Behavioral Pain Scale - translation, reliability, and validity in a Swedish context

Nurses' perceptions of patient pain, delirium, and sedation assessments in the intensive care unit: A qualitative study

BACKGROUND

Pain, delirium, and sedation should be assessed routinely using validated assessment scales. Inappropriately managed pain, delirium, and sedation in critically ill patients can have serious consequences regarding mortality, morbidity, and increased healthcare costs. Despite the benefits of a bundled approach to pain, delirium, and sedation assessments, few studies have explored nurses' perceptions of using validated scales for such assessments. Furthermore, no studies have examined nurses' perceptions of undertaking these assessments as a bundled approach.

OBJECTIVES

The objective of this study was to explore nurses' knowledge, perceptions, attitudes, and experiences regarding the use of validated pain, delirium, and sedation assessment tools as a bundled approach in the intensive care unit (ICU).

METHODS

A qualitative exploratory descriptive design was adopted. We conducted four focus groups and 10 individual interviews with 23 nurses from a 26-bed adult ICU at an Australian metropolitan tertiary teaching hospital. Data were analysed using thematic analysis techniques.

FINDINGS

Four themes were identified: (i) factors impacting nurses' ability to undertake pain, delirium, and sedation assessments in the ICU; (ii) use, misuse, and nonuse of tools and use of alternative strategies to assess pain, delirium, and sedation; (iii) implementing assessment tools; and (iv) consequences of suboptimal pain, delirium, and sedation assessments. A gap was found in nurses' use of validated scales to assess pain, delirium, and sedation as a bundled approach, and they were not familiar with using a bundled approach to assessment.

CONCLUSION

The practice gap could be addressed using a carefully planned implementation strategy. Strategies could include a policy and protocol for assessing pain, delirium, and sedation in the ICU, engagement of change champions to facilitate uptake of the strategy, reminder and feedback systems, further in-service education, and ongoing workplace training for nurses.

Pain management in surgical intensive care patients: A retrospective observational research

Sepsis and septic shock are the most common causes of death in non-cardiac surgical intensive care units (ICU). Adequate analgesia is essential to achieve positive outcomes. There were differences in pain management between patients with and without sepsis or septic shock. The release of inflammatory mediators, especially cytokines, in sepsis or septic shock decreases the pain threshold. Septic intensive care patients probably require higher doses of opioids than do non-septic patients. A retrospective observational study was carried out in an anesthesiologic intensive care unit from January 1, 2014 to June 30, 2016. Patients were divided into 4 groups according to the following criteria: sepsis ("yes/no" and communication ability "yes/no"). After adjusting for the number of cases using the pairing method, a total of 356 patients were recruited. The endpoint of our study was defined as the "total opioid dose". Statistical evaluations were performed using t tests and 2-factor analysis of variance. There was a significant difference in opioid doses between communicative and non-communicative ICU patients F(1, 352) = 55.102, P < .001). This effect was observed in the ICU patients with and without sepsis. The mean sufentanil dose was significantly higher in non-communicative patients than in communicative patients group (E(1, 352) = 51.435, P < .001, partial ƞ2 = 0.144). The effect of higher opioid- (F(1, 352) = 1.941, P = .161) and sufentanil (F(1, 352) = 1.798, P = .342) requirement was not statistically significant due to sepsis. The hypothesis that sepsis decreases the pain threshold could not be proven in this study. The effect of a higher opioid requirement is not directly caused by sepsis but by communication ability. Furthermore, we were able to show through our investigations and especially through the data of the pain recording instruments that the septic and non-septic intensive care patients receive sufficient pain therapy treatment in our ICU. Regular pain evaluations should be performed on patients in the ICUs who are able to communicate and those who are not.

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.

Behavioral Pain Scale and Critical Care Pain Observation Tool for pain evaluation in orotracheally tubed critical patients. A systematic review of the literature

Objective:

To describe the appropriateness of two behavioral scales, the Behavioral Pain Scale and the Critical Care Pain Observation Tool, for pain assessment in orotracheally intubated patients admitted to intensive care units.

Method:

Using the methodology recommended by the Cochrane Center, a systematic literature review was performed in the electronic database EBSCO Host (CINAHL Complete; MEDLINE® Complete; Nursing & Allied Health Collection: Comprehensive; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Cochrane Methodology Register; Library, Information Science & Technology Abstracts; MedicLatina). Two searches were conducted using the following English terms in the search field: “behavioral pain scale” AND “critical care pain observation tool” AND “behavioral pain scale” OR “critical care pain observation tool”. Two independent reviewers performed the critical evaluation and data extraction and synthesis.

Results:

Fifteen studies were included that showed that the Behavioral Pain Scale and the Critical Care Pain Observation Tool are valid and reliable scales for pain assessment in orotracheally intubated patients admitted to the intensive care unit. The scales showed similar psychometric properties and good reliability.

Conclusion:

Both scales are adequate for assessing pain in orotracheally intubated patients admitted to intensive care units; however, they exhibit limitations in specific populations, such as trauma, burn and neurosurgical patients. Further studies on the subject and in specific populations are suggested.

