ISSU ES I N CLINICA L NUR SIN G

Living with unexplained chest pain
Margaretha Jerlock

MSc, RN, RNT

Lecturer, Faculty of Health and Caring Science, Institute of Nursing, The Sahlgrenska Academy at Goteborg University,
¨
Goteborg, Sweden
¨

Fannie Gaston-Johansson

PhD, RN

Professor, Faculty of Health and Caring Science, Institute of Nursing, The Sahlgrenska Academy at Goteborg University,
¨
Goteborg, Sweden, and Johns Hopkins University, School of Nursing, Baltimore, MD, USA
¨

Ella Danielson

PhD, RN

Associate Professor, Faculty of Health and Caring Science, Institute of Nursing, The Sahlgrenska Academy at Goteborg
¨
University, Goteborg, Sweden
¨

Submitted for publication: 19 July 2004
Accepted for publication: 1 February 2005

Correspondence:
Margaretha Jerlock
Institute of Nursing
The Sahlgrenska Academy
Goteborg University
¨
Box 457, SE-40530 Goteborg
¨
Sweden
Telephone: þ46 31 773 60 39
E-mail: margaretha.jerlock@fhs.gu.se

956

J E R L O C K M , G A S T O N - J O H A N S S O N F & D A N I E L S O N E ( 2 0 0 5 ) Journal of
Clinical Nursing 14, 956–964
Living with unexplained chest pain
Aim. The aim was to describe patients’ experience of unexplained chest pain, and how the pain affected their everyday life.
Background. Chest pain is one of the most common reasons for patients to consult the emergency department. Often no clear ischaemic heart disease or any other somatic explanation is found. Exploring the pain experience and how the pain affects everyday life may provide insights into the patients’ perspective, fill the gaps in our knowledge about this condition and give needed direction for nursing practice. Method. The study sample (n ¼ 19) included 11 men and eight women admitted to the emergency department. An open-ended unstructured interview was conducted with each patient and the data were analysed using content analysis.
Results. The categories concerning pain include the informants’ descriptions of several aspects of pain. These aspects are described in four categories and four subcategories: (i) pain location, (ii) pain duration with the subcategories ‘periodic pain’ and ‘continuous pain’, (iii) pain intensity, (iv) quality of pain with the subcategories ‘sensory aspects’ and ‘affective aspects’ . The content of pain experience in everyday life was divided into four subthemes and was further abstracted into a theme. Four subthemes, each comprising several meaning units, were created and labelled: (i) fear and anxiety, (ii) feeling of uncertainty, (iii) feeling of stress, and
(iv) loss of strength. In these descriptions, it was obvious that chest pain considerably disturbed and affected the informants’ lives and an overall theme ‘intrusion into the everyday life world’ emerged.
Conclusion. The results of this study show that unexplained chest pain intrudes into everyday life in a destructive manner that cannot be ignored.
Relevance to clinical practice. Patients are not receiving optimal care to relieve their pain and there is therefore a need for specialized nurses who can give adequate help and support.

Ó 2005 Blackwell Publishing Ltd

Issues in clinical nursing

Living with unexplained chest pain

Key words: chest pain, content analysis, everyday life, patients’ experience, symptom perception, unexplained

Introduction
Chest pain is one of the most common reasons for patients to consult the emergency department. Frequently, there is evidence neither of ischaemic heart disease nor any other somatic disorder (Eslick et al. 2003). Naturally, the majority of these patients fear that they have cardiac disease but fewer than half of them will receive a final diagnosis of acute myocardial infarction (MI) or unstable angina (Bass &
Mayou 2002). There are numerous non-cardiac disorders that are common in patients with unexplained chest pain and may explain chest pain, e.g. musculoskeletal, oesophageal, breathing and panic disorders (Karlson et al. 1994, Chambers et al. 1999, Dammen et al. 2000).
Patients with unexplained chest pain have symptoms suggestive of ischaemia but with no objective evidence of coronary heart disease. These symptoms can be experienced both during exertion, bringing long-term physical limitations, impairment of daily activities and high consumption of medical services (Karlson et al. 1994, Van Peski-Oosterbaan et al. 1998). While pain is the most obvious symptom, other symptoms, such as breathlessness, anxiety and depression, are also common in these patients (Eslick et al. 2003).
Many patients with these symptoms have had negative cardiac evaluations and despite reassurance, many of them return to emergency departments with complaints of chest pain. This is understandable given that central chest pain is often perceived as a threat to life. This fear and anxiety concerning potential heart disease can increase pain (Tueth
1995). Patients with unexplained chest pain are often confused about the diagnosis and the implications for care.
They are often investigated for coronary heart disease and are told that their hearts are healthy but when pain persists and they see a new physician, it can be again assumed that they have angina (Chambers 1997).
Karlson et al. (1994) and Atienza et al. (1999) have shown that well-being and quality of life profiles in patients suffering from unexplained chest pain deteriorate in accordance with increasing severity of pain. In a study by Karlson et al.
(1994), the results show clearly that informants in whom a diagnosis of acute MI was not confirmed more frequently reported various cardiovascular, psychosomatic and psychological symptoms after one year than patients surviving a confirmed MI. In a population-based study (n ¼ 646) Eslick et al. (2003) found that non-cardiac chest pain significantly influenced quality of life.

