Nurses' management of children's acute postoperative pain: A theory of bureaucratic caring deductive study

Background: Few studies have examined the translation of nurses' knowledge of pain management into clinical practice or how nurses negotiated the bureaucracy of caring to treat patients' acute pain. Purpose: This study describes factors that influence pediatric nurses' actions in caring for hospitalized children's acute post-surgical pain. Method: Ray's Theory of Bureaucratic Caring provided the theoretical framework for this mixed methods study of ethnography and human factors engineering. Fourteen nurses were observed throughout their shifts (175.5 h) to elucidate humanistic and bureaucratic influences. Findings: Of 105 pain assessments, nurses intervened with pharmacologic (n = 45) and biobehavioral (n = 13) interventions for pediatric patients' post-surgical pain in less than 11 min; and 25 assessments revealed patients did not have pain. Pain was assessed and no intervention was provided to 4 patients who were asleep, 5 patients who refused, 2 patients who had no ordered analgesics and 10 patients who were assessed prior to peak effectiveness of their prior analgesic. Overall pain was well-controlled. Of the 28 themes identified, the interplay of 6 categorized to the social/cultural humanistic, 7 political, and 6 technologic/physiological bureaucratic dimensions most strongly influenced pain care. Discussion: To achieve optimal pain care outcomes, nurses' and parents' pain management knowledge was less influential for clinical practice translation than nurses' negotiation of other dimensions of bureaucratic caring.