Critical Care Evaluation

RITICAL

CARE NURSES

PAIN ASSESSMENT AND

MANAGEMENT PRACTICES:
A SURVEY IN CANADA
By Louise Rose, RN, PhD, Orla Smith, RN, MN, CNCC(C), Cline Glinas, 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, and Judy Watt-Watson, RN, PhD

This article is supplemented by an AJCC Patient Care

Page on page 260.
2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2012611

www.ajcconline.org

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 selfreport 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. (American Journal
of Critical Care. 2012;21:251-259)

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251

ccording to cumulative research, 3 key issues are important considerations in

pain assessment and management. First, most, if not all, critically ill adults experience pain and discomfort.1,2 Second, appropriate analgesia, in combination with
minimal3 or no sedation,4 is preferable to deep sedation because of the adverse
consequences of the latter, such as prolonged duration of mechanical ventilation,5
prolonged length of stay in the intensive care unit (ICU),5 and health careassociated infections.6 Third, survivors of critical illness experience physical and psychological sequelae for
months to years after discharge from the ICU,7 a situation that might be mitigated by structured
pain assessment and management practices in critical care.8,9 Therefore, structured pain assessment and management are essential aspects of high-quality care in the ICU.

Several clinical scoring tools used to detect and

quantify pain in critically ill patients who are able
or unable to communicate have been evaluated.10,11
As well, professional societies have published guidelines12-14 that recommend frequent pain assessment
with validated scoring tools and observation of painrelated behaviors for all critically ill patients regardless of a patients diagnosis at admission, level of
consciousness, or depth of sedation. In a recent large,
prospective, observational study,15,16 systematic pain
assessment, using self-report or behavioral tools as
appropriate, reduced the duration of mechanical
ventilation and ICU length of stay. Published surveys17-20 of pain management practices in adult ICUs
addressed the preferred analgesia prescribing patterns

of physicians and did not describe use of pain scoring tools, nurses awareness of analgesia practice
guidelines, and education about pain during professional development.
Our primary objective was to compare the proportion of nurses who use patient self-report tools
with the proportion using behavioral pain assessment tools for patients able and unable to communicate. Our secondary objectives were to determine
(1) factors associated with use of behavioral tools;
(2) behavioral and physiological indicators of pain;
(3) awareness of local and international guidelines
for pain assessment and management; (4) the content of education on pain; and (5) pain communication and management practices.

Methods
About the Authors
Louise Rose is the Lawrence S. Bloomberg Professor in
Critical Care, Elena Luk is a doctoral student, and Michael
McGillion is an assistant professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto,
Ontario. Judy Watt-Watson is professor emerita and
executive director, Centre for Advanced Studies in Professional Practice, Lawrence S. Bloomberg Faculty of
Nursing. Orla Smith is a research manager, critical care,
and adjunct scientist, Keenan Research Centre, Li Ka
Shing Knowledge Institute, St Michaels Hospital,
Toronto, Ontario. Cline Glinas is an assistant professor in the School of Nursing, McGill University, and Centre for Nursing Research and Lady Davis Institute,
Jewish General Hospital, Montreal, Quebec. Lynn Haslam
is an acute practice nurse, Department of Anaesthesia,
and Craig Dale is an advanced practice nurse, Department of Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario. Lisa
Burry is a clinical pharmacy specialist in the intensive
care unit, Mt. Sinai Hospital, Toronto, Ontario. Sangeeta
Mehta is a critical care physician and research director,
Mt. Sinai Hospital, and an associate professor, University of Toronto, Toronto, Ontario.
Corresponding author: Louise Rose, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, Ontario, Canada, M5T IP8 (e-mail:
louise.rose@utoronto.ca).