In a study by Spalding et al. (2003) the results show that of
108 individuals with atypical chest pain, nearly half were discharged without a diagnosis and one year later, several of those with persistent symptoms remained undiagnosed.
According to Good (1994), undiagnosed and untreated illness influences a person’s view of his or her own health as naming the origin of the pain is a way to seize power to alleviate it and if the intensity demands urgency.
It is important to elicit the patient’s beliefs about chest pain. Some patients entertain abnormal attitudes and beliefs about their symptoms. These include exaggerated fears of death, marked conviction of disease despite normal findings, and intense bodily preoccupation (Tew et al. 1995, Chambers
& Bass 1998).
Little attention has been paid within either medical or nursing research to describe the experience of unexplained chest pain. Exploring unexplained chest pain experience and how the pain affects everyday life would provide insight into the patient’s own perspective, fill gaps in our knowledge and give required direction to nursing practice.

Aim
The aim was to describe patients’ experience of unexplained chest pain, and how the pain affects their everyday life.

Method
This study forms part of a larger project that uses mainly quantitative methods and focuses on the influence of psychosocial factors in patients’ experience of unexplained chest pain. A qualitative approach was used in the present study to gain a deeper understanding of patients’ experience of unexplained chest pain. The qualitative method makes it possible to gain knowledge about this experience of pain that complements the quantitative data.

Selection of informants
This study was carried out at an emergency department at a university hospital in western Sweden over a three-month period. The Ethics Committee of Goteborg University,
¨
Sweden, approved the study.
The study sample included 19 patients, men and women, admitted to the emergency department. Criteria for inclusion in the study were: (i) when cardiac diseases increase at great

Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964

957

M Jerlock et al.

age the patient must be under 70 years of age, (ii) a medical doctor should have ascertained that the patient’s symptoms had no apparent organic cause, (iii) the patient should have experienced more than two incidents of chest pain in more than four weeks. Those who had difficulties in understanding and speaking Swedish, who had suffered previous angina pectoris or an MI were excluded.
Eleven men and eight women participated (n ¼ 19) in the study. The ages ranged from 18 to 63 years (median ¼ 51 for women, 37 for men). One more interview was conducted but was excluded from the study when it became apparent that there was an organic cause to the pain. Six informants were manual workers, four were owners of a business, three held leadership positions, two were receptionists, one was a musician and one was a student. Two informants were receiving disability pensions and four were on temporary sick leave. Three women and two men were immigrants.

the informant’s home and one was conducted at the informant’s workplace.

Interview
An open-ended unstructured interview was conducted. The interview was narrative in form and was conducted as a conversation in which the informant was encouraged to talk freely (Mishler 1986). The main questions were: Can you tell me what it is like to have chest pain and can you tell me how chest pain influences your everyday life? This type of questions invites participation and narration. Some informants had not described their experience to anybody before this interview. The interviews were conducted in Swedish and lasted from 40 to 75 minutes, with the exception of one, which lasted 140 minutes. The interviews were tape-recorded and transcribed verbatim by the first author before analysis.

