Pain assessment in critical care: what have we learnt from research

KathleenShannon RN DipApp Sci (Nurs), BNGrad Cert CritCare, Masters(Research)Candidate, TheUniversity ofMelbourne, ClinicalDevelopmentNurse, MelbournePrivate Hospital,Royal Parade,Parkville, Vic. 3052,Australia. Tel: +613 93424800; Fax:+61 3 93424855;Email: [email protected]

Dr TraceyBucknall RN ICUCert, BN Grad DipAdv Nurs, PhD,Executive Director,Victorian Centrefor NursingPractice Research,Associate Professor,School of Nursing,Faculty ofMedicine, Dentistryand HealthSciences, TheUniversity ofMelbourne, Level1, 723 SwanstonStreet, Carlton,Vic. 3053,Australia. Tel: +613 83440773; Fax:+61 3 93474172;E-mail: [email protected]

(Requests foroffprints to KS)

Manuscriptaccepted: 28/02/03

Original article

Pain assessment in criticalcare: what have we learntfrom researchKathleen Shannon and Tracey Bucknall

Despite an ongoing acknowledgement in the literature that pain is a significant problemwithin the critical care environment, this issue has not been adequately addressed by criticalcare nurses. This paper examines strategies for changing pain management practices incritical care, including reviewing documentation practices, the utilisation of guidelines andalgorithms to augment clinical decision making, and increasing educational opportunitiesavailable to critical care nurses. It is recommended that pain assessment be given a higherpriority within the clinical context, particularly as inadequate pain assessment andmanagement has been linked to increased morbidity and mortality within critical care.Importantly, critical care nurses need to not only be aware of research-based painmanagement practices, but also lead the way in implementation and continuous evaluationas a measure of decreasing patient pain in the future.© 2003 Elsevier Science Ltd. All rights reserved.

KEYWORDS: Pain assessment; Critical care; Documentation; Research.

Pain has long been identified as animportant problem for critically ill patients.Indeed, researchers have identified anumber of barriers to effective painmanagement in critical care, includingcommunication, technology, knowledge andtime constraints. However, critical care nursescontinually fail to address these limitationsand to accurately assess pain in their routinepractice. In this paper, it is argued thatimproved pain assessment is a logical steptoward overcoming many of the barriers toeffective pain management previouslyidentified in the research literature. Strategiesfor changing practice to optimise painassessment are discussed before the paperconcludes with the identification ofimplications for the critical care setting, inparticular, the need to attribute a higher profile

to the assessment of pain within the clinicaldomain.

Significance of pain for thecritically illDespite studies of patient recollections of thecritical care experience being limited in bothsample size and number, researchers haveidentified pain as a significant problem forcritically ill patients (Chyun, 1989; Dracup &Bryan-Brown, 1995; Murray, 1990;Pooler-Lunse & Price, 1992; Porter 1985;Puntillo 1988, 1990, 1994; Simpson et al., 1989;Stein-Parbury & McKinley, 2000). For thepurpose of this paper, critically ill is defined asthose patients requiring constanthaemodynamic monitoring, observation,intervention and evaluation.

154 Intensive and Critical Care Nursing (2003) 19, 154–162 © 2003 E l sev i e r S c i ence L td . A l l r i gh t s re se r ved .

doi:10.1016/S0964-3397(03)00027-2

Pain assessment in critical care

In a study of 24 patients from two hospitalsbeing interviewed after transfer from ICU,Puntillo (1990) found that 63% rated their painas being moderate to severe in intensity.Similarly, in a study of 59 patient recollectionsof their critical care experience, Simpson et al.(1989) identified pain as the major stressorassociated with negative impact. While thesmall sample size and inadequate samplingfrom both of these studies limit thegeneralisability of the results, the findings stillprovide an insight as to potential impact ofpain for the critically ill patient. Similar resultswere reported in a large national survey of5150 United Kingdom acute care hospitalisedpatients (Bruster et al., 1994). This studyshowed 61% of patients suffered pain and 33%were in pain almost continuously.

