Critical Care Nurses’ Pain Assessment and

Management Practices: A Survey in Canada 

Louise Rose, RN, PhD;
 
Orla Smith, RN, MN, CNCC(C);
 
Céline Gélinas, RN, PhD;
 
Lynn Haslam, RN, MN, NP(Hons);
 
Craig Dale, RN, BScN(Hons), CNCC(C);
 
Elena Luk, RN, BScN(Hons), CNCC(C);
 
Lisa Burry, PharmD;
 
Michael McGillion, RN, PhD;
 
Sangeeta Mehta, MD, FRCP;
 
Judy Watt-Watson, RN, PhD
Am J Crit Care (2012) 21 (4): 251–259.
https://doi.org/10.4037/ajcc2012611
 Share IconShare 
 Tools IconTools 
 Get Permissions
Background
Regular pain assessment can lead to decreased incidence of pain and shorter durations of
mechanical ventilation and stays in the intensive care unit.
Objectives
To document knowledge and perceptions of pain assessment and management practices
among Canadian intensive care unit nurses.
Methods
A self-administered questionnaire was mailed to 3753 intensive care unit nurses identified
through the 12 Canadian provincial/territorial nursing associations responsible for
professional regulation.
Results
A total of 842 nurses (24%) responded, and 802 surveys could be evaluated. Nurses were
significantly less likely (P < .001) to use a pain assessment tool for patients unable to
communicate (267 nurses, 33%) than for patients able to self-report (712 nurses, 89%).
Significantly fewer respondents (P < .001) rated behavioral pain assessment tools as
moderately to extremely important (595 nurses, 74%) compared with self-report tools
(703 nurses, 88%). Routine (>50% of the time) discussion of pain scores during nursing
handover was reported by 492 nurses (61%), and targeting of analgesia to a pain score or
other assessment parameters by physicians by 333 nurses (42%). Few nurses (n = 235;
29%) were aware of professional society guidelines for pain assessment and management.
Routine use of a behavioral pain tool was associated with awareness of published
guidelines (odds ratio, 2.5; 95% CI, 1.7–3.7) and clinical availability of the tool (odds ratio,
2.6; 95% CI, 1.6–4.3).
Conclusions
A substantial proportion of intensive care unit nurses did not use pain assessment tools
for patients unable to communicate and were unaware of pain management guidelines
published by professional societies.

Assessing pain in critically ill adults

Stites, Mindy MSN, APRN, ACNS-BC, ACCNS-AG, CCRN, CCNS; Surprise, Jennifer
MSN, APRN, RN-BC, ACNS-BC

Author Information

Nursing Critical Care  9(4):p 36-41, July 2014. | DOI:  10.1097/01.CCN.0000451024.15197.3d

 FREE

Metrics

In Brief
It's a malicious circle when it comes to pain in the ICU. Pain that goes untreated because it's
unrecognized leads to prolonged pain and anxiety in the critically ill, which delays recovery.

Figure

Pain is a frequent source of stress in the ICU and is experienced by nearly all critically ill
patients during their stay.1 Inadequate recognition and management of pain is associated with
an increased risk of hemodynamic instability, hyperglycemia, alterations in immune system
functioning, and release of catecholamines, cortisol, and antidiuretic hormone.2

In addition, it's possible for untreated acute pain to produce neurohumoral changes, neuronal
remodeling, and long-lasting psychological and emotional stress, which may lead to
prolonged chronic pain states.3 Yet, the under treatment of pain is common in the ICUs due to
lack of recognition and concerns about the adverse effects of medications (respiratory
depression and hemodynamic compromise).4 This is especially troubling as pain and anxiety
in the critically ill are inextricably linked, with both contributing to poor outcomes in the
critically ill patient.
The recent DOLOREA study highlighted the importance of pain management in the ICU by
demonstrating a reduction in the use of hypnotics, midazolam, duration of mechanical
ventilation, and ICU length of stay with a standardized assessment of pain.5

The assessment and treatment of pain is mandated by multiple regulatory bodies including
The Joint Commission, and the Centers for Medicare and Medicaid Services, and is now a
publically reported quality measure.6,7 In addition, multiple best practice organizations,
including the American Society for Pain Management Nursing (ASPMN), the Society for
Critical Care Medicine (SCCM), and the American Association of Critical Care Nurses
(AACN), have developed guidelines to arm nurses with the information needed to perform an
evidence-based approach to pain management in the critically ill (see The pathophysiology of
acute pain).8–10 The purpose of this article is to summarize the most recent evidence on the
assessment of pain in the critically ill adult and provide specific clinical practice
recommendations for critical care nurses.

