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

ObjectiveThis integrative review sought to identify and synthesise quantitative and qualitative evidence on barriers to pain management in adult intensive care units (ICUs).BackgroundPain 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.MethodsAn 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.ResultsNine 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.ConclusionsThe 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 registrationCRD42020179913     

Clinical tools for the assessment of pain in sedated critically ill adults

Aim: This paper aims to review the evidence regarding pain assessment tools for sedated patients and to establish whether the use of a tool can be recommended in practice. Background: Pain assessment is a challenging area of critical care nursing practice, particularly among sedated patients. Tools to aid in assessing pain among this patient group have been developed and tested recently. Search strategy: In this systematic review five papers that tested pain assessment tools for sedated patients are discussed. These papers were identified via the CINAHL and MEDLINE databases using the search terms: ‘pain assessment’ and ‘sedated’ or ‘unconscious’ or ‘critically ill’ or ‘critical illness’ or ‘critical care’. Conclusions: The Behavioural Pain Scale (BPS) has been tested among the broadest range of patients and was found to be a reliable and valid tool in three studies. Research is needed to further demonstrate the reliability and validity of the Critical‐Care Pain Observation Tool (CPOT), as the paper of Gelinas et al. did not test its internal consistency and domain structure. The CPOT also needs testing among different critical care populations. The design of Odhner et al. study did not allow adequate testing of the Non‐verbal Pain Scale (NVPS). Implications for practice: The implementation of the BPS can be recommended in intensive care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions. The CPOT may also prove useful in assessing pain among sedated patients, but first requires further validation. Also, further research is needed into the effects of pain assessment tools on pain management practices and patient outcomes.     

A cross-sectional study of predictors of pain control during the transition from the surgical intensive care unit to surgical ward

Background

The transition of patients from the intensive care unit (ICU) to the ward is a complicated process and patients may be at risk of increased levels of pain.

Implementation of the Critical Care Pain Observation Tool increases the frequency of pain assessment for noncommunicative ICU patients

BackgroundPain is a common stressor for ICU patients, necessitating routine assessment. For patients who are unable to communicate, self-report tools are unsuitable, and the use of an observational tool is required to assess pain appropriately. The Critical Care Pain Observation Tool (CPOT) is the most reliable tool currently available to assess pain in these patients. We investigated whether the implementation of the CPOT in one Australian ICU could increase frequency of appropriate pain assessments, and if this would affect the administration of analgesia and sedation.MethodsIn this before and after study, we first performed a retrospective chart audit on 441 adult ICU patient charts, over 49 days. Data collected included frequency and type of pain assessments, sedation and analgesia administered, communication and CAM-ICU status, and bedside nurse-perceived pain. During the implementation phase, new policy and guideline documents were released, and ICU charts were redesigned to incorporate the CPOT. All nursing staff attended an education session on pain assessment and correct use of the CPOT. The chart audit was repeated, capturing 344 charts over 43 days.ResultsMean total assessments in 24 hours increased from 7.2 to 7.9 for communicative, 3.0 to 8.9 for non-communicative, and 5.1 to 9.1 for transitioning patients. For non-communicative patients there was a significant increase in observational assessments including the CPOT (1.7 to 8.3), and a decrease in inappropriate use of self-report tools (1.3 to 0.2). We also observed significant increases in administration of paracetamol, opiates, propofol, patient-controlled analgesia, modified-release opiates, and neuropathic pain agents.ConclusionsImplementation of the CPOT using standardised education and resources led to increased frequency of pain assessment, particularly for non-communicative patients. Appropriate observational assessments were also more frequently used for these patients. Analgesic administration generally increased, as did the use of propofol.     

Video education for critical care nurses to assess pain with a behavioural pain assessment tool: A descriptive comparative study

AimTo evaluate the impact of video education on critical care nurses’ knowledge and skills in using a behavioural pain assessment tool for intensive care patients and to explore the nurses’ experiences with video education.MethodsForty-eight nurses in one intensive care unit watched an educational video on the use of the Critical-Care Pain Observation Tool, then assessed pain in two patients with the tool and took a knowledge test. The researcher made parallel pain assessments. Interrater reliability of patients’ pain assessment between nurses and the researcher was determined to examine nurses’ skills in using the tool after education. Twenty nurses were interviewed about their experiences with the video education. Interviews were analysed with deductive thematic analysis.ResultsThe knowledge test scores indicated that the nurses learned the principles of how to use the tool. The interrater reliability of pain assessments reached a moderate level of agreement during the painful procedure, with a weighted kappa coefficient value of 0.48, CL [0.37, 0.58]. The nurses perceived video education positively, but requested additional interaction.ConclusionsVideo education is useful in teaching the principles of using a pain assessment tool. Additional clinical training is required for nurses to reach adequate skills in using the tool.     

