023 ; Walker & Avant, 2019 ). In contrast, Rodgers’ evolutionary method, although flexible and iterative, may be less suitable for researchers new to concept analysis due to its nonlinear structure, which can complicate the generalizability and replicability of results ( Ghadirian et al., 2014 ; Gunawan et al., 2023 ). Penrod and Hupcey’s principle-based approach evaluates concepts through epistemological, pragmatic, linguistic, and logical principles, providing a more in-depth analysis but demanding a high level of expertise in theoretical frameworks ( Gunawan et al., 2023 ). Finally, Schwartz-Barcott and Kim’s hybrid model, while effective in combining theoretical and empirical phases, is prone to potential bias and limitations in generalizability, making it less ideal for analyzing CPOP ( Gunawan et al., 2023 ; Walker & Avant, 2019 ). In summary, Walker and Avant’s methodology is the most practical and effective choice for analyzing CPOP. Walker and Avant’s step-by-step framework offers a transparent and replicable process, making it particularly well-suited for exploring complex concepts such as pain acceptance in CPOP. This methodology includes selecting the concept, defining the aims or purposes of the analysis, thoroughly exploring all possible uses of the concept, determining defining attributes, identifying a model case, delineating borderline and contrary cases, discerning antecedents and consequences, and specifying empirical referents ( Walker & Avant, 2019 ). A systematic search in PubMed, Web of Science, and CINAHL identified studies addressing acceptance in CPOP. The search utilized a combination of Medical Subject Headings (MeSH) and free-text keywords, including “Acceptance,” “Acceptance and Commitment Therapy,” “Chronic Pain,” “Postoperative Pain,” “Chronic Postoperative Pain,” “Chronic Postsurgical Pain,” “Persistent Postsurgical Pain,” and “Psychological Flexibility.” The focus was on studies published between 2009 and 2024 that explored acceptance in any chronic pain, including CPOP, among adult populations aged 18 years and older. Only studies published in English with full-text availability were included, resulting in 16 articles relevant to acceptance in CPOP as shown in Figure 1 .

Sixteen publications recovered through the literature search guided the development of the concept analysis and discovered the essential attributes, antecedents, and consequences of pain acceptance using the Walker and Avant methodology ( Catalino et al., 2017 ; Craner et al., 2017 ; Dance et al., 2016 ; Dindo et al., 2018 ; Droppert & Knowles, 2022 ; Elander et al., 2009 ; Esteve et al., 2021 ; Fisher et al., 2021 ; Ford et al., 2018 ; Gentili et al., 2019 ; Jensen et al., 2016 ; Kapadi & Elander, 2020 ; Kim et al., 2020 ; Kratz et al., 2017 ; Lami et al., 2018 ; McCracken, 2024 ; Thompson & McCracken, 2011 ; Wang et al., 2019 ). The evidence reveals an ample amount of research on pain acceptance in individuals with chronic pain conditions such as fibromyalgia, hemophilia, endometriosis, breast cancer, and spinal cord injuries, with fewer studies addressing CPOP conditions like lumbar fusions ( Craner et al., 2017 ; Dance et al., 2016 ; Droppert & Knowles, 2022 ; Elander et al., 2009 ; Jensen et al., 2016 ; Kapadi & Elander, 2020 ; Thompson & McCracken, 2011 ). As illustrated in Table 1 , the evidence defines pain acceptance in chronic pain as the willingness to engage in activities despite persistent pain ( Craner et al., 2017 ; Jensen et al., 2016 ; Kapadi & Elander, 2020 ). In the context of CPOP, pain acceptance involves embracing postoperative pain, while adhering to surgical recovery limitations and addressing unique postoperative challenges such as preventing complications and promoting healing ( Dance et al., 2016 ; Dindo et al., 2018 ). Defining attributes are the qualities of a concept that recur frequently and offer the most explicit comprehension of the concept ( Walker & Avant, 2019 ). Four essential attributes of pain acceptance in CPOP are open-mindedness/receptivity, present orientation, self-acceptance, and endurance ( Catalino et al., 2017 ; Lami et al., 2018 ; Thompson & McCracken, 2011 ). Open-mindedness/receptivity enables individuals to accept and process their experiences, thoughts, and emotions without judgment ( Catalino et al., 2017 ). Open-mindedness helps individuals develop resilience and optimism, thus enhancing their capacity to handle CPOP and improve their quality of life ( Catalino et al., 2017 ; Thompson & McCracken, 2011 ). Endurance is the ability to overcome hardship, inspiring the CPOP patient to move on with optimism and self-assurance. Accepting pain and overcoming barriers requires willpower; without this form of endurance, the individual may give up ( Kim et al., 2020 ; Thompson & McCracken, 2011 ). The ability of CPOP patients to accept pain is attributed to their orientation towards and focus on the present moment. Through the pain acceptance process, people can understand that despite their condition’s pain and difficulty, they can change how they see things ( Thompson & McCracken, 2011 ; Weinrib et al., 2017 ). Individuals who accept pain can live in the present and are psychologically adaptable enough to create a new