Nerve function, as well as psychological, emotional, spiritual, and environmental factors, all
play a role in how pain is ultimately perceived by the patient. The variability of this process is
exemplified in the different perception of pain from one person to the next; providing further
evidence that each person's pain is subjective. Patients present with differing developmental
levels, language barriers, cognitive and emotional variances that affect the perception of pain.
These differences, combined with the complexity of critical illness, give rise to challenges in
adequately assessing and treating pain.

Clinician perception of pain

Often, it's left to the caregivers, physicians, and nurses, to determine if symptoms are
managed well. It's nurses who are at the bedside and are generally responsible for advocating
for the patient's well-being. The nurse's understanding of the patient's comfort level can help
the nurse better care for the patient and avoid under or overtreatment.

Unfortunately, clinician perception of pain is often skewed. This issue is well established
through studies over the years in which patient pain intensity reports don't correlate with the
nurses' assessments.13 A study published in 2013 amplifies this concern that nurses'
perceptions of patients' pain are underestimated compared with patient experiences.13 A study
of a cross section of 86 ICU nurses in three different hospitals was designed to describe the
nurses' perceptions of unpleasant signs and symptoms in mechanically ventilated adults. They
were asked to estimate the likelihood of the occurrence of certain unpleasant symptoms
among their patients. While previous studies have established that most ICU patients report
pain, more than half of the surveyed nurses reported that pain, anxiety, or dyspnea occurred
in less than 20% of the patients. The authors considered this to be an underestimation of pain.

With increasing complexity of technology and advances in the science of critical illness,
patients in the ICU possess varying levels of ability to report their needs. As the trend toward
minimal sedation has proceeded, the population of the ICU has changed. While some patients
may be alert and able to respond verbally, others may have varying levels of consciousness or
mental clarity. It's with these patients that the approach to pain management is most
challenging. The fact that pain exists and is perceived no matter the level of consciousness
has been established.
The critically ill patient experiences pain due to varying causes, including: disease process,
surgery, trauma, and medical interventions. The range of procedures, spanning from patient
turning and repositioning to mechanical ventilation and endotracheal suctioning, inherently
cause some level of discomfort.

Critical care patients in a landmark study done by Puntillo were asked about their pain
experiences after transfer from the ICU. A majority reported moderate-to-severe pain from
such causes as incisions, movement, coughing, suctioning, and chest tube removal.14

More recently, a multinational study of 3,851 patients in ICUs who were able to self-report,
cited chest tube removal, wound drain removal, and arterial line insertion as the most painful
procedures experienced.15 Other causes of pain in the ICU are immobility and infection.

The pain assessment hierarchy

Self-report of pain is the gold standard of pain assessment and should be the primary
assessment method in critically ill patients who're capable of providing the information to the
provider.8–10 However, many patients in the intensive care unit are incapable of self-report by
nature of their illness (shock, respiratory failure, cerebral insult) or by nature of the therapies
being provided (mechanical ventilation, sedation). Healthcare professionals are bound by
ethical principles to provide comfort to all patients whether they're able to speak for
themselves or not.10

Foremost to the approach to pain should be a plan for a systematic assessment.12 An

established and routine monitoring and assessment of pain improves treatment,
communication, and patient satisfaction. It's necessary to provide ongoing assessment not
only to determine the approach toward management, but also to evaluate the outcomes.
Within the ASPMN guidelines from 2006 are recommendations for a hierarchical approach to
the intubated and/or unconscious person unable to self-report.10 Self-report should be elicited
with every assessment for pain. The variability of consciousness in this population makes it
sometimes possible to obtain a self-report, while other times not. The ASPMN guidelines
further provide for a step-wise approach to treat pain when the self-report isn't feasible.

The next step in this hierarchical approach is to identify diagnoses or procedures that would
be considered painful in the fully conscious, verbal patient. As noted previously, many
procedures associated with critical illness are painful, some more than others. It's assumed
that the nonverbal patient also has pain due to these potential causes of pain. Pasero and
McCaffery in 2002 introduced the concept “assume pain is present” as a means of
documenting this unconfirmed pain based solely upon the fact that procedures or pathologies
exist in this patient that are normally considered painful.16

Patient behaviors may be observed as clues to pain assessment. Behaviors have been
correlated with pain intensity scales in the patient who's able to self-report.17 When
appropriate, behavioral assessment through the use of tools can help provide consistent
systematic evaluation between clinicians over time. In patients incapable of self-report, a
multitude of tools exist to identify the presence of pain. The optimal behavioral assessment
tool is valid, meaning its variables measure what it's designed to measure (pain, in this case)
and reliable, meaning that it identifies what it's intended to identify all of the time, regardless
of who administers the tool. The best tools are also highly sensitive, meaning that if pain is
present, it's detected, and specific, meaning that the tool identifies only pain and isn't subject
to interference from other clinical conditions (such as anxiety or delirium).