Comparison of the Zurich Observation Pain Assessment with the Behavioural Pain Scale and the Critical Care Pain Observation Tool in nonverbal patients in the intensive care unit: A prospective observational study

ObjectivesTo determine the concordance of Zurich Observation Pain Assessment (ZOPA) with the behavioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) to detect pain in nonverbal ICU patients.DesignProspective observational study [BASEC-Nr. PB_2016-02324].SettingA total of 49 ICU patients from cardiovascular, visceral and thoracic surgery and neurology and neurosurgery were recruited. Data from 24 patients were analyzed.Main Outcome MeasurementsThree independent observers assessed pain with the BPS, the CPOT or ZOPA prior, during and after a potential painful nursing intervention. Tools were randomized concerning the pain management after each pain assessment. Frequency of nine additional pain indicating items from a previous qualitative, explorative study was calculated.ResultsZOPA was positive in 32 of 33 measuring cycles (97.0%; 95%CI: 84.2-99.9%), followed by the CPOT (28/33 cycles, 84.8%; 95%CI: 68.1–94.9%) and the BPS (23/33 cycles, 67.0%; 95%CI: 51.3–84.4%). In 22/33 cycles all tools were concordant (66.7%; 95%CI: 48.2-82.0%). Analgesics were provided in 29 out of 33 cycles (87.9%; 95%CI: 71.8–96.6%). Additional pain indicating items were inconsistently reported.ConclusionZOPA is concordant with the BPS and the CPOT to indicate pain but detects pain earlier due to the low threshold value. Inclusion of further items does not improve pain assessment.     

Cross-validation of the Care Dependency Scale in intensive care unit (ICU-CDS)

ObjectivesThe Care Dependency Scale is a theory-based, comprehensive tool widely used in low-intensity care settings to evaluate patients’ dependency. This study aimed to test the psychometric properties of the Care Dependency Scale in intensive care units.Research methodology/designA multicentre cross-sectional validation study was conducted. Exploratory factor analysis and confirmatory factor analysis were performed using a Maximum Likelihood robust estimator with Geomin oblique rotation.SettingAdult patients admitted to intensive care units of four Italian hospitals.ResultsThe sample included 453 patients (mean age = 68 years, 62% male). The exploratory factor analysis, conducted on a subsample of 227 patients, revealed a two-factor structure (Physical care dependency and Psychosocial care dependency) with good fit indexes. The confirmatory factor analysis was conducted on another subsample of 226 patients and a second-order factor was specified. The model tested yielded adequate fit indexes. Concurrent and known-groups validity, and reliability, were also adequate.ConclusionThe Care Dependency Scale is a multidimensional, valid and reliable tool able to assess the care dependency of critically ill patients. It can help to distinguish between physical and psychosocial needs and to create a base for patient-customised and holistic care.     

Pupillary dilation reflex and behavioural pain scale: Study of diagnostic test

BackgroundThe objective of this study was to assess the value of the pupillary dilation reflex as an assessment pain tool in critically ill patients. It is important to continue working for the well-being and security of critically ill patients.MethodsWe studied the diagnostic accuracy of the pupillary dilation reflex against the Behavioral Pain Scale. Inclusion criteria were: age greater than 18, receiving mechanical ventilation, with a basal score of the Behavioural Pain Scale of three and a Richmond Agitation and Sedation score between −1 and −4. We studied the responses to a non-painful stimulus, four calibrated stimuli, after a tracheal aspiration and with and without pain. The receiver operating curve was plotted and we calculated the area under the curve. We identified the cut-off points showing the highest sensitivity and specificity and studied diagnostic performance based on negative predictive value, positive predictive value, and accuracy. These were reported with their 95% confidence intervals.Results183 measurements were performed. An AUC of 0.88(95% CI 0.83–0.94) was obtained. The pupillary dilation reflex of 11.5% had a sensitivity of 89.8%(95% CI 78.2–95.6) and a specificity of 78.4%(95% CI 70.6–84.5) with an accuracy of 81.4(75.2–86.4). The pupillary dilation reflex detected nociceptive pain response in 15.8% of the measurements that did not show pain according to the Behavioural Pain Scale.ConclusionsPupillometry may be a valid alternative for identifying pain in critically ill patients.     