Procedure

Content analysis

Informants who participated in the quantitative part of the project were asked to complete a questionnaire. On the same occasion, informants who fulfilled the criteria for this study were asked whether they would be willing to participate in an interview. The information was given both in written form and verbally. The informant was assured that their participation was voluntary and that it would not influence their treatment or contact with the physician. Further, each informant was assured confidentiality and was informed that he/she could withdraw from the study at any time. Having given their informed consent, the informant then provided contact information. A few days after the patient had been discharged from the hospital the informants were contacted by telephone for the interview. The informant was free to decide the time and place for this interview.
Seventeen interviews were conducted in a room at the hospital emergency department, one interview took place at

Content analysis was performed in this study (Polit &
Hungler 1999, Krippendorff 2004). The first step in the analysis consisted of the first author (MJ) listening to, reading and summarizing every interview. This provided a general sense of the content. According to the data collected, the content was then divided into two domains: ‘pain’ and ‘pain experience in everyday life’. The analysis proceeded according to the following steps. The text was divided into meaning units: single words, parts of and whole sentences. The meaning units were then condensed in each interview
(n ¼ 19). From the condensations about pain, the content was formulated into four categories and four subcategories
(Table 1). The content concerning pain experience in everyday life was formulated into four subthemes and was further abstracted into a theme (Baxter 1994) (Table 2). The domain of pain describes more manifest and concrete content, while the domain of pain experience in everyday life contains more

Table 1 Examples from the analysis process of the domain ‘pain’
Meaning units

Condensations

It aches in the chest, sometimes I get superficial pain, but now it is inside the chest. (I 1)
Chest pain comes three times a year and it lasts four to five days each time and when it comes it is there all the time. (I 3)
It hurts terribly. (I 7)
It crushes so hard, and I get so frightened. (I 14)

In the chest deep and superficial

958

Three times a year
Four to five days each time constantly pain
Severe pain
It crushes
Get frightened

Subcategories

Categories
Pain location

Periodic pain
Continuous pain

Sensory aspects
Affective aspects

Pain duration

Pain intensity
Quality of pain

Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964

Issues in clinical nursing

Living with unexplained chest pain

Table 2 Examples from the analysis process of the domain ‘experience of pain in everyday life’
Meaning units

Condensations

Subtheme

Theme

I feel very frightened, I don’t want to die. (I 14)
I do not know how much I dare to exert myself when I do not know what it is. (I 6)
It is difficult when everybody says different things. (I 3)
I hardly managed to go to the grocery. (I 10)

Feel frightened of dying
Feel unsafe at exertion

Fear and anxiety
Feeling of uncertainty

Intrusion into the everyday life world

Different information about the pain causes frustration
Do not have the physical strength

Feeling of stress

latent content with a deeper meaning, which has to be interpreted (Polit & Hungler 1999).
Each step of the analysis was carried out independently by the first (MJ) and last author (ED). The second author (FGJ) read and analysed parts of the texts. Agreement between the authors was largely good. If not further analysis was performed until consensus was reached within the research team. Results
Pain experience
The categories concerning pain include the informants’ descriptions of several aspects of pain. These aspects are described in four categories and four subcategories: (i) pain location, (ii) pain duration with the subcategories ‘periodic pain’ and ‘continuous pain’, (iii) pain intensity, (iv) quality of pain with the subcategories ‘sensory aspects’ and ‘affective aspects’ (cf. Table 1).
Pain location
This category contains the informants’ descriptions of the location of chest pain. Pain was mostly located on the left side of the chest or, in some cases, more towards the right side of the chest. A few informants described radiation to the left arm, shoulder or back. Sometimes the pain was felt to be deep and sometimes superficial.
Pain duration
This category describes the duration of pain with the subcategories ‘periodic’ and ‘continuous pain’. The informants had experienced chest pain for anywhere between eight months and 27 years (median six years).
Periodic pain. Chest pain was experienced as episodic and unpredictable. The informants described the pain episodes as occurring: ‘every few hours, once a week, four to five times a year or once a year’. Some of the informants experienced chest pain with one or two weeks pain-free periods now and

Loss of strength

then. Over the years, pain tended to recur increasingly frequently. A 41-year-old man who had had chest pain for
10 years explained:
It started 10 years ago when we moved abroad. It was stressful. After that, the pain came at long intervals until last year, when it became worse and worse. (I 9)

Continuous pain. During the pain period, which could last for periods of only days or up to several months, pain was present almost every day or there was continuous pain with intermittent exacerbations. Pain often came in the evenings when the informant was relaxing. Some of the informants woke at night because of pain and some had pain when they woke up in the morning.
Pain intensity
This category describes the intensity of pain. The intensity of chest pain was not specifically related to activity or to rest.
Physical activity as well as rest could induce, exacerbate or relieve the pain. The words used by the informants to describe the intensity of pain are shown in Table 3.
Quality of pain
This category describes the quality of pain with the subcategories sensory and affective aspects. Table 4 shows examples of the informants’ descriptions of pain quality.