252

Survey Development and Testing

The methods used to develop the survey have
been described.21 Survey items addressed perceived
pain assessment and management practices for
patients able and patients unable to self-report
pain. Because several behavioral pain assessment
tools are now available, questions were included to
ascertain perceived frequency of use of various tools
and the relevance of a list of 25 behaviors included
in 7 behavioral pain assessment tools22-28 with 5point scales anchored by never and routinely. Additionally, information was gathered on pain education
received during professional development and
enablers of and barriers to effective pain practices.
The original survey was pilot tested in 5 ICUs in a
single hospital. On the basis of the response patterns
in the pilot test and comments provided by participants, the survey was revised by changing the order
of the items, refining wording, deleting redundant
items, and adding an item on awareness of guidelines
of national and international professional societies
on pain assessment and management. Survey test-

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retest reliability was assessed by using a panel of 10

ICU nurses not involved in the original pilot test.
The revised survey was forward-backward translated
for use in the 2 francophone provinces of Canada
by a bilingual member of the study team. Comparison of the 2 versions, by the primary and francophone investigators (L.R. and C.G.), revealed
alterations of meaning for some behavioral descriptors, which were resolved through discussion.
Sampling and Study Population
The sample frame was 16 036 nurses who identified critical care in a hospital setting as their primary area of practice whose names were obtained
from the 12 provincial/territorial nursing associations of Canada responsible for regulation of the
nursing profession. On the basis of assumptions of
a response distribution of 50%, a 3% margin of
error, and 95% confidence intervals, an estimated
total of 938 responses were required for the study.
On the basis of a predicted response rate of 30%
and the need to oversample by 20% because of misclassification of nurses employment location, 3753
surveys were distributed. In order to obtain representation of ICU nurses across all provinces and
territories, a stratified, disproportionate, random
sampling strategy was used that took into account
the number of potentially surveyable critical care
nurses in each province. The sample included 1251
of 7712 nurses (16%) from Ontario, 1251 of 5923
nurses (21%) from provinces with more than 1500
ICU nurses (Alberta, Quebec, British Columbia),
and 1251 of 2401 nurses (52%) from provinces
with less than 1500 ICU nurses (all other provinces).
Nurses practicing in adult ICUs were eligible
to participate. Nurses who worked solely in pediatric ICUs were excluded because different pain
assessment tools are used for infants and children.
Nurses were requested to confirm their eligibility
on the survey, and in order to facilitate calculation
of the true survey denominator, nurses who were
incorrectly identified as working in critical care
were asked to return the questionnaire without
completing survey items.
Implementation of the Survey
The research ethics board of the University of
Toronto, Toronto, Ontario, approved the study.
Survey distribution methods were dictated by the
provincial nursing associations. In 5 provinces,
nurses contact details were provided to the study
investigators after completion of confidentiality
agreements enabling the study coordinating center
to manage distribution of the survey and reminders.

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In 6 provinces, the relevant nursing associations

distributed surveys and reminders according to the
study protocol. Because of the inability of the nursing association to distribute surveys, the nurse manager of 1 of the 2 ICUs in the remaining province
(Prince Edward Island) assisted with survey distribution. In order to maximize response rates, survey
were mailed in 3 rounds, with 2
weeks between rounds, (June to
August 2010) to all provinces and
2 e-mail reminders were sent in
those provinces in which e-mail
contacts were available. Participants were provided with a selfaddressed, postage-paid reply
envelope to return the survey to
the coordinating center.

A stratified,
disproportionate,
random sampling
strategy was used
to include intensive care unit
nurses from all
Canadian provinces
and territories.

Statistical Methods
Test-retest reliability was evaluated by using the Cohen statistic; a value of 0.4 or greater was
considered to represent moderate
to good agreement.29 Because some surveys had missing data, item denominators varied. Categorical data
were summarized as proportions and 95% confidence intervals. The five response categories (never,
seldom, sometimes, often, routinely) were
dichotomized as 50% of the time or less (never, seldom, sometimes) and >50% of the time (often,
routinely). McNemar tests were used to compare
responses about pain assessment practices for
patients able to self-report with responses for patients
unable to communicate. Relative risk calculations
were used to examine perceived importance of preemptive analgesia for various painful procedures24
and the importance of pain assessment for medical
vs surgical patients. Variability in the use of assessment tools and awareness of professional guidelines
across regions was determined by using 2 tests.
Variables selected a priori as most likely to be
associated with often to routine use of behavioral
pain assessment tools (awareness of current guidelines, availability of tools, education on use of the
tools, presence of protocols or
guidelines, years of ICU experience)
were examined by using multiple
logistic regression. All models were
assessed for collinearity and goodness of fit. All tests were 2-tailed,
and P = .05 was considered significant. Analyses
were performed by using SPSS, version 18.0 (IBM
SPSS, Armonk, New York), and SAS, version 9.1
(SAS Institute Inc, Cary, North Carolina), software.