Although airway maintenance andcirculatory support are critical to patientmanagement, pain assessment must beafforded a higher priority than currentlygiven. For the critically ill patient that requiresconstant haemodynamic monitoring andmanagement, poorly managed pain has beenfound to have serious physiological andpsychological sequelae (Stanik-Hutt, 1998). Infact, it is widely accepted that pain cancompromise recovery and negatively affectboth morbidity and mortality (Dracup &Bryan-Brown, 1995). The literature describesphysiological complications associated withpain, including increased pulmonarycomplications and increased cardiac work(Pooler-Lunse & Price, 1992), as well asdepression and anxiety (Desbians et al., 1996).In light of this evidence, proficient painmanagement for critically ill patients is asignificant factor in maximising their chanceof recovery (Kaiser, 1992; Puntillo & Weiss,1994).

Barriers to pain assessment andmanagement in critical careNotwithstanding the significant impact painhas been found to have on long-term outcomesfor ICU patients, the accurate assessment ofpain presents a number of challenges forclinicians. These difficulties are largely due tothe complex nature of the critically ill patientand the unique challenges that affect the pain

assessment process within the critical careenvironment. Barriers to pain assessmentinclude both individual variables related tonursing knowledge and experience, andequally important, the external variables thatmay be out of the individual nurses control attimes. These variables include the patient’sability to communicate, the increasingpresence of technology and the rapidlychanging situations common in critical carethat place time constraints on the nurse’sability to make pain assessment decisions andalso to implement their decisions (Alpen &Titler, 1994; Hamill-Ruth & Marohn, 1999).

Nursing knowledge

Winslow (1998) cites naiveté andmisconceptions as major barriers to effectivepain management. In fact, Camp (1988) assertsthat critical care nurses are among manyspeciality nurses and physicians who recognisethat their basic education did not provideadequate instruction in caring for patients inpain. Despite this acknowledgement, there hasbeen little evidence in the clinical setting thatcritical care nurses have improved their painmanagement practices through increasing theirknowledge base. Indeed, Stanton (1991) arguesthat the pain suffered by critically ill patientsmay be reduced by improving nurses’knowledge and understanding of pain andpain-relief, combined with improvedcommunication of the problem.

Research related to critical care nurses’ painassessment practices in the clinical settingremains limited despite an increased awarenessof the significance of pain for the critically illpatient. In non-critical patient populations, thelevel of congruence between the patients’ andnurses’ perception of pain levels isdemonstrably poor (Boegeskov Nielson et al.,1994; Camp, 1988; McKinley & Botti, 1991;Dudley & Holm, 1984; Teske et al., 1983). In astudy conducted in an Australian intensive careunit, Ferguson et al. (1997) found significantdifferences between nurses’ and patients’average pain intensity scores throughout theirICU stay. The nurses’ were found to haveconsistently underestimated their patients’pain, reinforcing the need for standardisedregular, systematic pain assessment.

© 2003 E l sev i e r S c i ence L td . A l l r i gh t s re se r ved . Intensive and Critical Care Nursing (2003) 19, 154–162 155

Intensive and Critical Care Nursing

A convenience sample of 71 critical carenurses participated in a survey of painassessment and management practicesconducted by Gujol (1994). The survey toolconsisted of two vignettes with two casespresented in each, with multiple choicequestions following each case related to theassessment of a pain score, the amount ofmedication to administer, and the concernswhich would affect choice of pain medication.Thirty percent of the nurses did not believe thepain ratings as indicated by the patients in thecases presented, and concerns of respiratorydepression, addiction, tolerance and physicaldependence affected the decisions of most ofthe nurses. Although a survey design islimited by self-reported information, theresults from this survey revealed manymisconceptions affecting critical care nurses’decisions regarding pain control. Furthermore,this study is consistent with other nursingliterature that highlights the need to prioritisepain management practices to improve patientcare within the critical care area(Fothergill-Bourbonnais & Wilson-Barnett,1992).