Table 3 Informants’ descriptions of the intensity of chest pain
Intensity of pain
Toothache in the chest
Severe ache
Terrible pain
Knife-like
Very hard
Like a strap tightening
Severe pain
Like stomachache
Intense pain

Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964

959

M Jerlock et al.

Fear and anxiety

Sensory aspects

Affective aspects

Cutting
Pressing
Hurting
Aching
Cramping
Crushing
Grabbing
Tightening
Nipping
Deep
Dull
Superficial
Fluttering
Splitting
Shooting
Radiating

Tiring
Annoying
Terrible
Very hard
Unpleasant
Frightening
Worrying
Difficulty breathing

Feeling of stress

Loss of strength

Figure 1 The subthemes composed of condensed meaning units and the emerged theme.

Sensory aspects. Pain appeared suddenly without prior warning and the informants described their pain in the following ways: ‘it really hurts, it is like a pressure, it tightens, it grabs, it crushes, and it is like a cramp’. The informants had no rational explanation for their pain and they could not remove or relieve it. None of the informants took pain-relieving medications even if the pain increased and they had to seek care at the emergency department.
Affective aspects. Some of the informants described pain as terrible, others as hard and unpleasant. Pain was also described as tiring, worrying and frightening. Informants expressed the difficulties they experienced in explaining to others how the pain felt. These informants were not always met with full respect for their symptoms when they sought care for their chest pain.

Pain experience in everyday life
Chest pain affected the informants’ everyday life in different ways. Four subthemes emerged: (i) fear and anxiety, (ii) feeling of uncertainty, (iii) feeling of stress, and (iv) loss of strength
(cf. Table 2). In the summarized descriptions, it was obvious that chest pain considerably disturbed and affected the informants’ lives. Pain intrudes into and deconstructs the everyday life world and the theme ‘intrusion into the everyday life world’ thus summarizes at a more abstract level the impact of unexplained chest pain upon everyday life (Fig. 1).
Fear and anxiety
In this subtheme the informants’ fear and anxiety of having an MI and dying is described. Many of the informants had
960

Feeling of uncertainty

Intrusion into the everyday life world

Table 4 Informants’ descriptions of the quality of pain

relatives who had died of heart diseases and, because of this, their own chest pain gave rise to a fear of MI and their chest pain became a threat to life itself. A 52-year-old woman explained: When I have this pain, I often fall asleep at night hoping I will not have a silent MI. I hope I will wake up in the morning. (I 10)

Thoughts of death were often in these peoples’ minds because they did not know, when pain appeared, whether it was an
MI or the usual pain. The fear of MI resulted in awareness of the body and body fixation. These informants noted every signal from the body, analysed it and tried to assess the level of danger it might imply.
When pain changed in nature, intensified or failed to disappear as it usually did, the fear of MI escalated, the informants could not handle the pain and they then had to seek care at the emergency department because they had difficulty getting professional help elsewhere.
Feeling of uncertainty
Unpredictable chest pain and questions about the cause created uncertainty in the informants. All informants had undergone investigations of the heart and these had shown no signs of ishaemic heart disease. No diagnoses were made, but chest pain remained – a threatening symptom reminding the person of their body. Pain could come at any time and it followed no pattern, which led to thoughts about the origin or cause of pain. These thoughts included: could it be
‘a virus, psychological, muscular, stress, panic disorder or could it be angina anyhow?’; What does the symptom mean?; How dangerous is the pain?; Is it possible to have a healthy heart despite the pain?; The unpredictable chest pain and the unanswered questions about the cause led to uncertainty. Just after an investigation they felt safe and secure: Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964

Issues in clinical nursing

Living with unexplained chest pain

Just after the investigation, like now, I can think, it hurts like Hell. I

My condition just disappeared a few weeks ago. I felt breathless

wonder what it really is. I know that the heart is healthy and I have

when I got up and when I went to the toilet…. I felt like an old man.

