Nurses' Assessment Practices of Pain Among Critically Ill Patients

European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

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.

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

OBJECTIVE

This integrative review sought to identify and synthesise quantitative and qualitative evidence on barriers to pain management in adult intensive care units (ICUs).

BACKGROUND

Pain is experienced by 58% of adult ICU patients, which leads to consequences such as decreased healing and delirium. Managing pain effectively is an integral part of the critical care nurse's role.

METHODS

An integrative review was conducted based on Whittemore and Knafl's approach. Peer-reviewed research articles were sourced from five databases. Included articles were limited to those published in English and Arabic. The quality of included papers was evaluated using the Mixed Methods Appraisal Tool (MMAT). Identified barriers to pain management in adult ICUs were mapped onto the components of the COM-B model. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Nine hundred and ninety-one papers were identified; 19 studies met the inclusion criteria. Seventeen studies focused on pain management from the perspective of nurses, whereas the remaining two focused on the perspectives of patients and nurses. Using the MMAT, two studies were rated 5 stars (out of 5), nine studies were rated 4 stars, seven studies were rated 3 stars, and one study was rated 2 stars. Lack of knowledge and skills was found to be psychological capability barriers, while nurse dependency on following doctor's orders, poor staffing levels, lack of pain assessment skills, and lack of education were barriers mapped to physical capability. Opportunity was represented by three barriers: inadequate documentation of pain and shortage of nurses were mapped to the physical opportunity, and poor communication to the social opportunity. Nurses' beliefs towards pain assessment were mapped to reflective motivation.

CONCLUSIONS

The findings of this study suggest that knowledge, nursing beliefs, insufficient numbers of nursing staff, lack of documentation, and lack of communication commonly affect pain management in adult ICUs.

PROSPERO REGISTRATION

CRD42020179913.

Nurses' assessment and management practices of pain among intensive care patients in King Khalid Hospital, Kharj, Riyadh

Background

Pain is a disagreeable combination of sensory and emotional sensations. Employing behavioral pain assessment tools is strongly associated with improved identification of pain.

Purpose

The main purpose of the study is to investigate Nurses' Assessment and Management Practices of Pain among Intensive Care Patients in King Khalid Hospital, Kharj, Riyadh.

Materials and methods

A self-administered questionnaire was employed in a descriptive cross-sectional study. The study focused on nurses employed in the intensive care unit at King Khalid Hospital in Al-Kharj Province. The researchers utilized convenience sampling to recruit participants. Out of the total 48 nurses approached 45 of them provided responses, leading to a response rate of 94%. The Critically Ill questionnaire was utilized to gather information regarding the treatment and evaluation of pain in patients who were in critical condition. Descriptive statistics and inferential statistics were employed to analyze the collected data.

Principal results

it was found that 88% of them utilized instruments to evaluate pain in patients who could express themselves. Among these instruments, the numeric rating scale was the most commonly employed. Furthermore, 77% of the nurses (35 in total) used a pain assessment tool for patients who were unable to communicate, with the Adult Nonverbal Pain Scale being the most frequently used tool in this case. The nurses' perception of the significance of pain assessment was positively associated with the regular utilization of pain assessment tools. Additionally, the nurses considered the use of pain assessment tools with patients who could communicate as more important compared to using such tools with patients who could not communicate.

Conclusions

Most ICU nurses utilized nurses' pain assessment instruments to assess the discomfort levels of both patients who could communicate and those who couldn't express themselves effectively. By employing such tools, nurses can improve patient outcomes, ensure effective pain management, and demonstrate a high standard of professional care.

The Association between Socio-Demographic Characteristics and Using Pain Assessment Tools among Critically Ill Patients

Background and Objectives: Pain is still undertreated among ICU patients, especially cognitively impaired patients. Nurses play a crucial role in their management. However, previous studies found that nurses had insufficient knowledge about pain assessment and management. Some nurses' socio-demographic characteristics, such as being female; age; years of experience; type of unit, either medical or surgical; education level; years of nursing experience; qualification; position; and hospital level, were found to be associated with their practices of pain assessment and management. This study aimed to examine the association between nurses' socio-demographic characteristics and the use of pain assessment tools for critically ill patients. Materials and Methods: A convenience sample of 200 Jordanian nurses responded to the Pain Assessment and Management for the Critically Ill questionnaire to achieve the study's aim. Results: The type of hospital, academic qualification, years of experience as a critical care nurse, and hospital affiliation were significantly associated with increased use of self-report pain assessment tools for verbal patients, while the type of hospital and hospital affiliation was significantly associated with an increased use of observational pain assessment tools for nonverbal patients. Conclusion: Examining the association between socio-demographic characteristics and the use of pain assessment tools for critically ill patients is essential for quality pain practice.

