RESEARCH
How do intensive care nurses assess patients’ pain? Fatma Eti Aslan, Aysel Badir and Deniz Selimen SUMMARY • Identification and evaluation of pain in critical care patients may be difficult because of communication problems. Moreover, at present there are very few nursing studies that examine the attitudes of critical care nurses towards the assessment of patients’ pain • This study was designed to determine the approach of critical care nurses towards assessing patients’ pain levels, and to evaluate the problems in nursing diagnosis of those having difficulty in articulating their pain symptoms • We used a questionnaire to assess nurses attitudes to patients’ pain. The study sample consisted of 91 critical care nurses who were recruited between January and February 2002. The results suggest that patient pain was considered undesirable by 44% of nurses. About 70·3% of the nurses reported resorting to administering analgesics to relieve their patients’ pain • Some 57·1% of nurses stated that they would have investigated whether the patients had really been experiencing pain, prior to administering the prescribed analgesics to patients • Some 85·7% of the sample indicated that the patients themselves would make the most accurate evaluation of their pain. The data suggested that 39·6% of nurses did not know how to evaluate pain symptoms in critical care patients suffering from complicated problems, and that 37·4% evaluated pain by monitoring the patients’ behaviours • The study demonstrated that most of the critical care nurses did not know how to evaluate pain in patients having communication problems. The paper concludes by suggesting that there is a clear need to address nursing education and training with regard to evaluation and management of patients’ pain whilst in critical care environment Key words: Critical care/ intensive care • Intensive care nurse • Nursing interventions • Pain assessment • Pain
INTRODUCTION Compared with nurses working in other areas, intensive care unit (ICU) nurses must be able to make rapid decisions and must be more aware of and sensitive to physiological and psychological changes in patients. Care in the ICU always depends on what the nurse interprets through the senses of observation, hearing and touch. The critical care nurse is in a position to immediately observe changes in the patient, and thus prevent the development of complications affecting recovery. Like many other aspects of care, the symptoms, assessment and management of pain, are of particular importance for patients in the ICU. Pain is a physiological manifestation that accompanies the individual during the birth process, over the course of growth and development, in sickness and at death. Pain is the most
Authors: FE Aslan, RN, PhD, Associate Professor, School of Nursing, Marmara University; A Badir, RN, PhD, Assistant Professor, School of Health Sciences, KOC University, Istanbul, Turkey; D Selimen, RN, PhD, Professor, School of Nursing, Marmara University, Istanbul, Turkey Address for correspondence: A Badir, Assistant Professor, RN, PhD, School of Health Sciences, KOC University, Rumelifeneri Yolu, 34450 Samyer, Istanbul, Turkey E-mail:
[email protected]
62
important and the most common subjective condition that makes individuals to seek help from health professionals. It is for this reason that pain assessment is very dependent on the nurse–patient relationship. However, nurses must also be skilled in obtaining a detailed pain history, which might involve analysing the patients’ experiences, continuous observation of physiological parameters and using pain assessment tools (Puntillo and Wilkie, 1991; Jezewski et al., 1993). The most reliable resource for data on the patient is the patient himself or herself. In cases where an endotracheal tube is in situ or a tracheostomy has been performed or in any other situation where the patient’s consciousness has been affected, the evaluation of pain becomes very difficult (Puntillo, 1990; Pasero and McCaffery, 2000). This raises the question of how pain is indeed assessed in the ICU and the accuracy of data obtained. Arguably, the close proximity of nurses to the patient puts them in a unique position to be able to effectively assess and manage the individuals’ needs and priorities. Many studies have shown, however, that nurses do not make efficient use of their proximity to the patient. Puntillo and Weis (1984) have suggested that nurses do not attempt to relieve patients’ pain if they themselves do not identify a cause for the pain. Nursing in Critical Care 2003 • Vol 8 No 2
Assessment of patients’ pain
Seers (1987) claimed that 54% of nurses’ expectations of patient pain tend to be lower than what is actually reported by patients. More recently, Libreri (1995) has concluded that 58% of physicians and nurses are not sufficiently knowledgeable about the management of patient pain, and therefore do not take adequate measures to relieve it. Owing to the wide range of invasive procedures and nursing interventions in health care, it can be safely stated that patients suffer from significant pain whilst in critical care, but they are unable to communicate their discomfort. Studies on pain evaluation approaches in the ICU setting remain limited (Puntillo, 1990; Lloyd, 1994; Carroll et al., 1999). Puntillo (1990) has suggested that although 63% of patients in the ICU are treated for pain by pharmacological measures, 80% of the ventilated patients can only indicate pain with