Alpen and Titler (1994) have reviewedstudies that assess nurses’ and otherhealthcare professionals’ knowledge andattitudes regarding pain management. Lack ofknowledge in numerous aspects of painmanagement is one of the most commonfindings. This was also supported in a morerecent study by Pederson et al. (1997), relatingto paediatric critical care nurses’ knowledge ofpain management. For this reason,Pooler-Lunse and Price (1992) argue that theeffective assessment and management of painrequires thorough knowledge of itsmechanisms, adverse affects and currenttherapies. The critical care nurse requires skillsin assessment, communication and medicationtitration, together with a strong commitmentand accountability to assess and individualisetreatment.

Communication

Pooler-Lunse and Price (1992) argued thatcritically ill patients who are unable tocommunicate effectively are at high risk ofsuffering pain. Mechanical or physiological

barriers to communication includeendotracheal intubation, loss of consciousness,metabolic disorders, sedation, restraints andfatigue (Fowler, 1997; Pooler-Lunse & Price,1992). These barriers hinder facial expressions,hand movements, moaning, crying or wincingin a situation where reliance on interpretationof behavioural and physiological indicators todiagnose pain is a common clinical occurrence(Puntillo et al., 1997).

Whilst Puntillo (1990) acknowledges theconstraints imposed by the environment andtreatment regimes for intensive care patientscan interfere with the natural process ofcommunication, the subjective experience ofpain presents a dilemma for the critical carenurse caring for a patient who has difficultycommunicating verbally. Christoph (1991) andCheever (1999) assert that the patient’s ownverbalisations are the most reliable indicatorsof pain regardless of whether the critically illpatient is intubated or sedated. Despiteconcern in the literature that intubation is abarrier to effective reporting of pain levels, inPuntillo’s (1994) small, single unit sample, shereported that patients were still able tocommunicate extensive information aboutprocedural pain even when intubated. Despitethe sampling limitations, the findings providesome insight as to the capability of gatheringsignificant information from intubated patientswhen proper assessment tools orcommunication instruments are used. Theintubated patients in the study utilised acombination of pain measurementinstruments to provide information abouttheir pain, including a simple 0–10 numericalrating scale, a body outline diagram to locatethe painful areas and also use of a word listto communicate their sensations andemotions.

Assessing pain in patients with impairedcommunication is not exclusive to critical carepatient populations. Literature relating to theassessment of pain in the confused, non-verbalelderly highlights the inherent difficultiesassociated with patient populations who cannotverbalise the pain experience (Marzinski,1991). Furthermore, Ferrell et al. (1995) foundthat although cognitive impairment amongelderly nursing home residents presents asubstantial barrier to pain assessment,



self-ratings of pain are reliable and valid wheninstruments that are suited to the individualpatient are administered in a manner sensitiveto individual disabilities. Certainly significantresearch has been conducted in paediatricpopulations using specific paediatric tools,such as the Wong/Baker Faces Rating Scale(Wong & Baker, 1988), that provide accuratemethods of assessing pain.

Technology

Invasive technology can restrict the reliance onmany behavioural indicators of pain, as thepatient is often rendered unable to controlmovements normally utilised to express pain.On the contrary, there is also a valid argumentthat the presence of an invasive line enablesconstant measurement of blood pressure andheart rate, two commonly utilised indicators ofpain, and therefore can assist the painassessment process. However, the sympatheticsymptoms, including hypertension andtachycardia, have also been found to beunreliable. With prolonged pain,parasympathetic stimulation may result inless observable signs, yet pain intensity remainsunchanged (Pooler-Lunse & Price, 1992). Astechnology can have a variable impact on thepain assessment process, an awareness ofthe potential implications is essential toenhance the positive aspects whilst takinginto consideration the reality of theunderlying physiology associated withprolonged pain.

Time constraints

Lack of time has been considered a significantbarrier to assessment of pain in the critical carearea. Alpen and Titler (1994) argue that criticalcare nurses frequently neglect pain assessmentwhilst attending more urgent patient needs.Clearly, critical care nurses need to view painwith the same degree of urgency andimportance as other changes in vital signs inorder to improve patient outcomes. Due to therapidly changing situations common in criticalcare, time constraints are often placed on thenurse’s ability to perform pain assessment andmanagement. In order to perform an accurateassessment of pain, a variety of methods may

be required, once again increasing theessential time necessary to gain a responsefrom the critically ill patient. Similarly, highwork demands and subsequent timeconstraints have been identified in otherhealthcare areas as impacting on the nurse’sability to meet patient’s pain managementrequirements (Bucknall et al., 2001; Maniaset al., 2002).