A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults

This is an updated, comprehensive review of the psychometric properties of behavioral pain assessment tools for use with noncommunicative, critically ill adults. Articles were searched in 5 health databases. A total of 106 articles were analyzed, including 54 recently published papers. Nine behavioral pain assessment tools developed for noncommunicative critically ill adults and 4 tools developed for other non-communicative populations were included. The scale development process, reliability, validity, feasibility, and clinical utility were analyzed using a 0 to 20 scoring system, and quality of evidence was also evaluated. The Behavioral Pain Scale, the Behavioral Pain Scale-Nonintubated, and the Critical-Care Pain Observation Tool remain the tools with the strongest psychometric properties, with validation testing having been conducted in multiple countries and various languages. Other tools may be good alternatives, but additional research on them is necessary.

To assess patients pain in intensive care: developing and testing the Swedish version of the Behavioural Pain Scale

OBJECTIVES

The Behavioural Pain Scale has previously been translated into Swedish and psychometrically tested. One of the domains- 'compliance with ventilation'- did not show equally as good psychometric proprieties as the other domains, which led to the question whether a development of that domain would be beneficial. This study aimed to develop the domain of 'breathing pattern' in the Swedish version of the Behavioural Pain Scale and then test the instrument for discriminant validity, inter-rater reliability and criterion validity.

METHOD

The domain 'breathing pattern' was developed and included when the Swedish version of the Behavioural Pain Scale was psychometrically tested in 360 paired assessments.

RESULTS

The instrument showed discriminant validity through a significant positive change on the scale before and during turning and inter-rater reliability with an absence of significant disagreement on the scale between the paired assessments. The developed domain had a better result in discriminant validity than the original domain. The instrument also showed higher sensitivity in discriminating pain compared to assessment without an instrument.

CONCLUSION

The Swedish version of the Behavioural Pain Scale, with a developed domain for 'breathing pattern' showed to be a reliable instrument for pain assessment in the adult intensive-care patient.

Evaluation of Observational and Behavioural Pain Assessment Tools in Nonverbal Intubated Critically Adult Patients after Open - Heart Surgery: A Systematic Review

BACKGROUND

Over 70% of patients hospitalised in an intensive care unit (ICU) often experience moderate to severe pain due to pre-existing diseases, trauma, surgery, aggressive procedures, and routine ICU care. Many patients hospitalised in ICU are not able to speak and express their pain due to various causes, including mechanical ventilation, reduced consciousness, and administration of sedative drugs. Therefore, the use of observational and behavioural pain tools is recommended in this group of patients given their inability to express pain.

AIM

To examine the existing observational and behavioural tools for assessment of in Nonverbal Intubated Critically Adult Patients after Open-Heart Surgery.

METHODS

A systematic review of available observational and behavioural tools for assessment of pain was undertaken using the COSMIN checklist. A literature search was conducted using the following databases: Ovid, Science Direct, Scopus, PubMed, and CINHAL databases, Google Scholar search engine as well as Persian resources Sid, Magiran, Iran doc, and IranMedex up to the end of 2017 were reviewed.

RESULTS

A total of 47 studies that had examined five tools used in intensive care units after cardiac surgery in patients under mechanical ventilation were reviewed. Each of the five tools included behavioural and observational items, and only one tool had physiological items. All the tools had been evaluated regarding validity and reliability. In the three tools, sensitivity, specificity, responsiveness, and satisfaction were considered.

CONCLUSION

Based on available evidence and investigations, CPOT and BPS tools have good validity and reliability to be used in pain assessment in Nonverbal Intubated Critically Adult Patients after Open-Heart Surgery. The NVPS tool requires more studies to be further confirmed before the assessment of pain in this group of patients.

Psychometric Properties of the Behavioral Pain Scale in Traumatic Brain Injury

BACKGROUND

Pain assessment of patients with traumatic brain injury is a challenge because they are unable to self-report their pain experience.

AIMS

To investigate the psychometric properties of validity, reliability, and responsiveness of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in patients with traumatic brain injury.

METHODS

This was an observational, cross-sectional, repeated-measure and analytical study. This study was developed at the medical and surgical ICUs in a high-complexity public hospital at Aracaju, Sergipe, Brazil. Thirty-seven adult patients with moderate or severe TBI were included. This study was completed with 444 independent observations, a pairwise comparison, and was performed simultaneously before, during, and after eye cleaning and endotracheal suctioning of 37 adult patients with moderate to severe traumatic brain injury.

RESULTS

The BPS-Br had good internal consistency (.7 ≤ α ≤ .9), good discriminant validity (p < .001), moderate to excellent reliability based on inter-rater agreement (intraclass correlation coefficient = 0.66-1.00; κ = 0.5-1.0), and high responsiveness (0.7-1.7). The upper limbs subscale had the highest score during the nociceptive procedure (1.8 ± 0.9). Deep sedation affected the increase of grading during painful procedures (p < .001).