their eyes, or by leg movements or by reaching out for the nurse’s arm. Interestingly, Stannard et al. (1996) noted that although nurses did administer the prescribed analgesics, patients still complained of unsuccessful pain control. Pederson et al. (1997) have further established that 63% of nurses, studied in a paediatric critical care setting, believe that they have been unable to achieve effective pain control in patients who are unable to communicate their pain. Puntillo (1997) has pointed to the discrepancy between the intensity of pain expressed by patients and the evaluation of this pain by nurses. She has established that nurses tend to underestimate patient pain and therefore decrease the amounts of analgesics administered. Inevitably, pain which is not adequately addressed may result in many complications, such as hypoxemia resulting from respiratory disorder, myocardial ischaemia resulting from increased sympathetic activity, sodium and water retention, decreased gastrointestinal activity and venous stasis related to inactivity and thrombo-embolisms (Alspach, 1994; Acello, 2000). Therefore, performing pain assessment is of vital importance for vulnerable groups such as ICU patients. The investigators have noted a lack of comprehensive pain assessment of ICU patients during their professional clinical practice experience. Literature searches of the relevant topics have also shown that there are no studies published on ICU pain assessment in Turkey. The aim of this study was to establish how critical care nurses in Istanbul, Turkey evaluate pain in patients who are unable to communicate verbally, i.e. confused, intubated patients or those with tracheostomies, and how they interpret physiological and behavioural pain responses. Nursing in Critical Care 2003 • Vol 8 No 2
Research questions
• How do ICU nurses define pain? • How do ICU nurses define the physiological reactions and behavioural responses of patients to pain? • How do ICU nurses evaluate pain in patients who are intubated, have a tracheostomy or are suffering from decreased levels of consciousness?
METHODS The current study was a cross-sectional survey consisting of demographic information and open-ended questions aiming to assess nurses’ definitions and assessment of pain in patients who were unable to communicate verbally. Data were collected in January–February 2002, from critical care nurses in three university hospitals of Istanbul, Turkey. Marmara University Hospital, on the Asian side, is a hospital with 400 beds, two critical care units of 14 beds each and a team of 16 critical care nurses. Istanbul University Cerrahpasa Medical School Hospital, on the European side, accommodates 2000 patients, has 35 critical care beds and operates with a team of 35 critical care nurses. Istanbul University’s Istanbul Medical School Hospital accommodates 1463 patients, has 41 critical care beds and 62 critical care nurses.
SAMPLE The scope of the study encompassed collecting questionnaire data from all 113 critical unit nurses who had been working at three public university hospitals in Istanbul for at least 1 year. We were able to interview 91 nurses who fit the study selection criteria, who were not on leave during data collection and gave verbal consent to participate in the study. Refusal to participate in the study was 6·8%.
DATA COLLECTION The survey questionnaire was based on current literature and on the knowledge and experience of the research team. The questionnaire consisted of 20 questions, 17 open-ended and 3 closed. The questionnaire was pilot tested in a sample of critical care nurses working in a hospital not included in the study. Questions that were misunderstood or did not seem to work were revised, according to the feedback received. Nursing staff from each unit were approached, and were invited to participate by the researchers who spent a day (7:00 am to 12 midday) on the site. To avoid introducing interviewer bias in a partially qualitative study, the questionnaire was delivered but not administered to the study participants who were asked to answer each of the questions on their own. The average time it took 63
Assessment of patients’ pain
for the participants to complete and return the questionnaire was 19min.
DATA ANALYSIS The three investigators evaluated the open-ended questions independently of each other, and grouped common views and phrases together. Repeated patterns in open-ended questions were listed in order of commonality. Nurses who gave oral consent to take part in the study were informed and guaranteed that the answers would be anonymous, confidential, and that the study data would be used only for scientific purposes. The study protocol was pre-approved by each of the three hospitals that provided the study sample.
RESULTS Findings presented in Tables1–4 reflect the individual characteristics of the nurses, their definitions of pain, their awareness of physiological and behavioural responses to pain and particularly their approaches towards pain assessment in relation to patients who are unable to communicate verbally. Demographic information collected from the subjects shows that 69·2% (n=63) of nurses were in the 20–29 age group, at an average age of 27·2+6; 59·3% (n=54) had 2-year associate degrees and 50·5% (n= 46) had 6–10 years of experience in the ICU. Only 14·3% (n=13) of the subjects had received pain management education (Table 1), but this was during student training and was limited to 2h a week for 1 year.