life within the parameters of their new reality without grieving the loss of their previous one ( Lami et al., 2018 ). Self-acceptance can improve CPOP patients’ self-confidence and make them less susceptible to suffering by embracing every element of themselves and overcoming internal conflicts ( Dance et al., 2016 ; Kim et al., 2020 ). By fostering self-acceptance, individuals with CPOP can develop the capacity to live with their pain without it interfering with their daily activities ( Lami et al., 2018 ). Antecedents must happen or occur before the occurrence of the concept ( Walker & Avant, 2019 ). The anticipation of upcoming surgery is a crucial antecedent that creates an environment for accepting pain associated with surgery ( Glare et al., 2019 ; Schug & Bruce, 2017 ). Furthermore, an individual’s psychological flexibility to embrace positive and negative life experiences is a substantial antecedent, facilitating a positive response to stressors like postoperative pain ( Ford et al., 2018 ; Gentili et al., 2019 ; McCracken, 2024 ). A robust social support system offers emotional, practical, and informational support in strengthening resilience and promoting overall well-being as they cope with the challenges of pain acceptance after surgery ( Fisher et al., 2021 ). The consequences are the outcomes that result from the occurrence of a concept ( Walker & Avant, 2019 ). The consequences of pain acceptance in postsurgery patients encompass various positive outcomes, particularly in the context of CPOP. Embracing their suffering, individuals with CPOP experience better pain control and reduced dependence on opioids ( Thapa & Euasobhon, 2018 ). Pain acceptance is a promising complement to pain management strategies that contribute to an overall enhancement in the quality of life for chronic pain patients ( Kapadi & Elander, 2020 ; Kratz et al., 2013 ). While pain acceptance is widely recognized as a beneficial approach, its potential challenges are often overlooked in studies. The willingness to function despite pain may lead caregivers and healthcare providers, including nurses, to underrate the severity of the pain, resulting in inadequate support or treatment and leaving individuals feeling helpless and frustrated ( McCracken, 2024 ; Smit et al., 2023 ). Additionally, a misunderstanding of pain acceptance might reduce the motivation to seek medical care for treatable conditions, potentially delaying necessary interventions and reducing the quality of life ( McCracken, 2024 ; Smit et al., 2023 ; Thompson & McCracken, 2011 ). Walker & Avant (2019) recommend a model case to clearly and concisely illustrate any concept by integrating its defining attributes into an example demonstrating its fundamental characteristics. Alex, a 58-year-old male diagnosed with a chest infection requiring thoracotomy, serves as a model case for CPOP as he demonstrates key attributes such as self-acceptance, present orientation, open-mindedness, and endurance. Before surgery, Alex participated in discussions with the surgical and anesthesiology team, displaying his willingness to understand and prepare for the postoperative phase. After the surgery, he manages his pain without allowing it to control his life and remains focused on the present. Additionally, his initiative to establish a local CPOP support group indicates his dedication and perseverance in helping others with similar experiences. A borderline case contains some, but not all, defining attributes of the concept under study. It closely resembles the model case but exhibits some dissimilarities that distinguish it from being a perfect example ( Walker & Avant, 2019 ). Whitney, a 32-year-old diagnosed with cholelithiasis and scheduled for a cholecystectomy, exemplifies a borderline case of pain acceptance after surgery. Initially, she refuses to express her concerns with the surgical team during her preoperative appointment, showing her reluctance to acknowledge the potential implications of surgery and associated pain. However, following a prolonged hospitalization for postoperative pain, she gradually engages in distraction techniques such as watching television and expresses a strong motivation to recover for her children. This mix of acceptance and struggle toward pain acceptance highlights the complex nature of acceptance in CPOP. Contrary cases are inconsistent with the studied concept ( Walker & Avant, 2019 ). Sarah, a 60-year-old woman scheduled for left leg amputation refuses to participate in discussions regarding surgery and pain management alternatives with her healthcare team before surgery, demonstrating a lack of openness and receptivity. After the procedure, she frequently expresses frustration and withdraws from daily activities, indicating her inability to focus on the present. Sarah also struggles with self-acceptance and rejects support groups and counseling, making it harder for her to manage postsurgical discomfort. As a result, she experiences negative emotions and perceives pain as a devastating barrier rather than something she can handle. Her response to pain shows the absence of essential attributes associated with pain acceptance as opposed to the positive response shown in the model case scenario.