CONCLUSIONS

Our results suggest the BPS-Br is a useful tool for clinical practice to evaluate the pain experienced by patients with traumatic brain injury. Further studies of different samples are needed to evaluate the benefits of systematic pain assessment of critically ill patients.

Pain measurement techniques: spotlight on mechanically ventilated patients

Background

Procedural pain is a frequent problem in intensive care units (ICUs). For that, pain assessment has been increasingly introduced to the ICU professional’s routine, and studies have been developed to show the relevance of measuring pain in critically ill patients.

Objective

This review aimed to describe pain measurement techniques for mechanically ventilated adult patients based on evidence and already published.

Method

Systematic literature search was performed on PubMed and Google Scholar. Keywords “pain”, “pain measurement”, “intensive care units” and “respiration, artificial” were combined to the Boolean operator AND. No language or publication year was limited in this search. The purpose and method of all papers were analyzed and only studies which described pain assessment in mechanically ventilated patients were included in this review.

Results

Objective methods were found in the literature to assess pain in mechanically ventilated adults. Behavioral scales were the most used method for pain measurement in noncommunicative patients. Vital signs were used, but the reliability of this method was questioned. Pupillometry, bispectral index and skin conductance were found and described as pain assessment methods.

Conclusion

This review showed that objective measures, as behavioral scales, are the gold standard tools to measure pain intensity in noncommunicative subjects. These data contribute to professionals’ knowledge about ICU pain measurement and emphasize its importance and consequences for adequate pain management.

Validation of Two Pain Assessment Tools Using a Standardized Nociceptive Stimulation in Critically Ill Adults

CONTEXT

The Behavioral Pain Scale (BPS) or the Critical-Care Pain Observation Tool (CPOT) are recommended in practice guidelines for pain assessment in critically ill adults unable to self-report. However, their use in another language requires cultural adaptation and validation testing.

OBJECTIVES

Cross-cultural adaptation of the CPOT and BPS English versions into Brazilian Portuguese, and their validation by comparing behavioral scores during rest, standardized nociceptive stimulation by pressure algometry (SNSPA), and turning were completed. In addition, we explored clinical variables that could predict the CPOT and BPS scores.

METHODS

A prospective cohort study was conducted with 168 medical-surgical critically ill adults unable to self-report in the intensive care unit. Two nurses were trained to use the CPOT and BPS Brazilian Portuguese versions at the following assessments: 1) baseline at rest, 2) after SNSPA with a pressure of 14 kgf/cm², 3) during turning, and 4) 15 minutes after turning.

RESULTS

Inter-rater reliability of nurses' CPOT and BPS scores was supported by high weighted kappa >0.7. Discriminative validation was supported with higher CPOT and BPS scores during SNSPA or turning in comparison to baseline (P < 0.001). The Glasgow Coma Scale score was the only variable that predicted CPOT and BPS scores with explained variance of 44.5% and 55.2%, respectively.

CONCLUSION

The use of the Brazilian CPOT and BPS versions showed good reliability and validity in critically ill adults unable to self-report. A standardized procedure, the SNSPA, was used for the first time in the validation process of these tools and helped us improve the validation process.

Pain assessment practices in Swedish and Norwegian neonatal care units

BACKGROUND

The use of measurement scales to assess pain in neonates is considered a prerequisite for effective management of pain, but these scales are still underutilised in clinical practice.

AIM

The aim of this study was to describe and compare pain assessment practices including the use of pain measurement scales in Norwegian and Swedish neonatal care units.

METHODS

A unit survey investigating practices regarding pain assessment and the use of pain measurement scales was sent to all neonatal units in Sweden and Norway (n = 55). All Norwegian and 92% of Swedish units responded.

RESULTS

A majority of the participating units (86.5%) assessed pain. Swedish units assessed and documented pain and used pain measurement scales more frequently than Norwegian units. The most frequently used scales were different versions of Astrid Lindgren's Pain Scale (ALPS) in Sweden and Echelle Douleur Inconfort Noveau-Ne (EDIN), ALPS and Premature Infant Pain Profile (PIPP) in Norway. Norwegian head nurses had more confidence in their pain assessment method and found the use of pain measurement scales more important than their Swedish colleagues.

CONCLUSION

The persisting difference between Swedish and Norwegian units in pain assessment and the use of pain measurement scales are not easily explained. However, the reported increased availability and reported use of pain measurement scales in neonatal care units in both countries may be seen as a contribution towards better awareness and recognition of pain, better pain management and potentially less suffering for vulnerable neonates.

Physiology of Pain

Acutely ill patients are challenging to frontline nurses because they frequently also have multiple chronic conditions. This article empowers all nurses to develop a foundational understanding of the physiology of acute and chronic pain. The skills, knowledge, and attitude to care for patients experiencing pain are a legal and ethical responsibility of all nurses. This article discusses the physiology of pain to include the neuronal receptors that respond to various painful stimuli, substances that stimulate nociceptors, the nerve pathways, modulation of the perception of pain, and acute verses chronic physiologic changes.