With respect to definitions of pain, 44% (n=40) of ICU nurses’ defined pain as an unpleasant sensation and another 44% (n=40) defined it as a physical condition (Table 2). All nurses who participated in the study reported having experienced pain themselves. With regard to the proportion of analgesics administered ‘as needed’, Table 2 indicates that 57·1% (n=52) of the nurses initially attempted to assess the patient and establish the nature of pain experienced before administering the medication. ICU nurses defined the physiological responses to pain as a tachycardia in 52·7% (n=48), as an increase in arterial blood pressure in 47·3% (n=43), as diaphoresis in 31·9% (n=29), as increased respiration rate in 25·3% (n=23) and as nausea/vomiting in 5·5% (n=5). However, it is disconcerting that a quarter of the participants (n=23) stated that they did not know what the physiological responses to pain were in an ICU patient (Table 3). In defining behavioural response to pain, 71·4% (n=65) ICU nurses pointed to restlessness, 22% (n=20) singled out crying/moaning, 12·1% (n=11) described body position and facial expressions and 7·8% (n=7) cited disorientation as a characteristic response (Table 3). Amongst the sample of nurses, 85·7% (n=78) stated that the most correct pain assessment would be that made by the patients themselves and 76·9% (n=70) said that there was not always a pathological explanation for pain. Twenty-seven nurses suggested that the most Table 2 Definition of pain and their approach in the administration of ‘as needed’ analgesics by the intensive care unit (ICU) nurses
Table 1 Individual characteristics of the intensive care unit (ICU) nurses Number (n = 91)
%
Age groups 20–29 years 30–39 years
63 28
69·2 30·8
Educational level Associate degree Bachelor degree
54 37
59·3 40·7
Nursing experience in nursing 1–5 years 6–10 years
44 47
48·4 51·6
Nursing experience in ICU 1–5 years 6–10 years
45 46
49·5 50·5
Pain management education* Received Not received
13 78
14·3 85·7
Individual characteristics
*Nurses indicated that they only received this education in their basic nursing training. 64
Definition of pain Unpleasant sense A physical sign A hurting situation Individual’s feeling Alarm sign of the organism Situation changing the priorities of life Situation where the organism does not develop immunity Unexplainable feeling Approaches in the administration of ‘as needed’ analgesics † Assessment of the patient Pain intensity Vital signs Allergies Side effects of the drug
Number (n = 91)*
%
40 40 33 13 12 11
44·0 44·0 36·3 14·3 13·2 12·1
3 1
3·3 1·1
52 40 31 25 9
57·1 44·0 34·1 27·5 9·9
*Percentages were calculated as to the group size. † More than one response was given. All experienced pain. Nursing in Critical Care 2003 • Vol 8 No 2
Assessment of patients’ pain
Table 3 Physiologic responses and pain behaviours of the patient according to the intensive care unit (ICU) nurses Responses and pain behaviours
Physiologic responses † Increase in heart rate Increase in blood pressure Diaphoresis, pallor Increase in respiration rate Do not know Nausea, vomiting Pain behaviours † Restlessness Crying, moaning Posture Facial expression Do not know Disorientation Dissatisfaction from care Massage in pain area Increase in extremities movement Decrease in movements
Pain assessment
Number (n = 91)*
%
48
52·7
43
47·3
29
31·9
23
25·3
23 5
25·3 5·5
65 20 11 11 9 7 7 6
71·4 22·0 12·1 12·1 9·9 7·7 7·7 6·6
6 4
6·6 4·4
*Percentages were calculated as to the group size. † More than one response was given.
accurate approach to pain evaluation would be to consider the statement of the patient, and 33% (n=30) indicated that vital signs would be taken as criteria in confused patients. About 37·4% (n=34) said that they would monitor behavioural cues suggestive of pain in patients who were unable to respond verbally owing to endotracheal intubation or a tracheostomy. Involving family members’ was also a strategy adopted by a majority of nurses to assist in managing the patient’s pain. For example 66% (n=60) claimed that they had previously sought help from the patient’s family in cases where patients could not communicate verbally (Table 4).
