Understanding the Culture of a Children’s Day Surgery Unit and its Influence on Day Surgery Nurses’ Pain Assessment Practice: A Focused Ethnography

Abstract

Background: Unit culture is an important factor to explore when studying nursing due to the highly social nature of nursing practice. Pediatric day surgery nurses are responsible for the assessment and management of children’s pain after surgery, but little is known about how their pain assessment practice is influenced by the nursing unit culture within which they work. The purpose of this study was to understand the unit culture of a pediatric day surgery unit through the perspectives of unit nurses, and how the culture has shaped their pain assessment practice when caring for children experiencing pain after surgery. Methods: Focused ethnography was used to explore the culture of a pediatric day surgery unit in Western Canada. Participants were nurses who worked regularly on the day surgery unit. Data was collected through document analysis of pain related policies, protocols, guidelines, and education; semi-structured interviews, and two focus groups. Data analysis was iterative and inductive based on the above data generated with the participants and deductive moving from analysis to interpretation in line with the chosen methodology. Results: The pediatric unit culture can be described with three major themes; the nursing team as the keystone of the unit, navigating tension between nurse priorities and organizational practices, and the dissonant relationship between day surgery nurses and outsiders. These aspects of the unit culture shaped nurses’ pain assessment practice and created shared definitions and practices. The unit nurses had a shared definition and expectation of pain which led to unit practices of anticipating and expecting pain, and giving ‘as needed’ pain medication on a schedule. The tension between nurse priorities and organizational practices led nurses to feel they did not have time for children to be in pain and so the reality of pain assessment on the day surgery unit was not to nurses’ desired standard. Nurses also placed behavioural expectations on their patients that could disrupt their pain assessment practice. Conclusion: Pediatric day surgery nurses live and work on a complex and fast-paced unit that necessitates efficiency and efficacy. Understanding the uniqueness and reality of the unit culture and nursing team is essential when introducing new pain related initiatives and bridging the theory practice gap.