Multidisciplinary collaboration

The critical care nurse depends oncollaboration with other staff in providingoptimum care for the patient. Medical staff arerequired to prescribe the medications,including analgesics and sedatives, which areoften utilised synergistically to control pain inthe critical care environment. The knowledgeand expertise of medical staff in relation topain management modalities available is animportant element to be considered in the painmanagement process.

In order to enable medical staff to prescribeadequate analgesia, there needs to be aneffective communication of the level of painbeing experienced by the patient. Hence theneed to perform regular, accurate painassessments which are then documented sothat an effective pain management plan can bedeveloped in conjunction with other membersof the multidisciplinary team.

Research limitationsRecognition of the limitations of the studiesthat have been conducted thus far in relationto the barriers to pain assessment andmanagement in critical care is required inorder to assess the utility of the researchfindings. Small sample sizes and studypopulations, which are derived from only oneor two hospitals, limit the generalisabilty ofthe results. Furthermore, study patients thathave undergone a specific group of proceduresare not necessarily representative of the entirecritically ill population. However, these studiesprovide beginning descriptions of the issuessurrounding pain assessment andmanagement in critical care, and can thereforebe utilised to provide the basis for furtherresearch.



Strategies for changing practiceIn understanding the barriers to nurses’decision making and pain managementpractices, it is possible to identify strategies thatcan assist nurses to overcome them. Strategiesto be examined in this paper have been provento successfully address the barriers describedearlier. These include an improvement indocumentation practices, the development ofguidelines and algorithms to augmentclinical decision making, and increasingeducation of critical care nurses in the areaof pain management (see Table 1 for asummary of strategies targeted towardsspecific barriers).

Table 1 Published strategies for implementation of improved pain management practices in critical care

Strategy Barriers addressed

Formulation and adoption of standards on pain assessment,reassessment and pain documentation (Alpen & Titler, 1994)

Communication, technology, nursingknowledge, time constraints

Utilisation of a detailed, standardised pain assessment andintervention notation algorithm that incorporatesbehavioural and physiological indicators (Puntillo et al., 1997)

Communication, nursing knowledge

Identify pain assessment tools that may be used and ensurethat it is incorporated into the daily routine (Alpen & Titler,1994; Kaiser, 1992)

Communication, time constraints

Development of physiological and behavioural pain-ratingtools to improve pain assessment in patients with alteredconsciousness (Carroll et al., 1999)

Communication, technology

Alternative tools, such as a communication board, for patientswith functional deficits should be readily available androutinely used (Carroll et al., 1999)

Communication, technology

Preprinted areas on assessment and flow records to helpensure consistent assessment of pain and reassessment afterpain interventions (Carroll et al., 1999; Caswell et al., 1996;Alpen & Titler, 1994)

Time constraints, nursing knowledge

Utilisation of a standardised pain flowsheet to assess painintensity and document pharmacologic intervention (Voigtet al., 1995; Tittle & McMillan, 1994)

Communication, nursing knowledge

Increase the knowledge of critical care nurses with regard topain, including the provision of workshops and promotingspecific staff members to become resources in painmanagement (Alpen & Titler, 1994)

Nursing knowledge

Revision of nursing curricula and development of long-termcontinuing education programs in the area of painmanagement (Tittle & McMillan, 1994; Pooler-Lunse & Price,1992)

Nursing knowledge

Incorporation of a pain management project as a QualityImprovement Activity, including the development andimplementation of pain management guidelines (Caswellet al., 1996; Alpen & Titler, 1994)

Communication, technology, nursingknowledge, time constraints

Implementation of a research-based pain managementprotocol, utilising the champion for change concept andparticipative method for change (Titler et al., 1994)

Nursing knowledge, time constraints

Promotion of pain as the “fifth vital sign” (Winslow, 1998;Stanik-Hutt, 1998)