DISCUSSION In recent years, many studies have been carried out on the mechanism of pain, concepts of pain, factors affecting the perception of pain, pain evaluation and control. It may not be possible, however, to apply the concept of ‘the patient’s own expression of pain’, which is the basis of pain evaluation, to all patients. There are many studies showing that intubated patients with particular health problems or those who, as a result of certain treatments, cannot communicate their pain do in fact suffer from a significant amount Nursing in Critical Care 2003 • Vol 8 No 2
Table 4 Pain assessment of the intensive care unit (ICU) nurses
What is the most accurate approach in pain assessment? † Believing in the patient’s expression Identification of the pain characteristics Use of pain scale Observing the physiological signs Pain history Observing the behaviours Assessing the algologists Assessment of the confused patient † Do not know Assessment of the vital signs Assessment of the behaviours Obtain previous pain behaviours from family/significant others Assessment of the patient who has verbal communication problem (patient with endotracheal tube or tracheostomy canule) Assessment of the behaviours Assessment of the vital signs Using written communication Using sign language Help needed for the patients who cannot communicate their pain † Family/significant others Physician Do not know Decision made according to the diagnosis
Number (n = 91)*
%
27 23 22 13 11 3 3
29·7 25·3 24·2 14·3 12·1 8·8 3·3
36 30 29
39·6 33·0 31·9
11
12·1
34 29 18 4
37·4 31·9 19·8 4·4
60 46 10
66·0 50·5 10·1
13
14·3
†
*Percentages were calculated as to the group size. † More than one response was given.
of discomfort (Puntillo and Weiss, 1984; Puntillo, 1990; Lloyd, 1994; Puntillo, 1997; Carroll et al., 1999; Bett, 2001; Puntillo et al., 2001). In this study, we have attempted to determine how intensive care nurses assess pain in patients who are unable to verbally communicate their pain (confused, intubated patients or those with tracheostomies); how nurses interpret physiological and behavioural pain responses and how they identify their approach to pain assessment. Our findings were evaluated in the light of current literature. The average clinical experience of the 91 critical care unit nurses included in our study was 5·4 ± 4 years. This suggests that, although professionally experienced, ICU nurses had minimal theoretical understanding of pain management and control. Indeed only 14·3% (n=13) had been exposed to instruction in these areas, and this training was limited to 2h only (Table 1). This finding is in agreement with that of other 65
Assessment of patients’ pain
researchers who have had reported that nurses are ineffective in pain assessment and have a limited knowledge base of pain (Puntillo and Weis, 1984; Seers, 1987; Lloyd, 1994; Libreri, 1995; Field, 1996; Stannard et al., 1996; Bett, 2001). Amongst the 91 ICU nurses in our study, 44% (n=40) defined pain as ‘an unpleasant sense’, and have taken the subjective and complex nature of pain into consideration. However, it is interesting that the same number of the nurses defined pain as a physical condition and expressed the need to look for a pathological basis in pain assessment. All the ICU nurses reported to have experienced pain themselves. Interestingly, nurses use analgesic intervention as a last resort in the care of the patient (Puntillo and Weis, 1984; Seers, 1987; Stannard et al., 1996; Carr, 1997). Indeed, even in cases where the patients made their pain known and analgesics were prescribed ‘as needed’, 57·1% (n=52) of our study sample failed to administer the medication immediately but waited until after verification of the extent of pain (Table 2). This approach could suggest a mistrust of the patient by nurses. It is believed that this may be owing to a lack of awareness of nurses of the consequences of unrelieved pain. Whilst the basis of pain assessment might include the patient’s own verbal statement, facial expressions, posture and body language, changes in heart rate, respiration and in arterial blood pressure as well as physiological changes such as sweating, nausea and vomiting could also be pain indicators of discomfort (Tittle and McMillan, 1994). In this context, when asked what the physiological and behavioural pain indicators are in patients who are unable to verbalize their feelings, a significant proportion of ICU nurses indicated awareness in this area (Table 3). This is promising in terms of the care of patients in the ICU who are unable to communicate their pain. Although 85·7% of ICU nurses stated that the patient suffering from the pain is the most reliable source of assessment, only 29·7% (n=27) of these nurses based their evaluations on the patient’s own communication (Table 4). We feel that this is clearly an indication of an inadequate knowledge of the subject, and is an area of development of ICU nursing. It was found that 33% (n=30) of the nurses in the study accepted vital signs as criteria in the pain assessment of confused patients. In the case of patients who are unable to verbalize their pain owing to endotracheal intubation or a tracheostomy, only 37·4% (n=34) stated that behavioural responses were monitored to determine the intensity of pain (Table 4). This is significant because critical care nurses are expected to monitor behavioural responses rather than vital signs. 66
