Barriers to nurse-led pain management for adult patients in intensive care units: An integrative review

Impact of implementing the critical-care pain observation tool in the adult intensive care unit: A nonrandomised stepped-wedge trial

BACKGROUND

Approximately 70% of patients in intensive care units (ICUs) experience untreated pain, often due to severe patient conditions and communication barriers.

AIM

The aim of this study was to implement the Critical-Care Pain Observation Tool (CPOT) to improve pain assessment in patients unable to self-report pain in the ICU.

METHOD

A stepped-wedge trial was conducted in six adult ICUs in Saudi Arabia between February and June 2022. The sequential transition of ICU clusters occurred in February 2022, from control to intervention, until all ICUs were exposed to the intervention. The primary outcome was the number of pain assessments, whereas the secondary outcomes were reassessments. Other outcomes were length of stay, mechanical ventilation duration, and administered doses of sedatives and analgesic agents. Statistical analyses were performed using the Statistical Analysis Software v9.4.

RESULTS

A total of 725 patients unable to self-report pain were included; 65% (n = 469) were male with an average age of 55 years. Implementing CPOT showed a significant increase in the number of pain assessments (rate ratio: 1.77, 95% confidence interval: 1.45, 2.16, p < 0.001) and reassessments (rate ratio: 13.99, 95% confidence interval: 8.14, 24.02, p < 0.001) between intervention and control conditions. There was no significant effect on the ICU length of stay, mechanical ventilation duration, and the amount of sedation (midazolam, propofol, and ketamine) and analgesia (fentanyl) administered.

CONCLUSION

The study indicates that the implementation of the CPOT increased the frequency of pain assessment and reassessment. However, the impact on patient outcomes remains inconclusive. Further investigations focussing on CPOT as the primary pain scale are necessary to determine its holistic impact on patient outcomes over the long term.

TRIAL REGISTRATION

NCT05488834.

CLINICAL TRIAL REGISTRATION NUMBER

This study was registered with the U.S. National Library of Medicine (ClinicalTrial.gov, NCT05488834).

Chinese Version of the Nonverbal Pain Assessment Tool: Critical Patient Reliability and Validity

AIMS AND OBJECTIVES

To translate and validate the Nonverbal Pain Assessment Tool.

BACKGROUND

Timely assessment of the pain degree of nonverbal intensive care unit (ICU) patients can provide humanistic care. However, there is a lack of pain assessment tools that can meet the needs of patients who cannot use language in ICUs in China.

DESIGN

A cross-sectional survey.

METHODS

We conducted forward-backward translation of the Nonverbal Pain Assessment Tool. A total of 300 critically ill patients in the intensive care unit who could not communicate verbally completed the Chinese version of the Nonverbal Pain Assessment Tool and the Critical Care Pain Observation Tool. Exploratory and confirmatory factor analyses were performed to verify structural validity, and content validity and reliability analyses were also conducted.

RESULTS

The Nonverbal Pain Assessment Tool demonstrated high internal consistency (α = 0.901) and interrater reliability (intraclass correlation coefficient = 0.981), with good split-half reliability. Content validity was established through acceptable item-level content validity index and scale-level content validity index scores. Exploratory factor analysis showed a single factor explaining 71.79% of total variance, and confirmatory factor analysis confirmed good model fit. The Spearman rank correlation coefficient was 0.917 between the Nonverbal Pain Assessment Tool and the Critical Care Pain Observation Tool. The Chinese Nonverbal Pain Assessment Tool demonstrated significant differences in scores between different states of consciousness and illness severity, supporting its known-groups validity.

CONCLUSION

The Chinese version of the Nonverbal Pain Assessment Tool is a reliable and valid tool for nonverbal pain assessment in ICU patients in China.

RELEVANCE TO CLINICAL PRACTICE

The Chinese version of the Nonverbal Pain Assessment Tool can assess the pain of patients who cannot use language in ICU, which provides a new valuable assessment tool for Chinese clinicians and nurses in pain assessment and management.

REPORTING METHOD

Our study followed the STROBE Checklists.

PATIENT OR PUBLIC CONTRIBUTION

Patients actively cooperated and participated in data collection during the implementation of the study.

Knowledge, attitudes, and perceived barriers regarding pain assessment and management among Thai critical care nurses: A cross-sectional study

BACKGROUND

Pain is a distressing problem which commonly occurs among critically ill patients. Nurses' knowledge of, attitudes, and perceived barriers to pain assessment and management can influence the effectiveness of nursing care.

OBJECTIVE

To explore the current knowledge of, attitudes, and perceived barriers to pain assessment and management among Thai critical care unit nurses.