A response rate of
24% yielded 802
evaluable surveys.

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Table 1
Participants demographics
Characteristic

No. (%)

Intensive care unit experience, y (n = 801)

<2
2-5
>5-10
>10

76 (9.5)
179 (22.3)
168 (21.0)
378 (47.2)

Highest qualication (n = 802)

Diploma in nursing
Bachelors degree in nursing
Masters degree

389 (48.5)
386 (48.1)
27 (3.4)

Employment status (n = 798)

Full-time
Part-time
Casuala

517 (64.8)
226 (28.3)
55 (6.9)

Shift rotation (n = 752)

Rotating shifts
Days only
Nights or evenings only

544 (72.3)
99 (13.2)
109 (14.5)

Type of intensive care unit (n = 799)

Combined
Cardiovascular
Medical (only)
Neuroscience (only)
Surgical (only)
Other

658 (82.4)
92 (11.5)
21 (2.6)
14 (1.8)
9 (1.1)
5 (0.6)

Hospital type (n = 782)

University afliated
Large community (200 beds)
Moderate community (50-199 beds)

446 (57.0)
169 (21.6)
167 (21.4)

Casual nurses work on an as-needed basis.

Results
Participants and Response Rate
Of the 3753 surveys mailed, 310 (8%) were
returned from nurses not working in critical care or
from the post office as return to sender; therefore,
the response rate was 842 of 3443 (24%). Exclusion
of surveys with 25% or greater incomplete responses
yielded 802 evaluable surveys. Response rates by
province ranged from 3% in Nunuvut and Northwest Territories to 33% in Yukon. Most nurses had
more than 5 years of ICU experience and worked in
ICUs with mixed populations of patients in university-affiliated hospitals (Table 1). The proportion of
nurses with a bachelor of nursing science degree was
similar to the proportion with a nursing diploma.
Pain Assessment Tools
The majority of nurses responded that frequent
assessment and documentation of pain are equally
important for patients able (750 nurses, 94%) and
unable (755 nurses, 94%) to communicate. However, nurses reported they were less likely to use a
behavioral pain assessment tool than a self-report

254

tool; 267 (33%) used a behavioral tool more than

50% of the time for patients unable to communicate, whereas 712 (89%) used a self-report tool
more than 50% of the time for patients able to
communicate (P < .001). Fewer nurses (595, 74%)
rated behavioral pain assessment as moderately
to extremely important in guiding pain assessment compared with those rating self-report tools
as moderately to extremely important (P < .001).
Only 492 nurses (61%) reported that pain scores
were discussed often or routinely during nurseto-nurse handover. Furthermore, just 333 nurses
(42%) described targeting administration of an
analgesic to a pain score or other assessment
parameters as prescribed by physicians.
The 0 to 10 numerical rating scale30 was the
preferred self-report tool; it was used by 762 of
the 777 nurses (98%) who identified the tool they
used. The most common behavioral pain assessment tools used were the Behavioral Pain Scale,23
used by 122 of 294 nurses (41%); the Adult Nonverbal Pain Scale,22 used by 111 of 294 nurses (38%);
and the Critical-Care Pain Observation Tool,28
used by 96 of 294 nurses (33%). Among the 445
nurses who did not use a formal pain assessment
tool, pain assessment for patients unable to communicate consisted of assessment of both behavioral and physiological indicators (342 nurses; 77%),
behavioral indicators only (60 nurses; 14%), and
physiological indicators only (36 nurses; 8%).
Additional indicators of pain noted by the 445
respondents were agitation (89 nurses; 20%), results
of assessment by a patients family (20 nurses; 4%),
and the patients condition, procedures, or medical
history (32 nurses; 7%). Among 790 respondents,
741 (94%) perceived nurses as most accurate in
detecting the presence of pain for patients unable
to communicate, 46 (6%) perceived patients family members as most accurate, and 3 (0.4%)
thought physicians were most accurate.
Use of a behavioral pain tool more than 50%
of the time was associated with awareness of published guidelines and clinical availability of a tool
when adjusting for education on pain assessment
tools, availability of protocols, ICU experience,
hospital type, and province (Table 2). Compared
with nurses in other regions, significantly more
nurses in Ontario reported use of self-report tools
(P = .003) and behavioral pain assessment tools
(P < .001) more than 50% of the time.
Pain Behaviors and Physiological Indicators
Among the 802 respondents, 36 nurses (4%)
considered all 25 listed behaviors as often to