This concept analysis guides healthcare practitioners with the necessary information to support individuals experiencing CPOP on their journey toward pain acceptance in CPOP by identifying defining attributes, antecedents, consequences, and case scenarios. A better understanding of pain acceptance in postoperative patients empowers healthcare practitioners to boost patients’ receptiveness to surgery and its after-effects and encourage psychological well-being and quality of life. Future research on pain acceptance in postoperative populations will help to understand and enable the development of evidence-based interventions aimed at improving the standards of life for individuals with CPOP.

The concept analysis of pain acceptance in individuals with CPOP highlights the multifaceted nature of this phenomenon and provides valuable insights for healthcare professionals aiming to improve outcomes in patients at high risk for CPOP ( Table 2 ). Identifying the defining attributes of pain acceptance—open-mindedness/receptivity, present orientation, self-acceptance, and endurance—is crucial for tailoring interventions that promote acceptance and enhance recovery after surgery ( Catalino et al., 2017 ; Thompson & McCracken, 2011 ; McCracken, 2024 ). Healthcare providers can identify these attributes through patient assessments that examine their psychological readiness, coping mechanisms, and engagement in the present moment ( Lami et al., 2018 ; Thompson & McCracken, 2011 ). For instance, open-mindedness/receptivity enables patients to approach their pain without judgment, fostering resilience and optimism, which can be encouraged through ACT or mindfulness-based interventions, which can be implemented pre- or postoperatively based on the individual’s need ( Reme et al., 2022 ; Weinrib, 2017). Present orientation helps individuals focus on the present moment, allowing them to engage with life despite ongoing pain, which can also be supported through mindfulness practices or ACT ( Lami et al., 2018 ; Thompson & McCracken, 2011 ; Weinberg et al., 2017), Self-acceptance is vital for building confidence and overcoming internal conflicts through motivational interviews or supportive counseling ( Dance et al., 2016 ; Kim et al., 2020 ; Lami et al., 2018 ). Endurance encourages persistence and willpower and can be supported through goal setting, graded physical activities, and peer support ( Kim et al., 2020 ; Lami et al., 2018 ; Weinrib et al., 2017 ). In addition to these defining attributes, understanding the antecedents—the factors that precede pain acceptance—is key to identifying individuals who may benefit from early interventions. Psychological flexibility, the ability to embrace positive and negative life experiences, is pivotal in fostering pain acceptance ( Ford et al., 2018 ; Gentili et al., 2019 ; McCracken, 2024 ). The anticipation of surgery is another antecedent that can shape how individuals approach their pain postoperatively. By assessing psychological readiness before surgery and providing preoperative education and support, healthcare providers can better prepare patients for the challenges of postoperative recovery ( Glare et al., 2019 ; Schug & Bruce, 2017 ). Moreover, a strong social support system is crucial in helping patients navigate pain acceptance, offering emotional and practical assistance during recovery ( Fisher et al., 2021 ). The consequences of promoting pain acceptance are substantial, with improved pain control, reduced opioid dependency, and better quality of life being key outcomes for CPOP patients, as depicted in Figure 2 ( Kapadi & Elander, 2020 ; Thapa & Euasobhon, 2018 ). By integrating the biopsychosocial model, healthcare providers can develop a holistic approach that might address the psychological, physical, and social factors that influence pain acceptance and success in their recovery ( Reme et al., 2022 ). Furthermore, considering model, borderline, and contrary cases allows healthcare professionals to tailor interventions to meet each patient’s unique needs, offering targeted strategies that address the complexities and challenges of pain acceptance in CPOP. This concept analysis highlights notable strengths while acknowledging its limitations. A key strength is the systematic application of Walker and Avant’s framework, which ensures a rigorous, clear, and replicable methodology. Identifying defining attributes—open-mindedness, present orientation, self-acceptance, and endurance—provides a comprehensive understanding of pain acceptance in CPOP. Furthermore, linking these attributes to antecedents and consequences enhances the clinical relevance of the analysis in the CPOP context. However, certain challenges and limitations emerge in this study. While pain acceptance is widely recognized in the context of chronic pain, it has not been the focus of a concept analysis, making the identification of attributes, antecedents, and consequences in CPOP particularly difficult. The exclusion of non-English publications and older studies may have further constrained the scope of the findings. Additionally, although the framework is methodical, its applicability to diverse chronic pain populations remains uncertain, raising questions about the generalizability of the findings. Despite these challenges, this analysis fills a critical gap and establishes a foundation for future research and evidence-based strategies to enhance outcomes for individuals with CPOP.