Communication, time constraints

Documentation

It is argued that pain should be considered tobe the “fifth vital sign”, and be measured anddocumented as carefully and regularly as heartrate, blood pressure, respiratory rate andtemperature (Winslow, 1998; Stanik-Hutt,1998). Kaiser (1992) recommends the use of apain assessment documentation tool. Aneffective pain assessment tool should formpart of the documentation process as a meansof improving communication not onlybetween patients and nurses but also betweennurses and medical staff. The incorporation ofan assessment tool and the allocation of aspecific place on the flowsheet for the



documentation of pain assessment provides avaluable external cue to prompt nurses toundertake the pain assessment process. Todate, there is not a universal pain assessmenttool that is suitable for all critically ill patients.Elements of a variety of different tools may berequired according to the condition of thepatient. For example, a patient with aparticular type of sensory impairment, orunable to read or write, will require a tool thatincorporates the needs according to thedisability present. A simple tool, which isstraightforward and not too time consuming,is valuable in the critical care environment.

The literature indicates the importance ofdocumenting findings in relation to painassessment (Hill, 1985), especially when thepatient is unable to relay this information tothe medical staff, as is the situation for manycritical care patients. The effectiveness oftherapies cannot be adjusted according to needif there is no record of the pain managementcarried out. Indeed, in the absence of this typeof documentation the effectiveness of therapiesis difficult to track and hampers continuity ofcare for patients.

The continued lack of pain assessmentdocumentation also highlights the ongoinggap between research and practice, given thatthere has been strong evidence since themid-1980s that documentation of painassessment improves pain management, andmost importantly, decreases patients’ pain.

The clinical decision making literaturedemonstrates that the external stimuli for thedecision maker reminds the individual ofvariables available to make these choices(Carroll & Johnson, 1990). Therefore, it isargued that flowchart documentation is likelyto prompt nurses to assess the patient’s typeand level of pain more frequently than if thedocumentation was not required. In raising thenurses’ awareness of a potential problem, itshould in fact improve the likelihood oftreatment should the patient require it.

Tittle and McMillan (1994) conclude thatnurses in both intensive care and surgical unitsdo not appropriately assess, manage orevaluate pain and pain-related side effects,and recommend that efforts must be made tochange nurses’ pain management behaviours.Their study involved a convenience sample of

44 adult patients being treated for pain. Theinvestigators reported how often nurses inboth settings recorded information relating toassessment of the patients’ pain andevaluation of pain-relief measures. Of the 20patients in ICU, not one had a pain ratingrecorded by the nurse throughout the 24-hourperiod. Data related to pain location wasrecorded for 50% of the patients, verbalstatements about the pain were recorded for20% of the ICU patients and observationsabout non-verbal behaviour were documentedfor only 5% of the patients. There was nodocumentation related to quality, pattern orintensity of pain. Once again, the small samplesize and restricted sample population limit thegeneralisability of the study results.

Despite research literature demonstratingthat critically ill patients, including thoseintubated or sedated, are able to communicateextensive information about their pain levels,critical care nurses continue to document theirown interpretation of the patients’ pain.Unfortunately, this is a subjectiveinterpretation of the patient’s pain that may infact underestimate the severity and indeed thelocation of the pain.

The use of nursing assessment sheets thatinclude a Visual Analogue Scale, questionsrelated to quality and pattern of pain and alsoa pain flowsheet to monitor the patients’ painstatus are not new recommendations (Alpen &Titler, 1994; Porter, 1995; Voigt et al., 1995).Indeed, adding the Visual Analogue Scale orother categorical measures with furtherquestions would strengthen the reliability ofpain assessments. However, it is important toremain consistent with the use of tools asresearch has shown that pain scores of 0–5 arenot interchangeable with those on a 0–10 scale(Carpenter & Brockopp, 1995). Titler et al.’s(1994) study demonstrated that a successfullyimplemented research-based pain managementprotocol led to a decline in the number ofpatients in pain, a decline in pain intensityand improvement in nurse’s knowledgeabout pain.

Although initially the documentationprocess may be seen to further impinge uponthe time constraints under which critical carenurses work, the resultant improvement inpain management should overcome the initial



concerns of increasing nurses’ time spent onpaperwork.