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Table 2
Variables associated with use of behavioral pain assessment tools
Use of pain tools > 50%
Variable

n/N

Odds ratio (95% CI)

% (95% CI)

Univariate

Multivariate

Aware of guidelines

122/235

52 (46-58)

3.1 (2.3-4.3)

2.5 (1.7-3.7)

Pain tool available

193/406

48 (43-52)

3.9 (2.8-5.4)

2.6 (1.6-4.3)

Received education on pain tools

206/522

40 (35-44)

2.3 (1.7-3.3)

1.3 (0.9-1.9)

Protocol available

190/406

47 (42-52)

3.6 (2.6-5.0)

1.6 (0.9-2.6)

Intensive care experience, y

<2
2-5
>5-10
>10

22/76
62/179
48/168
135/378

29
35
29
36

(20-40)
(28-42)
(22-36)
(31-41)

1
1.3 (0.7-2.3)
1.0 (0.5-1.8)
1.4 (0.8-2.3)

1
1.2 (0.6-2.3)
0.8 (0.4-1.6)
1.0 (0.6-1.9)

Hospital type
University afliated
Community, 200 beds
Community, 50-199 beds

135/446
61/169
63/167

30 (26-35)
36 (29-44)
38 (31-45)

1
0.7 (0.5-1.0)
0.9 (0.6-1.5)

1
1.2 (0.8-1.9)
1.4 (0.9-2.1)

23
42
40
29
34
38
22
30
11

2.5
2.3
1.4
1.7
2.1
0.9
1.4
0.4

Provincea
Quebec
Ontario
Alberta
Newfoundland
Nova Scotia
British Columbia
Manitoba
New Brunswick
Saskatchewan
a

28/122
96/226
44/109
7/24
18/53
32/84
12/55
22/74
5/45

(16-31)
(36-49)
(32-50)
(15-49)
(23-47)
(28-49)
(13-34)
(21-41)
(5-24)

1
(1.5-4.1)
(1.3-4.0)
(0.5-3.7)
(0.9-3.5)
(1.1-3.8)
(0.4-2.0)
(0.7-2.7)
(0.2-1.2)

1.5
2.8
1.6
2.1
1.4
1.1
1.5
0.4

1
(0.8-2.6)
(1.5-5.3)
(0.6-4.6)
(1.0-4.7)
(0.7-2.7)
(0.5-2.5)
(0.7-3.1)
(0.1-1.3)

Prince Edward Island, Yukon and Northern Territories were not included because they provided 5 or fewer responses.

routinely indicative of pain, whereas 21 nurses (3%)

considered only 5 of the listed behaviors as often to
routinely indicative of pain. Grimacing, a descriptor
used in all 7 behavioral tools, was most often rated
as routinely indicative of pain, by 581 nurses (72%;
Table 3). Frowning and restlessness, used in 6 of the
7 tools, ranked 6th and 10th highest, respectively,
for behaviors considered routinely indicative of
pain. Behaviors most often rated as never to seldom
indicative of pain were not following commands
(361 of 784 nurses; 46%), trying to climb out of
bed (302 of 782 nurses; 39%), striking staff (302 of
780 nurses; 39%), sighing (272 of 779 nurses; 35%),
and closing eyes (255 of 749 nurses; 34%).
Most nurses (733 of 796; 92%) considered physiological indicators moderately to extremely important for detection of pain. Among 529 nurses,
increased blood pressure (471 nurses, 89%), respiratory
rate (421 nurses, 80%), heart rate (390 nurses, 74%),
diaphoresis (122 nurses, 23%) and change in oxygenation status (47 nurses, 9%) were the physiological indicators most frequently identified as indicative of pain.
Guidelines and Education
Of the 802 respondents, only 235 nurses
(29%) had read any published guidelines or practice

