BACKGROUND: The recognition, assessment and management of pain in hospital settings is suboptimal, and is a particular challenge in patients with dementia. The existing process guiding pain assessment and management in clinical settings is based on the assumption that nurses follow a sequential linear approach to decision making. In this paper we re-evaluate this theoretical assumption drawing on findings from a study of pain recognition, assessment and management in patients with dementia. AIM: To provide a revised conceptual model of pain recognition, assessment and management based on sense-making theories of decision making. METHODS: The research we refer to is an exploratory ethnographic study using nested case sites. Patients with dementia (n=31) were the unit of data collection, nested in 11 wards (vascular, continuing care, stroke rehabilitation, orthopaedic, acute medicine, care of the elderly, elective and emergency surgery), located in four NHS hospital organizations in the UK. Data consisted of observations of patients at bedside (170h in total); observations of the context of care; audits of patient hospital records; documentary analysis of artefacts; semi-structured interviews (n=56) and informal open conversations with staff and carers (family members). FINDINGS: Existing conceptualizations of pain recognition, assessment and management do not fully explain how the decision process occurs in clinical practice. Our research indicates that pain recognition, assessment and management is not an individual cognitive activity; rather it is carried out by groups of individuals over time and within a specific organizational culture or climate, which influences both health care professional and patient behaviour. CONCLUSIONS: We propose a revised theoretical model of decision making related to pain assessment and management for patients with dementia based on theories of sense-making, which is reflective of the reality of clinical decision making in acute hospital wards. The revised model recognizes the salience of individual cognition as well as acknowledging that decisions are constructed through social interaction and organizational context. The model will be used in further research to develop decision support interventions to assist with the assessment and management of patients with dementia in acute hospital settings.