Guidelines and algorithms to augmentclinical decision making

The clinical practice guidelines developed bythe National Health and Medical ResearchCouncil in Australia (NHMRC, 1999) to assisthealth professionals in the management ofacute pain recommend the use of an algorithmfor management of pain in the ICU. The use ofsuch guidelines assists clinical decisionmaking by providing a consensus on the bestavailable research evidence to assist theclinicians in assessing and treating pain.Guidelines relating to the pain assessmentprocess are a particular necessity for cliniciansin the critical care setting where knowledgerelating to pain management practices hasbeen acknowledged to be inadequate.However, these guidelines are difficult for anindividual nurse to implement in practicebecause the recommendations lack specificityfor the local clinical setting in which they areto be implemented. Bucknall et al. (2001) haveargued for these guidelines to be translated tothe local environment. The translation may bein the form of an algorithm or decision tree.Puntillo et al. (1997) found that the use of adetailed, standardised pain assessment andintervention notation algorithm assisted inmaking more accurate assessments of patients’pain intensity, and therefore improved thelevel of congruence between patients’ andnurses’ perceptions of pain intensity.

Education

The concept of raising the profile of pain, inparticular the promotion of pain as the fifthvital sign, would encourage critical care nursesto conduct and document pain assessmentprocesses as readily as other routineobservations. Tittle and McMillan (1994)strongly argued for a revision of nursingcurricula and the development of long-termcontinuing education programmes in order toimprove nursing practice in the area of painmanagement. Nurses can also contribute topatients’ well being by taking some

responsibility for their learning. In seeking agreater understanding of the methods ofrelieving patients’ pain, critical care nursesmust translate updated information into theirown clinical setting. Particularly whenorganisations, such as NHMRC, CochraneCollaboration and the Joanna BriggsInstitute, have produced national guidelines,systemic reviews and practice informationsheets, respectively, on the topic of painmanagement.

Implications for further researchThe National Health and Medical ResearchCouncil (NHMRC) in Australia noted that themanagement of acute pain fails to be givenappropriate priority and that acute pain is notproperly treated in a variety of clinicalsituations (NHMRC, 1999). In reviewing thescientific evidence for the management ofacute pain in intensive care, the NHMRCfound that there is a paucity of data on whichto base rational treatment for this particularpopulation. Too often the gold standard,randomised controlled trials, providingclinicians with evidence of effectiveness oftreatments, has not been conducted in thecritical care setting. Therefore, there is anurgent need for application of specific dataobtained in this setting.

Continuous evaluation of pain managementpractices, including a review of theprioritisation of pain, and also the level ofknowledge of critical care nurses in relation toresearch-based pain management strategieswould not only promote improved painmanagement but would also assist in theplanning of further education.Recommendations arising from this continuousevaluation cycle would be utilised to decreasepatient pain experiences in critical care.

Research reviewing and measuring theutilisation of pain management guidelines andalgorithms in critical care settings wouldprovide significant insight as to the currentpractice of critical care nurses and theeffectiveness of such tools. Of further interestwould be a review of the documentationpractices of critical care nurses in relation topain assessment. Documentation to trackpatients’ pain experience assists us in



understanding the subjective experience andalso the contextual influences.

Whilst there has been much literatureproviding evidence on nurses’ perceptions ofpractice, and their decision making undercontrolled situations, there is very littleobservational research to investigate actualpain assessment practices of critical carenurses in routine clinical practice. Thisresearch has the potential to provide anincredible richness of data on the complexinterplay of variables influencing nurses’decision making that cannot be obtained fromsurveys or randomised controlled trials.

ConclusionThe need to be accountable and responsible foreffective pain assessment is an essential factorin improving pain management for thecritically ill. Acknowledgement by critical carenurses that the pain management process, andin particular the assessment of pain, is poorlyundertaken within the critical careenvironment is an important step towardsimproving pain management.

The literature presents vast amounts ofscientific evidence as to the significance ofpain for the critically ill, yet a paucity on theeffectiveness of pain management. Critical carenurses need to not only be aware ofresearch-based pain management practices,but also lead the way in implementation andcontinuous evaluation as a measure ofdecreasing patient pain in the future.

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Pain assessment in critical care: what have we learnt from research