Postoperative pain is still poorly managed among surgical patients despite evidence-based approaches to its treatment being well established. Prompted by the persistence of this problem, many researchers have studied factors influencing postoperative pain management. Empirical clinical research has dominated this area and has presented a set of factors which, albeit important, have not taken into account the influence of contextual factors on the individual’s practices in pain management. This study is designed to examine the role of context on the practices and interactions of professionals and patients during postoperative pain management. Informed by the insights of post-structuralism, it uses nonparticipant observation, informal and semi-structured interviews with participants of both genders (29 staff nurses, 13 surgeons, 38 patients, and 20 patients’ family members), and a document review to construct a case study of four surgical patients’ wards in two Jordanian hospitals. Also included is a descriptive analysis of pain and distress scores, and a thematic analysis of the raw data The findings reveal both a significant problem with pain among Jordanian surgical patients, and limited engagement by nurses in postoperative pain management. It is found that a series of socio-cultural and organizational factors limit participants’ practices in respect of pain management. Influential socio-cultural factors include: sexual surveillance, an inferior public view of nurses, patriarchal ideas, and use of personal influence (wasta). Organisational factors include: hierarchical observations, fear of punishment, the subordination of nursing staff, perceptions of low staffing and high workload, and social hierarchies, such as rank. In combination these contextual factors operate as a set of disciplinary and power mechanisms that limit the ability of nurses to become involved in patients’ pain management; impede nursing professionalism by restricting autonomy and self-regulation; reduce some of the patients’ willingness to communicate pain and lead to a reluctance to be cared for by professionals of a different gender. It is concluded that in this area organisational policies are subservient to nurses’ culturally constructed approaches to pain management. As such, socio-cultural factors appeared to have a greater effect than organizational factors. Recommendations are made to address the situation and provide for appropriate pain relief after surgery.

Recent literature suggests that 84% of lower extremity amputations (LEAs) are due to peripheral arterial occlusive disease (PAOD), and half of those will have diabetes. Only 40% will go on to rehabilitate with a prosthetic limb and the remainder will be wheelchair dependent. Until now, the majority of research has focused on the short-term clinical outcomes in this population e.g. prosthetic fitting, morbidity and mortality rates. There is a dearth of research into the long-term impact of a LEA on the individual’s quality of life (QoL), especially in those with PAOD with or without diabetes. Aim This thesis aims to determine which factors influence QoL after an LEA due to PAOD in the presence or absence of diabetes. Methods A prospective review of medical case notes and other relevant documentation was conducted on all patients who underwent a major lower extremity amputation for PAOD in NHS Greater Glasgow and Clyde in Scotland, between 1st March 2014 and 28th February 2015. Patients who consented to follow-up completed the EQ-5D-5L QoL measure, Reintegration into Normal Living (RNLI) and the Prosthetic Limb Users Survey of Mobility (PLUS-M), 6 and 12 months after LEA. Semi-structured interviews were conducted on 15 participants who completed follow up questionnaires to explore their views and experiences of living with a LEA and to understand which factors influence their QoL. Results There were 171 participants with a LEA in one year and their mean age was 66.2 years, 75% were males and 53% had diabetes. Over two thirds of the cohort lived in the two most deprived areas in Glasgow. From the follow up questionnaires (n=101) participation, measured by the RNLI had the greatest influence on QoL six and twelve months after LEA. Limb fitting positively influenced QoL, however, level of mobility was poor for all levels of LEA and there was a positive association between mobility (PLUS-M) and QoL. Mortality was seven times greater in those who were not limb fitted. Face-to-face interviews identified five broad themes that influenced QoL: the prosthesis; experience of pain; social support/isolation; sense of self/identity and interactions with others with an amputation. Conclusion Quality of Life was influenced by several factors, primarily participation, which was improved if limb-fitted. Those of male gender, younger age and diagnosed with diabetes were more likely to have a prosthesis fitted. While having a prosthesis did not determine QoL per se, those with greater levels of mobility were more likely to be able to participate, feel less isolated and require less social support which afforded them greater levels of QoL. Conversely, those who were wheelchair dependent or had poorer levels of prosthetic mobility reported lower levels of QoL; which was associated with dependence on social support, feelings of isolation and changes in the way they felt about themselves.