excellent results on the exercise stress test. I still think about it

(I 15)

though, even if I think of it in a more positive way. After two years or so I’ll begin to wonder again: could it be the heart anyway?… You get this feeling of uncertainty, which increases the longer you are from the time of the investigation. You become more and more uncertain and you take no risks. (I 1)

When seeking care, the informants sought affirmation. Men claimed that the results of the investigations were the most important thing. They were evidence of a healthy heart.
Women wanted to be investigated too, but they also stated that they wanted to talk to a professional about their situation because they thought that might help to decrease stress and by that get rid of pain.
For some informants, physical exertion relieved pain and in some it exacerbated it. However, although exertion might relieve chest pain, informants tended to abstain from physical activity because they never felt safe. Pain could appear at anytime and they did not know how much they dared to exert themselves. Examples of activities that these informants abstained from include swimming, playing golf, going to the gym and running. Walking was seen as much safer and many walked long distances without problems, though not when they were experiencing pain. Even a short walk to the shop might then be too strenuous.
Feeling of stress
In this subtheme, the informants’ expressions over the undiagnosed chest pain is described. Many of the informants wondered whether stress or mental strain could have caused their chest pain. Both men and women experienced stressful situations at work or/and at home and felt an inner pressure all the time. These informants described how their unexplained and undiagnosed chest pain also induced stress and a pressure to sort through various possible explanations for their condition. When these informants sought care at the hospital, they never met the same physician and each physician might offer a different opinion about the cause of pain. Loss of strength
The informants described how chest pain weakened their physical and mental strength. They felt fatigued and unable to manage daily life activities as competently as usual. This influenced all everyday activities. The informants knew that they were in good physical shape but when they were experiencing chest pain they felt feeble. A 28-year-old man explained: When they were experiencing chest pain and feeling tired these informants abstained from doing things like going to the cinema, to a cafe, to a party or inviting friends over for
´
dinner. Chest pain also affected sexual life. Women claimed that they lost their interest in sex and did not want to be near their spouses. They did not feel well, they felt fatigued and depressed. With only one exception, men did not talk about their sexual lives. When a great deal of time had passed since his last investigation, he became unsure of how much he dared to exert his body. If he had chest pain he took no risks.
The informants described disturbances in concentration and memory and these troubled them. At work, this could affect decision-making when the pain absorbed too much of their attention and disturbed their thinking. Pain could also disturb concentration during leisure time:
It is very hard, very hard; I cannot concentrate on anything fun. It disturbs my life so much. I can’t explain it better…. For example if I try to read something, I can’t go on with it, I have to change position or walk a little. I am interested in many programs on television, but it is very difficult to follow an interesting program without being disturbed by the pain. (I 14)

Many of the informants described how being in pain every day made them irritable and they would lose their patience easily and this could affect their relationship with their spouse. Resignation and despair were common among the informants. They described a feeling of hopelessness, powerlessness and loss of control. A 27-year-old man said:
I think that I will have to live with this pain all my life. If I can in some way accept the pain, I think it’ll be easier to manage… but I will always have some pain. It’s just something you have, something you got. (I 18)

Theme. Intrusion into the everyday life world
The meaning of intrusion into the everyday life world is that the unexplained chest pain has a ‘life world-destroying’ quality. Pain is intrusive and disturbs the everyday life world.
The unpredictable pain is almost continuously present, affecting almost every aspect of life. Everyday life with its activity, rest, sleep, thoughts, relationships, sexual activity and work is dramatically affected by pain. Experiences of pain, fear and anxiety, uncertainty, stress and loss of strength all interact negatively with each other and affect both the content and structure of life. Table 5 shows the frequencies of

Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964

961

M Jerlock et al.
Table 5 The frequencies of subthemes in the theme ‘Intrusion into the everyday life world’

Interview
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19

Fear and anxiety Feeling of uncertainty Feeling of stress Loss of strength ·
·
·

·
·
·
·
·
·
·

·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·

·
·
·
·
·
·
·
·
·
·
·
·

·
·
·
·
·
·
·
·
·
·
·
·
·
·

·
·
·
·
·
·
·
·
·

·
·
·
·

subthemes occurring within the theme of intrusion into the everyday life world.

