{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T19:56:13Z","timestamp":1790538973999,"version":"4.1.0"},"reference-count":35,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T00:00:00Z","timestamp":1790467200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T00:00:00Z","timestamp":1790467200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Nursing Philosophy"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>Pain assessment often follows a hierarchy: self\u2010report is treated as the gold standard, while behavioural and physiological evidence are used when the report is unavailable. This protects patients against professional disbelief but can make those unable to self\u2010report appear unable to contribute to knowledge about their pain. I argue that verbal report and nonverbal expression belong to one interpretive practice while retaining different epistemic roles. Self\u2010report carries presumptive first\u2010person authority because it conveys experience, meaning, and preferences. Behavioural evidence is indirect, context\u2010dependent, and fallible, but it is genuine evidence. Physiological evidence is less specific and should remain an adjunct. When self\u2010report is unavailable, what changes is not the kind of pain a patient may have but the evidence available and what it can justify. Drawing on the social communication model of pain, nursing accounts of tacit and relational knowledge, phenomenology, and epistemic injustice, I use functional distress to name an organised pattern of clinically significant change. The functional\u2010distress framework explains when that pattern supports suspicion of pain. It is not another assessment instrument; it shows how clinicians combine validated tools with timing, relationships, clinical context, alternative explanations, and reassessment. Functional distress does not prove pain. It can provide reversible grounds for suspicion; separately, risk, vulnerability, and reversibility may justify a proportionate precautionary response. The ethical task is to preserve first\u2010person authority without treating patients who cannot exercise it as epistemically absent.<\/jats:p>","DOI":"10.1111\/nup.70125","type":"journal-article","created":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T18:58:46Z","timestamp":1790535526000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Knowing Pain Without Certainty: Recognition When Self\u2010Report is Unavailable"],"prefix":"10.1111","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8751-9854","authenticated-orcid":false,"given":"R. Colin","family":"Blenis","sequence":"first","affiliation":[{"name":"Chamberlain University Atlanta Georgia US"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,27]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.pain.2013.05.019"},{"key":"e_1_2_11_3_1","doi-asserted-by":"crossref","DOI":"10.1097\/00000446-198412000-00027","volume-title":"From Novice to Expert: Excellence and Power in Clinical Nursing Practice","author":"Benner P.","year":"1984"},{"key":"e_1_2_11_4_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11673-016-9761-x"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.300.1.60"},{"key":"e_1_2_11_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/00012272-197810000-00004"},{"key":"e_1_2_11_7_1","volume-title":"Knowledge Development in Nursing: Theory and Process","author":"Chinn P. 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(Original work published 1960)."},{"key":"e_1_2_11_15_1","doi-asserted-by":"publisher","DOI":"10.1111\/jan.70455"},{"key":"e_1_2_11_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.pmn.2011.10.002"},{"key":"e_1_2_11_17_1","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.1516047113"},{"key":"e_1_2_11_18_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11019-025-10264-9"},{"key":"e_1_2_11_19_1","volume-title":"The absent body","author":"Leder D.","year":"1990"},{"key":"e_1_2_11_20_1","doi-asserted-by":"publisher","DOI":"10.1007\/s13347-026-01074-9"},{"key":"e_1_2_11_21_1","volume-title":"Nursing Practice Theories Related to Cognition, Bodily Pain, and Man\u2010environment Interactions. University of California","author":"McCaffery M.","year":"1968"},{"key":"e_1_2_11_22_1","doi-asserted-by":"publisher","DOI":"10.1111\/nin.12672"},{"issue":"3","key":"e_1_2_11_23_1","first-page":"293","article-title":"The Flacc: A Behavioral Scale for Scoring Postoperative Pain in Young Children","volume":"23","author":"Merkel S. I.","year":"1997","journal-title":"Pediatric Nursing"},{"key":"e_1_2_11_24_1","doi-asserted-by":"crossref","unstructured":"Merleau\u2010Ponty M.(2012) Phenomenology of Perception (D. A. Landes Trans.). Routledge. 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The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician And Patient. Kluwer Academic.","DOI":"10.1007\/978-94-011-2630-4"},{"key":"e_1_2_11_35_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.JAM.0000043422.31640.F7"},{"key":"e_1_2_11_36_1","unstructured":"Wittgenstein L.(2009). Philosophical Investigations (G. E. M. Anscombe P. M. S. Hacker & J. Schulte Trans.; 4th ed.). Wiley\u2010Blackwell. 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