It's important to remember that observational pain scales require the presence of a
spontaneous, neuromuscular-mediated physical response that can be observed by a third party
in order to be effective. Therefore, patients with quadriplegia, neuromuscular disorders, and
those receiving neuromuscular blocking agents, are unable to be assessed with these tools.

Additionally, patients with significant neurologic injury, hemodynamic compromise, or

delirium were commonly excluded in the testing of these tools, making it difficult to
conclude if the tools are valid and reliable in these patient populations.21,23,28

Obtaining the perspective of the family or caregivers of the patient is another element in the
assessment of pain. While the opinion of a family member cannot be solely used as an
accurate interpretation of the patient's pain, it's important to include their opinions in the
assessment based upon their familiarity and past experiences with the patient.

Finally, if the observations made previously provide sufficient data that pain is present, an
analgesic trial may be initiated. This is because several of the behaviors (for example, body
movement, ventilator dysynchrony) found on behavioral assessment tools are nonspecific for
pain, and can indicate the presence of other conditions, such as anxiety or dyspnea.

While analgesics are initiated, the patient's behaviors are observed for any changes that would
indicate some positive response. After the analgesic trial, the continuation of the analgesic
regimen is determined based upon the response, and other goals of care. Different
medications may be more appropriate in certain situations. For example, the ASPMN
guidelines suggest weighing the risks and benefits of increasing opioids in the brain-injured
patient who needs neurologic assessments. In this case, shorter acting opioids may be used.
Similarly, nonopioid medications may be just as useful for certain types of pain without the
sedative adverse reactions.

Conclusion and implications for further research

Pain assessment in the critically ill is challenging, but exceedingly important work.
Guidelines have been put forth by three national organizations to meet the challenge of
assessing pain in this population. Within these guidelines, general recommendations for
utilization of a hierarchy of pain assessment techniques are supported, as outlined earlier.

The assessment of pain should be completed on a routine basis. Self-report of pain is the most
reliable method of pain assessment and should be attempted with all patients. In patients
undergoing potentially painful interventions (turning, endotracheal suctioning), preemptive
treatment is recommended. If self-report is unable to be obtained, the use of a behavioral
assessment tool, such as the Behavioral Pain Scale (BPS) or Critical-Care Pain Observation
Tool (CPOT) should be used. Changes in vital signs can indicate the presence of pain, but
shouldn't be used independently to determine the presence of pain. Additional methods such
as proxy reporting or attempting an analgesic trial, can be used in patients who are unable to
be assessed through behavioral assessment scales. (See Behavioral pain assessment tools.)

Since publication of the various guidelines, some issues have arisen that may benefit from
further exploration. Specifically, research has been proposed to evaluate the usefulness of
behavioral tools in patients with traumatic brain injuries. It may be deduced that since the
brain plays a role in the perception of pain, injury to the brain could pose unique assessment
challenges.

Similarly, patients receiving neuromuscular blockade or those with delirium, quadriplegia, or

significant neurologic insults (such as the comatose patient) may not exhibit typical pain
behaviors. Continued exploration into the objective study of pain using alternate techniques
may provide evidence for pain perception in these patients.

The pathophysiology of acute pain

The variability of pain perception from patient to patient is inherent in his or her own brain
activity and experiences. An understanding of basic physiology of acute pain is important to
provide the caregiver a foundation to support appropriate assessment and interventions.11 The
process of how pain occurs normally in the body is called nociception.12

Nociception involves four steps: transduction, transmission, perception, and modulation.

Transduction

The process begins with transduction, or the activation of neurons by a noxious stimulus. The
activation begins with a release of chemical mediators that result in an action potential, and
ultimately a pain impulse.

Transmission

Next, in transmission, the impulse is transmitted from the site of the noxious stimulus, along
A-delta fibers and C fibers across the spinal cord at the dorsal horn, and to the brain.