Discussion
The results of our study provide descriptions of patients’ experience of unexplained chest pain itself and how pain affects everyday life. Pain is the origin of the experience and thus ‘an uninvited guest’, which intrudes into everyday life, bringing feelings of fear and anxiety, uncertainty, stress and loss of strength. The intrusion into everyday life is destructive of the quality of the world of a patients’ everyday life.
According to Toombs (1993), chronically ill patients lose their previously taken-for-granted continuity of life. In our study, it was obvious that informants with unexplained chest pain could not use their body to the same extent as usual in practical and social life; they had difficulty managing daily activities such as chores, being together with friends, recreational and sexual activity.
These informants had all had pain for more than eight months. Chronic pain generally persists for six months or more (Merskey & Bogduk 1994). The informants in our study were asked to describe their pain freely and the words used in their descriptions had a very high intensity value
(Gaston-Johansson 1996). This means that the informants live their everyday life with severe chest pain. When the pain changed in nature or worsened, they sought care at the
962

emergency department because of their anxiety and fear of having an MI.
The informants in our study had not received optimal help to relieve their pain. They had been discharged with the assurance that they were healthy and that they did not need any treatment. This indicates that the cause of pain as well as the pain management require further attention. The informants experienced illness despite their physicians’ assurances about the health of their heart. Kleinman
(1988) argues that there is a discrepancy between disease as it is conceptualized by the physician and illness as it is experienced by the person. The informants were convinced that pain was a sign of something being wrong with their body and that it had a bodily cause and they therefore wanted more diagnostic tests. They described their frustration about their undiagnosed illness because a somatic disease can be physically cured and the pain thereby relieved. The current medical model of acute care fragments treatment, isolates individuals and individualizes their experience (Charmaz 2000). According to Toombs (1993), professional care needs to make a paradigmatic shift from its current disease perspective to a perspective that deals with caring for the patient suffering from illness.
More than half of the patients with no organic cause for their chest pain continue to experience chest pain one year after discharge from the hospital (Karlson et al. 1997). The healthcare staff needs to meet and establish contact with patients with unexplained chest pain in order to understand the origin of their pain. By establishing communication about pain, descriptions of it may be helpful in providing a bridge between the patient’s perception and report of pain and the nurse’s evaluation of it (Gaston-Johansson 1996, Caldwell &
Miaskowski 2000).
Patients with this type of pain have to live with it and continue to manage their everyday lives. Our informants also suffered a loss of physical and mental strength and this greatly impaired their daily lives. They felt stressed by the fatigue and the difficulties they experienced in concentrating, working fast, exerting themselves. The results of this study regarding impairment of daily activities are in agreement with previous studies that have shown that patients with chest pain but no ischaemic heart disease have a poor quality of life
(Karlson et al. 1994, 1997, Lau et al. 1996, Eslick et al.
2002).
The unpredictability of pain meant that informants felt uncertain about exerting themselves. Walking was an activity in which the informants felt they had control over their body and this made them feel secure. When making up activity programmes for these patients, walking is therefore a suitable activity. Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964

Issues in clinical nursing

The informants were preoccupied with their pain. Even during pain-free periods, the pain was present in their minds and their attention was focused upon pain signals from the chest. Similar findings are reported from studies regarding other types of pain, such as musculoskeletal pain and fibromyalgia (Johansson et al. 1999, Hallberg & Carlsson
2000, Paulson et al. 2001).
Many of the informants in our study perceived that they had no hope of being cured. They thought that they would have to live with their chest pain for ever because no one could offer an explanation for it. In the long term, resignation and despair are dysfunctional and may result in increased chronicity of pain (Hallberg & Carlsson 2000). It is important to understand how patients’ illness perception and illness behaviour are shaped in a cultural and social context. To understand the experience of pain we have to know what ill patients think, feel and do in their natural settings (Charmaz 2000).
The interviews conducted in this study show that it is easy to get information about the pain experience in daily life. The readiness with which our informants spoke about their pain suggests that they had a need to talk about it. According to
Frank (1995) telling stories is a requirement from the ill body in attempting to verbalize the experience of illness as the biomedicine cannot describe. Skott (2001) discusses the art of narrative communication in nursing care and argues that the narratives not only portray the illness experience but also perform a healing function. Nursing care is based on human sciences and nurses possess extensive knowledge about the human being from psychological, sociological, cultural and biomedical perspectives, but opportunities must be created for nurses to carry out narrative conversations. The use of illness narratives in nursing care would give the nurse an opportunity to gather knowledge about how the individual’s life problems are created, controlled and made meaningful. Further, this provides information about how the patient perceives and monitors their own body and labels and categorizes bodily symptoms. In the healing process, the illness narrative would be a bridge connecting the body, the self and the life world
(Kleinman 1988, Skott 2001). This communication could be important in deriving an accurate clinical diagnosis.