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recommendations for pain assessment and management. A total of 67 nurses (8%) were familiar with
the sedation and analgesia guidelines of the Society
of Critical Care Medicine12 published in 2002, 60
nurses (7%) were familiar with the 2006 recommendations for the assessment of pain in nonverbal
patients of the American Society of
Pain Management Nursing,13 and
178 nurses (22%) had read the
best-practice guidelines on pain of
the Registered Nurses Association
of Ontario.14 Awareness of published guidelines or practice recommendations was higher in
Ontario (138 of 221 nurses; 62%)
than in other regions: 59 of 312
nurses (19%) in Alberta, British
Columbia, and Quebec; and 38 of
258 nurses (15%) in all other provinces and territories (P < .001). When nurses familiar with the bestpractice guidelines of the Registered Nurses
Association of Ontario were excluded from the
analysis, awareness of guidelines across regions did
not vary (Society of Critical Care Medicine guidelines, P = .57; American Society of Pain Management Nursing guidelines, P = .09).

Just 42% of
nurses target
administration of
an analgesic to a
pain score or
other assessment.

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Table 3
Nurses ratings of behaviors suggestive of pain
Behaviora

Never to sometimes 50%

Not following commands

784

641 (81.8)

90 (11.5)

53 (6.8)

Striking staff

782

624 (79.8)

96 (12.3)

62 (7.9)

Trying to climb out of bed

780

621 (79.6)

108 (13.8)

51 (6.5)

Closing eyes

749

600 (80.1)

95 (12.7)

54 (7.2)

Sighing

779

588 (75.5)

140 (18.0)

51 (6.6)

Attempting to sit up

789

583 (73.9)

135 (17.1)

71 (9.0)

Seeking attention through movements

777

464 (59.7)

213 (27.4)

100 (12.9)

Pulling endotracheal tube

787

449 (57.1)

206 (26.2)

132 (16.8)

Retraction of upper extremities

774

436 (56.3)

216 (27.9)

122 (15.8)

Thrashing extremities

786

431 (54.8)

227 (28.9)

128 (16.3)

Slow cautious movements

790

381 (48.2)

262 (33.2)

147 (18.6)

Resistance to passive movements

792

331 (41.8)

280 (35.4)

181 (22.9)

Withdrawing

790

327 (41.4)

263 (33.3)

200 (25.3)

Repetitive touching of area of the body

791

315 (39.8)

293 (37.0)

183 (23.1)

Arching

785

275 (35.0)

286 (36.4)

224 (28.5)

Restlessness

797

214 (26.8)

339 (42.5)

244 (30.6)

Rigidity

790

193 (24.4)

388 (49.1)

209 (26.5)

Splinting

782

148 (18.9)

246 (31.5)

388 (49.6)

Fighting ventilator/activation of alarms

796

126 (15.8)

304 (38.2)

366 (46.0)

Brow lowering/frowning

788

122 (15.5)

305 (38.7)

361 (45.8)

Vocalization

782

112 (14.3)

274 (35.0)

396 (50.6)

Clenching sts/teeth

797

98 (12.3)

298 (37.4)

401 (50.3)

Guarding

798

83 (10.4)

322 (40.4)

393 (49.2)

Wincing

796

24 (3.0)

203 (25.5)

569 (71.5)

Grimacing

802

16 (2.0)

205 (25.6)

581 (72.4)