METHODS

A cross-sectional survey conducted between November 2022 and January 2023 among 158 Thai nurses working in one of eight adult critical care units in a tertiary hospital, evaluated their knowledge of, attitudes, and perceived barriers to pain assessment and management.

RESULTS

Nurses possessed inadequate knowledge and negative attitudes regarding pain assessment and management. The most important barrier to pain assessment and management was "patients are unable to communicate their pain". The results showed a significantly weak positive correlation between nurses' attitudes toward pain assessment and management age (r = 0.26, p = 0.001), year of ICU experience (r = 0.29, p < 0.001), and obtaining a certificate in intensive care nursing (r = 0.37, P < 0.001).

CONCLUSIONS

Thai critical care unit nurses possessed inadequate knowledge and negative attitudes. Further training and education regarding pain assessment and management could include case studies or simulation and immersive virtual reality to improve critical care unit nurses' knowledge and attitudes as well as identifying potential barriers to pain assessment and management in the critical care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

The implications for clinical practice recommend that continued quality assurance procedures should be implemented and maintained to evaluate the effectiveness of current pain assessment practices. Additionally, the perceived barriers to effective pain assessment and management should be considered and managed not only through continued education and training but could include using nursing case review, morbidity and mortality data identifying those patients that experience chronic pain post-ICU discharge.

Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review

AIM

The utility and uptake of pain management interventions across intensive care settings is inconsistent. A rapid realist review was conducted to synthesise the evidence for the purpose of theory building and refinement.

DESIGN

A five-step iterative process was employed to develop project scope/ research questions, collate evidence, appraise literature, synthesise evidence and interpret information from data sources.

METHODS

Realist synthesis method was employed to systematically review literature for developing a programme theory.

DATA SOURCES

Initial searches were undertaken in three electronic databases: MEDLINE, CINHAL and OVID. The review was supplemented with key articles from bibliographic search of identified articles. The first 200 hits from Google Scholar were screened.

RESULTS

Three action-oriented themes emerged as integral to successful implementation of pain management interventions. These included health facility actions, unit/team leader actions and individual nurses' actions.

CONCLUSION

Pain assessment interventions are influenced by a constellation of factors which trigger mechanisms yielding effective implementation outcomes.

IMPLICATIONS

The results have implications on policy makers, health organisations, nursing teams and nurses concerned with optimising the successful implementation of pain management interventions.

IMPACT

The review enabled formation of a programme theory concerned with explaining how to effectively implement pain management interventions in intensive care.

REPORTING METHOD

This review was informed by RAMESES publication standards for realist synthesis.

PUBLIC CONTRIBUTION

No patient or public contribution. The study protocol was registered in Open Science Framework. 10.17605/OSF.IO/J7AEZ.

Evaluating the relationship between pain empathy, knowledge and attitudes among nurses in North China: a cross-sectional study

BACKGROUND

Effective pain management is closely related to nurses' knowledge, attitudes and empathy regarding pain. Nursing educators and managers should understand the relationship between nurses' pain management knowledge, attitudes and empathy level, and take targeted measures accordingly. Currently, there is limited study exploring the relationship between pain empathy and pain knowledge and attitudes among nurses in North China.

OBJECTIVES

The purpose of this study was to investigate the level of nurses' pain management knowledge and attitudes and pain empathy, to analyze the factors influencing pain empathy, and to explore the relationship between these two variables.

DESIGN

This study was a quantitative, descriptive-correlation design.

SETTING AND PARTICIPANTS

The study population was registered nurses in North China, the sample included 177 registered nurses in North China.

METHODS

Data were collected with the "General data questionnaire", "Knowledge and attitudes survey regarding pain" (KASRP) and the "Empathy for pain scale" (EPS) via Wechat mini program "Questionnaire Star".

RESULTS

The 177 registered nurses completed the survey. The averege correct rate for KASRP was (51.94 ± 9.44)%, and none of the respondents achieved a percentage score of >80%. The mean score for pain empathy was (2.78 ± 0.78), the empathy reactions dimension was (2.99 ± 0.77), and the body and mind discomfort dimension was (2.71 ± 0.80). The results of multiple stepwise linear regression showed that whether they had received empathy training, whether they had greater trauma or severe pain and whether they had negative emotions were independent influencing factors for EPS scores. Pearson correlation analysis showed that KASRP scores were positively correlated with EPS scores (r = 0.242, P < 0.05).

CONCLUSIONS

The pain knowledge and attitudes of nurses in North China are far from optimal. Nurses have a relatively low accuracy rate in areas such as medication knowledge, assessment of patient pain based on case studies, and handling PRN prescriptions. Nursing educators and administrators need to design some pain management courses in a targeted manner. Nurses' empathy for pain was at a moderate level. Pain empathy was positively correlated with pain knowledge and attitudes, suggesting that empathy for pain can be developed postnatally.