Patients’ recovery after surgery is one of the most important health processes in planned hospital healthcare and has a direct impact on welfare and welfare systems. Therefore, what nurses do in the im­mediate postoperative period is of vital importance. This thesis addresses the question of understanding how nurses work in managing post-operative pain by exploring their daily nursing practices and experiences in responding to the patient in pain within a Thai cultural context. The project applied a qualitative methodology where the local culture and its day-to-day practices of pain management were studied by using observations, focus groups, in-depth interviews and a critical incident interview approach with nurses. Informants were recruited at a public hospital in Bangkok in a surgical ward. In all, 100 hours of observations, 39 interviews and 69 descriptions of critical incidents related to nurse’s pain management were gathered. The data analysis followed the principles of qualitative research. The findings showed that, although there is a clearly defined approach to pain management, the response system followed by the nurses to address patients’ pain is complex and includes much lead time between assessing patients’ pain and the nurses responding to the pain. Furthermore, nurses are caught in what is labeled a patient pa­radigm, where evidence of pain often is double- and triple-checked by scoring and recording signs that are then subject to confirmation by a third party. Underpinning this is a culture of pain management cultivated between the nurses that rests first and foremost on their own experiences and a working/professional culture where nurses offer each other practical help in urgent situations, but seldom discuss event-based strategies together. Nevertheless, when nurses described situations when they were successful in practicing pain management, they considered their own engagement and their availability of time, space and therapeutic options to be important. Keywords: Culture of nursing, Nursing in pain management, Pain assessment, Perception of pain, Pain management, Pain post-operative

Thesis (Ph.D.)--Indiana University, 2010. / Title from screen (viewed on April 1, 2010). Department of Pharmacology and Toxicology, Indiana University-Purdue University Indianapolis (IUPUI). Advisor(s): Theodore R. Cummins, Grant D. Nicol, Gerry S. Oxford, Andy Hudmon, John H. Schild. Includes vitae. Includes bibliographical references (leaves 232-266).

The thesis deals with a definition of pain management issues, role of nurses working with patients in pain and, particularly, perception of pain of patients by nurses. The objective of the research was to identify and to study pain management procedures and, at the same time, to present how nurses perceive and experience the care of patients in pain. The empirical part of the thesis was performed through qualitative investigation using semi-structured interviews with nurses and patients. The respondents included 12 nurses and 8 patients. Based on results of the investigation covert participatory observation was selected as a complementary method. 6 nurses were observed while taking care of patients during a post-surgery period. Most frequently, nurses rate pain of patients by means of VAS (Visual Analogue Scale), however, they quite often assess the value subjectively. Nurses then record the found values regularly into the patient´s chart. Nurses would also appreciate more cooperation with physicians in order to increase efficiency of pain rating. Nurses are able to respond very well to patient´s verbalization of pain and they perceive differences in communication in such situations. The majority of nurses choose pro-active approach to pain alleviation. Nurses have the basic knowledge about non-pharmacological pain alleviation. Perception of pain by nurses is partly affected by length of their practice and by their own experience with pain. Nurses perceive negatively those situations when pain management interventions are not sufficiently effective, when they cannot contact physicians or when they cannot act based on their own discretion. In such situations nurses demonstrate signs of distress. This problem aggravates when nurses work with patients suffering from chronic pain. Nurses have only limited opportunities to improve their education in pain management and communication with patients in pain. Patients in pain mostly see the care provided by nurses positively but they have also provided numerous recommendations for the nurses. The empirical research has shown that nurses meet with patients in pain nearly every day while performing their nursing practice and that assessment of pain plays an important role in pain alleviation. In most cases the exposure of nurses to patients in pain causes their negative emotional experience, such as sadness or fear of complications. Their experience is affected by several factors. In general, the issues of pain perception by nurses in comparison with pain management techniques are often neglected. Nevertheless, from the viewpoint of mental stress, pain perception is an indisputable factor that deserves more detailed investigation.