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Aim: The aim of this study was to explore the factors influencing orthopedic surgery nurses' decisions to administer pro re nata (PRN) opioid analgesia for postoperative pain. Background: Fast-track surgery programs reduce length of stay by identifying and addressing factors causing patients to remain in hospital, including pain (H. Kehlet, Lancet. 2013;381:9878(9878)). The management of acute pain is an important component of quality care for patients after total knee arthroplasty. Methods: The study used a qualitative design of focused ethnography. Ten nurses working on an orthopedic surgery unit at a large urban hospital in western Canada participated in semistructured interviews that used a patient vignette to examine factors that influenced participants' pain management in the context of fast-track surgery. Interviews were transcribed and analyzed using thematic analysis and constant comparison. Findings: Nurses described a complex clinical environment where the interplay of several factors informed decisions to administer PRN opioid analgesia. The unit's culture and physical space influenced nurses' assessments of pain and their decisions whether to treat pain with PRN opioids. Each nurse's self-concept affected pain management decisions because of perceived importance of pain control and perceived duty to provide analgesics. The subjectivity of pain added another layer of complexity as nurses responded to the patient's expression of pain from within the milieu of the unit culture and their unique self-concept. Conclusion: Understanding the complexity of factors that influence nurses' postoperative pain management provides clinical nurses and nursing leaders with directions for future education and research, guided by the goal of continued improvement in pain management in the challenging setting of fast-track surgeries. [ABSTRACT FROM AUTHOR]

• Reflection can be seen as a useful tool to enable the practitioner to explore the everyday world of clinical practice. This paper reviews the background to reflection and its relevance to nursing in reducing the theory — practice gap and its role in generating theory from practice. • Exemplars from clinical practice are reflected upon and Carper's (1978) 'Patterns of Knowing' are used as a framework to identify nursing knowledge embedded in practice. • The process of reflection in critically discussed in the author's experience. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "The Relevance of Scholarship for Nursing Research and Practice," by A. Kitson in a 2006 issue.