The effect of music on delirium,pain, sedation and anxiety in patients receiving mechanical ventilation in the intensive care unit

ObjectivesTo examine the effects of music for patients under mechanical ventilation support in the intensive care unit on their delirium, pain, sedation, and anxiety.Research methodology/designA single-blind, randomized, controlled trial.SettingThe study was conducted with delirium positive patients between August 2020 and September 2021 in the medical/surgical intensive care unit of a university hospital in Turkey.MethodsThe study sample was selected through a simple and stratified randomization method; patients who met the inclusion criteria were assigned to the music, noise reduction or control group. The data were collected by using a Confusion Assessment Method for the ICU (CAM-ICU), CAM-ICU-7, Critical Care Pain Observation Tool (CPOT), Richmond Agitation-Sedation Scale (RASS), Facial Anxiety Scale (FAS), PRE-DELIRIC model, and Glasgow Coma Scale (GCS). The interventions were repeated twice a day for five days.ResultsA total of 36 patients were included, with 12 patients in each group. Significant decreases were found in the severity of delirium and pain and the level of sedation and anxiety in the music compared to the other groups (p < 0.05). The number of patients with delirium and the number of days with mechanical ventilation was found to be significantly lower in the music group compared to the other groups (p < 0.05).ConclusionMusic intervention may be used as a nursing intervention to control delirium, pain, need for sedation and anxiety in intensive care unit patients. However, additional studies with larger sample is needed to validate findings.     

Management of procedural pain in the intensive care unit

Pain is a common experience for inpatients, and intensive care unit (ICU) patients undergo more pain than other departmental patients, with an incidence of 50% at rest and up to 80% during common care procedures. At present, the management of persistent pain in ICU patients has attracted considerable attention, and there are many related clinical studies and guidelines. However, the management of transient pain caused by certain ICU procedures has not received sufficient attention. We reviewed the different management strategies for procedural pain in the ICU and reached a conclusion. Pain management is a process of continuous quality improvement that requires multidisciplinary team cooperation, pain-related training of all relevant personnel, effective relief of all kinds of pain, and improvement of patients' quality of life. In clinical work, which involves complex and diverse patients, we should pay attention to the following points for procedural pain: (1) Consider not only the patient's persistent pain but also his or her procedural pain; (2) Conduct multimodal pain management; (3) Provide combined sedation on the basis of pain management; and (4) Perform individualized pain management. Until now, the pain management of procedural pain in the ICU has not attracted extensive attention. Therefore, we expect additional studies to solve the existing problems of procedural pain management in the ICU.     

Validation of the Turkish version of the Pain Sensitivity Questionnaire in patients with chronic pain

ObjectiveThe Pain Sensitivity Questionnaire (PSQ) is a clinically beneficial instrument that has been proven to be correlated with various experimental pain sensitivity assessments in healthy people and in patients with chronic pain. In this study, we aimed to translate the PSQ into Turkish (PSQ-T) and validate it for the measurement of pain sensitivity among Turkish people.MethodsSeventy-three patients with chronic back pain who were planning to undergo an interventional procedure completed the Brief Pain Inventory-Short Form (BPI-SF), Beck Depression Inventory (BDI), Beck Anxiety Inventory, Pain Catastrophizing Scale, and PSQ prior to their procedure. Subcutaneous infiltration of lidocaine was used as a standardized experimental pain stimulus. Pain was evaluated using a visual analog scale (VAS 1: infiltration in the hand, and VAS 2: infiltration in the procedure area)ResultsScores on the PSQ-T were significantly correlated with those on the BPI-SF. A significant positive relationship was observed between VAS 1 and VAS 2 values and the PSQ-T score, BPI pain score, and BPI interference score.ConclusionsThe PSQ-T can be used as a valid and reliable tool for the assessment of pain sensitivity in the Turkish population.     

Validation and properties of the verbal numeric scale in children with acute pain

Although the verbal numeric scale (VNS) is used frequently at patients’ bedsides, it has never been formally validated in children with acute pain. In order to validate this scale, a prospective cohort study was performed in children between 8 and 17 years presenting to a pediatric emergency department (ED) with acute pain. Pain was graded using the VNS, the visual analogue scale (VAS), and the verbal rating scale (VRS). A second assessment was done before discharge. We determined a priori that in order to be valid, the VNS would need to: correlate with the VAS (concurrent validity); decrease after intervention to reduce pain (construct validity); and be associated with the VRS categories (content validity). The VNS interchangeability with the VAS, its minimal clinically significant difference, and test–retest reliability were also determined. A total of 202 patients (mean age: 12.2 ± 2.6 years) were enrolled. The VNS correlated with the VAS: r_ic = 0.93, p < 0.001. There were differences in the VNS before versus after interventions (p < 0.001), and between VRS categories (mild versus moderate, p < 0.001; moderate versus severe, p < 0.001). The 95% limits of agreement (interchangeability) between VNS/VAS were outside the a priori set limit of ±2.0: −1.8, 2.5. The VNS minimal clinically significant difference was 1. The VNS had good test–retest reliability with 95% limits of agreement of −0.9 and 1.2. In conclusion, the VNS provides a valid and reliable scale to evaluate acute pain in children aged 8–17 years but is not interchangeable with the VAS.