Often 51%-75%

Routinely>75%

Behaviors identied from descriptors used in the Adult Nonverbal Pain Scale,22 Behavioral Pain Scale,23 Pain Behavioral Assessment Tool,24 Checklist of
Nonverbal Pain Indicators,26 Behavioral Pain Rating Scale,27 PAIN algorithm,25 and the Critical-Care Pain Observation Tool.28

In regards to education on pain assessment during

professional development, pain assessment methods
and tools was the topic covered for the greatest number
of ICU nurses (522 of 796 nurses; 66%). Next, in order,
were pharmacological pain management principles
(518 of 799 nurses; 65%) and pain neuropathophysiology (504 of 794 nurses; 63%). Fewer nurses had education on practice recommendations (353 of 792 nurses;
45%), nonpharmacological pain management (423
of 799 nurses; 53%) and psychological consequences
(443 of 795 nurses; 56%) of unrelieved pain.
Practice Patterns
Even though most nurses perceived pain assessment as moderately to extremely important for surgical
(801 of 801 nurses; 100%), medical (761 of 801

256

nurses; 95%), trauma (792 of 797 nurses; 99%), and

burn (791 of 793 nurses; 99.7%) patients, more nurses
rated pain assessment of lower importance for medical
patients than for surgical (relative risk, 0.95; 95% CI,
0.94-0.97). When asked to consider the importance of
pain assessment for patients with decreased level of
consciousness regardless of admission category, fewer
nurses (675 of 791; 85%) rated it as moderately to
extremely important. The importance of preemptive
analgesia was considered lower for endotracheal suctioning than for drain removal, placement of an invasive catheter, repositioning, and wound care (Table 4).

Discussion
Pain assessment and management are core
competencies of ICU nurses. To our knowledge, our

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results provide the largest and most diverse representation of ICU nurses perceptions of pain assessment and management practices examined to date.
The most important finding of our study is that a
substantial proportion of the nurses did not use
pain assessment tools for patients unable to communicate and were unaware of practice recommendations published by professional societies for pain
assessment and management in critically ill adults.
Awareness of guidelines influenced use of behavioral pain assessment tools, underscoring the
importance of ongoing knowledge-translation
strategies. Although assessment and documentation
of pain were considered equally important for
patients able and unable to communicate, in practice, behavioral pain assessment tools were considered less useful than patient self-report tools.
Targeting of analgesia to a pain score also occurred
infrequently, although this finding may be more
indicative of physicians practice patterns.
Infrequent use of behavioral pain assessment
tools as described by our participants is supported
by other investigations of pain assessment and
management practice. In an observational study of
sedation and analgesia in 44 French ICUs, Payen et
al31 found that a pain assessment tool was used for
just 28% of patients receiving mechanical ventilation; analgesia was given without pain assessment
more than 50% of the time. In a single-center Canadian study32 on pain documentation by ICU nurses
and physicians, 183 pain assessment episodes were
documented for 52 patients (mean, 3.5 episodes
per patient); however, documentation incorporated
use of a pain assessment tool for only 3 episodes
(1.6%). In an earlier study33 of analgesia practices in
a single US medical ICU, only one-third of patients
received any form of analgesic, and only 50% of
sedated patients received analgesics. Administration
of analgesics was based on pain assessment with a
self-report tool for patients able to communicate
and by physicians estimation of pain for patients
unable to communicate.
The majority of our respondents were unaware
of professional society guidelines, a situation that
creates a major barrier to adoption of the guidelines
into clinical practice. Despite the publication of 3
guidelines pertinent to pain assessment and management of critically ill patients, ICU nurses, the clinicians most directly responsible for pain assessment
and treatment, have not adopted the guidelines. In
a previous Canadian survey34 of clinicians attitudes
toward clinical practice guidelines, 65% of nurses
and physicians used professional guidelines, and
nurses, in particular, trusted guidelines endorsed by

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Table 4
Need for preemptive analgesia
for intensive care procedures
Relative risk
(95% CI)

n/Na

% (95% CI)

Wound care

767/801

96 (94-97)

Repositioning

720/801

90 (88-92)

0.9 (0.9-1.0)

Invasive catheter placement

720/801

90 (88-92)

0.9 (0.9-1.0)