Perception

It's in the brain where pain perception becomes complex. Several areas of the brain play a
role in the awareness of pain: the limbic system, responsible for behavior and emotional
responses; the reticular system where motor and autonomic responses are formed; and the
somatosensory cortex where memory and cognitive recognition of pain takes place.
Therefore, pain is influenced through sensory input, affective response, and cognitive
evaluation learned over time.11

Modulation

The fourth step in the process of nociception, modulation, refers to the amplification or
reduction of pain signal intensities that play a role in changing the person's reaction to the
pain.

Behavioral pain assessment tools

In recent years, several systematic reviews have been completed to identify the most valid
and reliable tool for use in critically ill adults. In all of these reviews, the BPS and the CPOT
have been identified as the superior tools.9,18,19
The BPS is designed for mechanically ventilated patients and consists of three observational
domains (facial expression, upper limb movements, and compliance with mechanical
ventilation) that are scored from 1 to 4, with higher numbers indicating higher levels of
discomfort.

The total BPS score can range from 3 (no pain) to 12 (maximum pain). The BPS has been
tested extensively in critically ill patients and found to be valid and has demonstrated high
interrater agreement, and good internal consistency. From a practice standpoint, the BPS is
easy to use and takes an average of 2 to 5 minutes to complete.20–25

The CPOT is designed for use in both intubated and nonintubated critical care patients. Four
domains, including facial expression, body movements, muscle tension, and ventilator
compliance or vocalization (extubated patients), are scored from 0 to 2, with a total score
ranging from 0 (no pain) to 8 (maximal pain).

The CPOT was originally developed in French, with subsequent versions being tested in
English and Spanish.26–28 Like the BPS, the CPOT has proven to be valid and reliable.28 In
testing, the CPOT has demonstrated a sensitivity of 86% and a specificity of 78% during
painful procedures, with the sensitivity decreasing to 83% prior to a painful procedure and
63% following the painful procedure. Specificity remained high at 83% and 97%,
respectively.30 In clinical practice, 100% of the nurse respondents reported that the CPOT
directives were clear and that the tool was easy to use. The majority also reported that the
CPOT was quick to use (78%), and that they would recommend the use of the CPOT
routinely in practice (72.7%).31

There are several limitations that need to be acknowledged when a BPS is used. It's important
to note that both tools have been unable to demonstrate a consistent correlation with the
patient's self-report of pain, especially when the patient was scored as having “no pain” on
the BPS or CPOT. In addition, an increasing score on a behavioral pain assessment tool
doesn't equate to an increasing severity of pain as on a 0 to 10 self-report tool.12 Clinical
nurses are encouraged to use these tools only to indicate the presence of pain and provide
analgesia when indicated.

Nurse's Evaluation of a Pain Management

Algorithm in Intensive Care Units
Author links open overlay panelBrita
F. Olsen PhD    , Tone Rustøen PhD    , Berit T. Valeberg PhD   
∗ † ‡ § ‖ ¶

Show more
Add to Mendeley
Share
Cite
https://doi.org/10.1016/j.pmn.2020.05.006Get rights and content

Abstract

Background
Many patients have memories of pain during intensive care unit stay. To improve
pain management, practice guidelines recommend that pain management should be
guided by routine pain assessment and suggest an assessment-driven, protocol-
based, stepwise approach. This recommendation prompted the development of a
pain-management algorithm.

Aim
Evaluate the feasibility and clinical utility of this algorithm.

Design
A descriptive survey.

Settings
One medical/surgical intensive care unit, one surgical intensive care unit, and
one postanesthesia care unit at two hospitals in Norway.

Participants/Subjects
Nurses working at the three units.

Methods
A pain-management algorithm, including three pain assessment tools and a guide to
pain assessment and pain management, was developed and implemented in three
intensive care units. Nurses working at the three units (n = 129) responded to a
questionnaire regarding the feasibility and clinical utility of the algorithm used.

Results
Our results suggested that nurses considered the new pain-management algorithm to
have relatively high feasibility, but somewhat lower clinical utility. Less than half of
respondents thought that pain treatment in clinical practice had become more
targeted using the tree pain-assessment tools (45%) and the algorithm for pain
assessment and pain management (24%).

Conclusions
Pain-management algorithms may be appropriate and useful in clinical practice.
However, to increase clinical utility and to achieve more targeted pain treatment,
more focus on pain-treatment actions and reassessment of patients’ pain is needed.
Further focus in clinical practice on how to implement an algorithm and more focus
on pain-treatment action and reassessment of patients’ pain is needed.