Methodological considerations
The qualitative study design allowed the informants to talk freely about their chest pain. The qualitative results show the informants’ experience through expressions, words and statements in the transcribed interviews.
The result was based on 19 interviews. The question is whether more interviews would have had any impact on the

Living with unexplained chest pain

results. Table 5 with frequencies, shows the subthemes in each interview which is an example of trustworthiness in our study. A greater number of interviews would probably not, therefore, add anything to the results. Conversely, fewer interviews might have limited the variations in ages, pain duration, and experiences of pain. One interview (I 17) is poorly represented. This informant talked about his life situation, but not in relation to chest pain.
One of the conditions for participation was experience of chest pain for more than four weeks and on more than two occasions. Many of the informants had had chest pain for many years and had long experience of unexplained chest pain. This gave rich information about the effect of pain on everyday life and there was considerable agreement between the experiences related by the various informants. The purpose of qualitative studies is not to generalize the results but rather to enhance understanding of the phenomenon, and the knowledge emerging from our study may therefore be transferred to other similar situations (Polit & Beck 2004).
The data were analysed manually and not with computer assistance. Manual analysis is time consuming, but the importance of being close to the text and having control over the material throughout the analysis was considered to be of vital importance. To avoid the risk of the researcher bias that may occur in the interpretation of qualitative data, precise rules for coding were established and the first and last author both analysed the text independently (Polit & Hungler
1999). The use of both manifest and latent content analysis provided a more comprehensive description than using only one approach (Polit & Hungler 1999).

Conclusion and relevance to clinical practice
The results of this study show that unexplained chest pain intrudes into everyday life in a destructive manner that cannot be ignored. Unexplained chest pain is a complex phenomenon and gives rise to feelings of fear and anxiety, uncertainty, stress and loss of strength. A nurse with special competence at the ward or at a nurse reception would give patients with unexplained chest pain the opportunity to access adequate help and support. The informants sought help when they did not recognize the pain or when their symptoms worsened. If patients were able to telephone a nurse when they felt fearful, anxious and uncertain about pain this would probably result in fewer visits to the emergency department.
The results of this study is a contribution to fill the gap in knowledge about what it is like to live with unexplained chest pain, but interventions in nursing practice are also required.
In further research it is a need for longitudinal-directed

Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964

963

M Jerlock et al.

studies to investigate whether nursing receptions with nurses who can give adequate help and support improve management and well-being in patients with unexplained chest pain.

Contributions
Study design: MJ, ED; data analysis: MJ, FG-J, ED; manuscript preparation: MJ, ED.