Drain removal

680/800

85 (82-87)

0.9 (0.9-0.9)

Endotracheal suctioning

503/801

63 (59-66)

0.7 (0.6-0.7)

Procedure

a Number of nurses rating need for the assessment of preemptive analgesia as

moderately to extremely important.

the nurses own professional organizations. One

explanation for the lack of awareness is that existing
guidelines have not been endorsed by either the
Canadian or American associations of critical care
nursing. However, a nurses practice is often situated
within an organizational context and therefore is
influenced by the policies and guidelines of the nurses
own ICU. If recommendations of guidelines for
pain assessment and management are to be widely
adopted, educational interventions
are required, assessment tools
need to be readily available, and
institutional policies and/or protocols should be developed that stipulate use of the guidelines.
Our data indicate that 10 of
the 25 behaviors included in
behavioral pain assessment tools
were not considered routinely
indicative of pain by most nurses.
Selection of behaviors that nurses
do not recognize as indicative of pain, as well as
inconsistencies in scoring these behaviors, brings
into question the clinical usefulness of the tools
and may be the reason the tools are not adopted
into practice. Further, although behaviors such as
striking staff, pulling at an endotracheal tube, and
trying to sit up or climb out of bed have been
included in pain assessment tools, these behaviors
are not specific to pain and may be due to other
commonly occurring causes, such as hypoxia,
acidemia, agitation, and delirium.35
The facial expressions of grimacing and wincing
were universally considered indicative of pain. According to the Facial Action Coding System, a technique
that involves digital recording and coding of facial
actions, 4 core actionsbrow lowering, orbit tightening, raising the upper lip and wrinkling the nose
(levator contraction), and eye closurehave been
associated with pain expression.36 Despite inclusion

A large number
of nurses do not
use pain assessment tools for
patients unable to
communicate.

AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2012, Volume 21, No. 4

257

of facial expression as an item in all behavioral pain

assessment tools, description of facial expressions is
not consistent, and scoring may differ across scales.37
Survey respondents considered physiological
signs such as blood pressure, respiratory rate, and
heart rate as essential elements of pain assessment.
Evaluation of physiological indicators is recommended in current guidelines,12 but recent evidence
does not support the validity of these indicators for
pain assessment in critically ill adults. Heart rate
and blood pressure can increase in response to both
painful and nonpainful procedures, indicating lack
of specificity.38 As recommended by the Task Force
of the American Society for Pain Management Nursing,13 a change in vital signs should be a stimulus
for further assessment of behavioral pain indicators
and analgesic management and not an independent
marker of the presence or absence of pain.
Limitations of our study include selection bias,
self-report bias, confounding, and lack of generalizability. Nurses who chose not to answer the survey
most likely were less interested in the topic than were
the nurses who did answer. Therefore, reported practices may represent the practices of nurses with more
knowledge and interest in pain assessment and management. Unknown confounding factors other than
those measured, such as tool availability and education on pain assessment, may have influenced use of
behavioral pain assessment tools. Despite adequate
representation of nurses from across Canada, ICU,
and hospital types, our findings may lack generalizability to practice in other countries. As with all selfreport surveys, responses reflect the perceptions of
respondents and may not reflect actual practice.

Conclusion
Most nurses do not use pain assessment tools
for patients unable to communicate and are unaware
of practice recommendations published by professional societies for pain assessment and management
in critically ill adults. This finding suggests inadequate
adoption of evidence and practice recommendations
for pain assessment and management of critically ill
patients, particularly for patients unable to communicate pain. Educational and novel knowledgetranslation interventions are needed that will improve
compliance with recommendations for pain assessment and management practices in adult ICUs.
ACKNOWLEDGMENTS
This study was conducted at the Lawrence S. Bloomberg
Faculty of Nursing. We thank Ruxandra Pinto for her statistical advice and assistance with data analysis and
Leasa Knechtel for her input into the design of the survey.

258

FINANCIAL DISCLOSURES
This study was supported by a research grant from the
American Association of Critical-Care Nurses and the
Nursing Research Fund of St Michaels Hospital.
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