Translation, cultural adaptation and recommendations for clinical implementation of the Abbey Pain Scale to a Swedish dementia care context

AIM

To translate and culturally adapt the APS for people with end-stage dementia in various care settings in Sweden and to investigate factors important for clinical implementation.

DESIGN

Qualitative study design with interviews with care staff.

METHODS

After an initial discussion of concepts, the Abbey Pain Scale was translated into Swedish and back into English to check for accuracy. The resulting Swedish version was then revised and culturally adapted through a series of interviews with nursing assistants, nurses and physicians (n = 11) to develop the final Swedish version.

RESULTS

A Swedish version of the Abbey Pain Scale was developed. The instrument was considered straightforward and easy to use, but needed adjustments to make it more comprehensible to staff with less education in health care or with other first languages than Swedish. It was found important to carefully introduce new staff members to the instrument, to ensure they understand all the words and items.

Nurses’ Pain Assessment Practices for Cognitively Intact and Impaired Older Adults in Intensive Care Units

Introduction

Pain is still under-recognized and undertreated among intensive care unit (ICU) patients, such as those being intubated or with dementia, cognitive impairments, or communication deficits due to inability to self-report. This study aimed to describe nurses' pain assessment practices for cognitively intact and impaired older adult ICU patients.

Methods

A descriptive correlational study of a convenience sample of 200 registered nurses was conducted in private, public, and university-affiliated hospitals in Irbid, Jordan. Descriptive statistics, such as mean, standard deviation, and frequency, were used to analyze the study data.

Results

Statistically significant differences were found in the proportion of nurses who assessed and documented pain every 1–4 h in cognitively intact patients than those with cognitive impairment (n = 67, 63.21% vs. n = 39, 36.79%), p = 0.002, compared to the proportion of nurses who never assessed and document pain in cognitively impaired patients than those without cognitive impairment (n = 38, 76.0% vs. n = 12, 24%), p < 0.001.

Discussion/Conclusion

Our study results showed that the majority of participant nurses felt that the use of pain assessment tools for cognitively intact and impaired older adult ICU patients to self-report is somewhat not at all important. This study also reported that nurses perceived themselves as the individuals who accurately rate the pain in cognitively intact patients, followed by the patients themselves.

A Comparison between Three Different Techniques Considering Quality Skills, Fatigue and Hand Pain during a Prolonged Infant Resuscitation: A Cross-Over Study with Lifeguards

The aim of the study was to compare the quality of CPR (Q-CPR), as well as the perceived fatigue and hand pain in a prolonged infant cardiopulmonary resuscitation (CPR) performed by lifeguards using three different techniques. A randomized crossover simulation study was used to compare three infant CPR techniques: the two-finger technique (TF); the two-thumb encircling technique (TTE) and the two-thumb-fist technique (TTF). 58 professional lifeguards performed three tests in pairs during a 20-min period of CPR. The rescuers performed compressions and ventilations in 15:2 cycles and changed their roles every 2 min. The variables of analysis were CPR quality components, rate of perceived exertion (RPE) and hand pain with numeric rating scale (NRS). All three techniques showed high Q-CPR results (TF: 86 ± 9%/TTE: 88 ± 9%/TTF: 86 ± 16%), and the TTE showed higher values than the TF (p = 0.03). In the RPE analysis, fatigue was not excessive with any of the three techniques (values 20 min between 3.2 for TF, 2.4 in TTE and 2.5 in TTF on a 10-point scale). TF reached a higher value in RPE than TTF in all the intervals analyzed (p < 0.05). In relation to NRS, TF showed significantly higher values than TTE and TTF (NRS minute 20 = TF 4.7 vs. TTE 2.5 & TTF 2.2; p < 0.001). In conclusion, all techniques have been shown to be effective in high-quality infant CPR in a prolonged resuscitation carried out by lifeguards. However, the two-finger technique is less efficient in relation to fatigue and hand pain compared with two-thumb technique (TF vs. TTF, p = 0.01).

Nurses' Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review

Aim

This review aims to examine nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients.

Background

Pain is one of the worst memories among critically ill patients. However, pain among those patients is still undertreated due to several barriers that impede effective management. Therefore, addressing the perceived barriers and facilitators to pain assessment management among critical care nurses is crucial.

Methods

A systematic search of pain assessment and management in critical care patient-relevant literature from four databases was done, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

The barriers and facilitators were categorized into four groups: nurse-related, patient-related, physician-related, and system-related. The most frequently reported barriers in this study included nurses’ lack of knowledge regarding the use of pain assessment tools, patients’ inability to communicate, physicians’ prescription of analgesics being independent of pain scores evaluation, and absence of standardized guidelines and protocols for pain evaluation and control. For the facilitators, the most reported ones include ongoing education and professional training related to pain assessment and management, patients’ ability to self-report pain, effective collaboration between physicians and nurses, and productive discussion of patients’ pain scores during nurse-to-nurse handovers.

