Pain is what the patient says it is, but… : an ethnographic study of the factors which influence nurses when they make pain management decisions in a clinical setting

Barriers to effective postoperative pain management mean many patients suffer needless pain. Few studies have observed nurses as they manage postoperative pain in a clinical setting; those who used observation have demonstrated the importance of context to pain management practice. This ethnographic study aimed to examine what factors influenced nurses when they made pain management decisions, and how the culture of the clinical environment impacted on pain management practice. One hundred and fifty seven hours of participant and non-participant observation, semistructured interviews with thirty-six members of staff, contemporaneous field notes, and document analysis were used to investigate the culture of pain management in one postoperative ward. Analysis identified three themes with sub themes. First, the revealing of a pain management culture, which incorporated the ward environment and processes, and a new finding of the silence of routine pain management communication. Second, nurses’ decision-making responses to pain management opportunities including a new finding of a single pain management action. The final theme is nurses’ expectations of patient behaviours and knowledge, including how patients should look, what they should say and know, and nurses’ responses to patients who do not conform to expectations. The findings suggest culturally mediated pain management behaviours, linked to a ward culture where pain was not a priority, leading to inattention to pain management. Using Social identity theory these behaviours are presented as in-group pain management social norms; part of the culture of ‘how pain management is done around here’. These pain management in-group behaviours are presented as the critical factors influencing nurses’ pain management decision-making in a clinical setting. They are not targeted through traditional education and their explication may indicate pain management education should be directed more towards cultural change