References
Atienza F, Velasco JA, Brown S, Ridocci F & Kaski J (1999)
Assessment of quality of life in patients with chest pain and normal coronary arteriogram (Syndrom X) using a specific questionnaire.
Clinical Cardiology 22, 283–290.
Bass C & Mayou R (2002) ABC of psychological medicine, chest pain. British Medical Journal 325, 588–592.
Baxter L (1994) Content analysis. In Studying Interpersonal Interaction (Montgomery M & Duck S eds). The Guilford Press,
London, pp. 239–254.
Caldwell M & Miaskowski C (2000) The symptom experience of angina in women. Pain Management Nursing 1, 69–78.
Chambers J (1997) Chest pain, heart, body or mind. Journal of
Psychosomatic Research 43, 161–165.
Chambers J & Bass C (1998) Atypical chest pain, looking beyond the heart. The Quarterly Journal of Medicine 91, 239–244.
Chambers J, Bass C & Mayou R (1999) Non-cardiac chest pain: assessment and management. Heart 82, 656–659.
Charmaz K (2000) Experiencing chronic illness. In The Handbook of
Social Studies in Health and Medicine (Albrecht GL, Fitzpatrick R
& Scrimshaw SC eds). Sage Publications, London, pp. 277–292.
Dammen T, Ekeberg Ø, Arnesen H & Friis S (2000) Personality profiles in patients referred for chest pain. Investigation with emphasis on panic disorder patients. Psychosomatics 41, 269–
276.
Eslick GD, Coulshed DS & Talley NJ (2002) Review article: the burden of illness of non cardiac chest pain. Aliment Pharmacology
Therapy 16, 1217–1223.
Eslick GD, Jones MP & Talley NJ (2003) Non-cardiac chest pain, prevalence, risk factors, impact and consulting – a populationbased study. Aliment Pharmacology Therapy 17, 1115–1124.
Frank A (1995) The Wounded Storyteller. Body Illness and Ethics.
Chicago Press, Chicago, IL.
Gaston-Johansson F (1996) Measurement of pain, the psychometric properties of Pain-O-Meter, a simple, inexpensive pain assessment tool that could change health care practices. Journal of Pain and
Symptom Management 12, 172–182.
Good B (1994) Medicine, Rationality, and Experience – An
Anthropological Perspective. Cambridge University Press, Cambridge.

964

Hallberg LR-M & Carlsson SG (2000) Coping with fibromyalgia, a qualitative study. Scandinavian Journal of Caring Sciences 14,
29–36.
Johansson EE, Hamberg K, Westman G & Lindgren G (1999) The meanings of pain: an exploration of women’s descriptions of symptoms. Social Science and Medicine 48, 1791–1802.
Karlson B, Wiklund I, Bengtson A & Herlitz J (1994) Prognosis, severity of symptoms and aspects of well-being among patients on whom myocardial infarction was ruled out. Clinical Cardiology
17, 427–431.
Karlson B, Sjoland H, Wahrborg P, Lindqvist J & Herlitz J (1997)
¨
¨
Patients discharged from emergency care after acute myocardial infarction was ruled out, early follow-up in relation to gender.
European Journal of Emergency Medicine 4, 72–80.
Kleinman A (1988) The Illness Narratives: Suffering, Healing, and the Human Condition. Basic Books, New York.
Krippendorff K (2004) Content Analysis. An Introduction to its
Methodology, 2nd edn. Sage Publications, London.
Lau G, Hui WM & Lam SK (1996) Life events and daily hassles in patients with atypical chest pain. The American Journal of Gastroenterology 91, 2157–2162.
Merskey H & Bogduk N (eds) (1994) IASP Classification of Chronic
Pain, 2nd edn. IASP, Seattle, WA.
Mishler E (1986) Research Interviewing, Context and Narrative.
Harvard University Press, London.
Paulson M, Danielson E, Larsson K & Norberg A (2001) Men’s description of their experience of nonmalignant pain of fibromyalgia type. Scandinavian Journal of Caring Sciences 15, 54–59.
Polit D & Beck C (2004) Nursing Research, Principles and Methods,
7th edn. Lippincott Williams & Wilkins, Philadelphia, PA.
Polit D & Hungler BP (1999) Nursing Research, Principles and
Methods, 6th edn. Lippincott, Philadelphia, PA.
Skott C (2001) Caring narratives and the strategy of presence, narrative communication in nursing practice and research. Nursing
Science Quarterly 14, 249–254.
Spalding L, Reay E & Kelly C (2003) Cause and outcome of atypical chest pain in patients admitted to hospital. Journal of the Royal
Society of Medicine 96, 122–125.
Tew R, Guthrie EA, Creed FH, Cotter F, Kisely S & Tomenson B
(1995) A long term follow-up study of patients with ischemic heart disease versus patients with nonspecific chest pain. Journal of
Psychosomatic Research 39, 977–985.
Toombs SK (1993) The Meaning of Illness: A Phenomenological
Account of the Different Perspectives of Physician and Patient.
Kluwer Academic Publishers, London.
Tueth M (1995) Managing recurrent nonischemic chest pain in the emergency department. American Journal of Emergency Medicine
15, 170–172.
Van Peski-Oosterbaan A, Spinhoven P, Willem Van Der Does AJ &
Bruschke VG (1998) Noncardiac chest pain, interest in a medical psychological treatment. Journal of Psychosomatic Research 45,
471–477.

Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14, 956–964