Conclusion

Various barriers and facilitators to pain assessment and management were identified and examined in this review. However, future research is still needed to further investigate these barriers and facilitators and examine any other potential associated factors among critical care nurses.

Relevance to Clinical Practice

The findings of our study could help hospital managers in developing continuous education and staff development training programs on assessing and managing pain for critical care patients. Also, our findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat pain in critical care patients.

Exploring the Face Validity of the Pain Numeric Rating Scale Among Healthcare Providers

ABSTRACT

BACKGROUND: Healthcare providers (HCPs) use the numeric rating scale (NRS) under the assumption that it provides reliable information from which to make decisions regarding analgesic administration. METHODS: We explored the face validity of the NRS using a prospective single-blinded observational design. Pre and post NRS scores were obtained from HCPs who submerged their hand in a bucket of ice water (pain stimulus). RESULTS: Despite a consistent similar pain source, individual HCPs rated their pain very differently (range, 2-10), and there was a significant difference in self-estimated pain tolerance (μ = 7.06 [SD, 1.43]) and actual pain scores (μ = 6.35 [SD, 2.2]; t = 4.08, P < .001). CONCLUSION: The findings indicate a limitation in the face validity of the NRS. The high variance in NRS scores reaffirms the subjectivity of pain perception and brings into question the utility of using NRS scores when determining analgesic dosages.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.

A Qualitative Study of Nurses' Perceptions of Narcotic Administration after Subarachnoid Hemorrhage

BACKGROUND

Nearly every patient admitted to a neuroscience intensive care unit (ICU) will experience pain and nurses are tasked with analgesic administration. Within the setting of the ongoing opioid epidemic it is not well understood how nurses meet the need to alleviate pain while individualizing analgesic administration.

AIMS

This qualitative study used a phenomenological approach to determine nurses' perceptions in pain management of patientswith subarachnoid hemorrhage (SAH).

DESIGN

Prospective qualitative inquiry using phenomenology SETTING: The study was conducted in a neuroscience intensive care unit at a university hospital.

PARTICIPANTS

Nine neuroscience intensive care unit nurses were enrolled using snowball sampling.

METHODS

Saturation was reached after nine individual nurse interviews. Hermeneutic cycling analysis was used throughout interviews and codes and themes were developed throughout the interview process. Rigor was established using triangulation, rich and thick descriptions, and member checks.

RESULTS

Emerging themes included discernment and hesitation. Discernment is supported by codes such as: "nursing judgement" and "follow the orders." Hesitation is supported by codes such as "clouded exam" and "over sedation." Eight nurses made references to hesitation of administering opioids due to the perception that it would cause a poorer neurological exam. All nurses described a reliance on education, experience, or intuition to guide their decision to administer opioids along with using approved pain scales. Themes were confirmed by member checks, which prompted slight modifications to coding.

CONCLUSIONS

Results of this study support that nurses do express apprehension in administering opioids to patients with (SAH). This apprehension leads to hesitation to administer the medication and a thought out discernment process.

Barriers and enablers of intensive care unit nurses' assessment and management of patients' pain

BACKGROUND

Inadequate pain assessment and management is a problem in hospitalized patients that impairs their well-being. Intensive care unit nurses' pain practices are affected by several barriers and enablers.

AIMS AND OBJECTIVES

To explore intensive care unit nurses' pain education, perceived barriers, and enablers of pain assessment and management practices among critically ill patients.

DESIGN

A cross-sectional descriptive design was used in the study.

METHODS

Convenience sampling technique was used, including 300 nurses recruited from 22 intensive care units in Jordan. The Pain Assessment and Management for Critically Ill Adults Survey was used to collect data. Descriptive statistics, spearman correlation, and chi-square tests were used to analyse the data.

RESULTS

Only 127 (42.3%) of the nurses reported moderate to extreme satisfaction about receiving professional development education related to pain among critically ill patients. Nurse workload (65.3%), patient instability (54.4%), patient inability to communicate (53.3%), and sedation interfering with pain assessment (50%) were reported by nurses as the most frequent barriers impacting pain assessment and management. Enablers of pain assessment and management reported most frequently were "pain assessment and management is a unit priority" (63.7%), "enthusiastic and motivated staff" (61.3%), "protocols and guidelines are in use" (57.4%), and "standardized assessment tools are in use" (57%). Some barriers and enablers to pain assessment and management and pain education differed significantly according to nurses' experience and hospital type.

CONCLUSION

This study identified a range of enablers and barriers to pain assessment and management practices perceived by intensive care unit nurses. Nurse workload was an important barrier while making pain assessments, and management a unit priority was an important enabler for pain assessment and management. Frequent assessment of barriers and enablers of pain assessment and management is needed in critical care units to improve nurses' practices. Pain education should be included in the hospitals' continuous educational program.