In her study, Puntillo (1990) showed that 80% of patient subjects, although under endotracheal intubation, attempted to indicate their pain with their eyes, by holding on to the nurse’s arm, or by moving their legs. It is vital to be able to monitor the behavioural indicators of pain in patients who are unable to communicate. Puntillo et al. (2001), in their study of 706 ICU nurses registered in the American Critical Care Unit Nurses Association, showed that 78% of ICU nurses accepted that critical care unit patients received inadequate pain treatment. In spite of this, it was also shown that 98% of these nurses did not administer the analgesics prescribed in case of need. In cases where the patient cannot speak and are perceived to be in discomfort, information as to the patient’s previous experiences with pain and their coping responses can be gathered from family members (Pasero and McCaffery, 2000). When asked about from whom they ask for help in cases where the patients cannot verbalize their pain, 66% (n=60) of critical care unit nurses said that they approached the family. This can be regarded as a correct approach (Table 4). In conclusion, it was established that most of the ICU nurses in the study defined pain as an unpleasant sensation and a physical finding, and that they accepted tachycardia and an increase in arterial blood pressure as a physiological response and restlessness as a behavioural response. The nurses showed that they considered the statement of the patient the most reliable means of pain assessment, and revealed that they themselves sought relief from analgesics in treating their own pain. In patients with difficulty in verbal communication of pain, the nurses said that they sought the help from patients’ families. A significant finding was that ICU nurses did not receive any in-service education on pain and pain assessment graduation, and that the education they ever received at all in this area was restricted to 2h of class-time in school. Our findings therefore have shown that ICU nurses should be supported with continuous professional education in relation to pain assessment and management, including alternative therapies. For future perspectives, the investigators hope to study a wider sample for a more comprehensive study of patient pain assessment in all of its aspects.
REFERENCES Acello B. (2000). Meeting JCAHO standards for pain control. Nursing; 30: 52–54. Alspach G. (1994). Pain management: dispelling some myths. Critical Care Nurse; 15: 13–16. Bett F. (2001). Pain tool audit in coronary care. Nursing Times; 97: 38–39. Carr E. (1997). How to improve pain management practices. Nursing Times; 93: 52–53.
Nursing in Critical Care 2003 • Vol 8 No 2
Assessment of patients’ pain
Carroll KC, Atkins PJ, Herold GR, Mlcek CA, Shively M, Clapton P, Glaser DN. (1999). Pain assessment and management in critically ill postoperative and trauma patients: a multisided study. American Journal of Critical Care; 8.2: 105–117. Field L. (1996). Are nurses underestimating patients’ pain postoperatively? British Journal of Nursing; 5: 778–784. Jezewski MA, Scherer Y, Miller C, Battista E. (1993). Consenting to DNAR: Critical care nurses’ interactions with patients and family members. American Journal of Critical Care; 2: 302–309. Libreri F. (1995). An acute pain service: a quality assurance survey of nurses and doctors. Journal of Advanced Nursing; 12: 33–38. Lloyd G. (1994). Nurses’ attitudes towards management of pain. Nursing Times; 90.43: 40–43. Pasero C, McCaffery M. (2000). When patients can’t report pain. American Journal of Nursing; 101: 69–70. Pederson C, Matt Hies D, McDonald S. (1997). A survey of paediatric critical care nurses’ knowledge of pain management. American Journal of Critical Care; 6: 289–295. Puntillo KA. (1990). Pain experiences of intensive care unit patients. Heart & Lung; 19: 526–533.
Puntillo KA. (1997). Stitch, stitch. Creating an effective pain management program for critically ill patients. American Journal of Critical Care; 6: 259–260. Puntillo KA, Benner P, Drought T, Drew B, Stotts N et al. (2001). End of life issues in intensive care units: a national random survey of nurses’ knowledge and beliefs. American Journal of Critical Care; 10: 216–229. Puntillo KA, Weiss SJ. (1984). Pain: its mediators and associated morbidity in critical ill cardiovascular surgical patients. Nursing Research; 43: 31–35. Puntillo KA, Wilkie DJ. (1991). Assessment of pain in the critically ill. In: Puntillo KA, (ed.), Pain in the Critically Ill: Assessment and Management. Gaithersburg: Aspen Publishers, 45–64. Seers K. (1987). Perception of pain. Nursing Times; 83: 37–39. Stannard D, Puntillo KA, Miaskowski C et al. (1996). Clinical judgement and management of postoperative pain in critical care patients. American Journal of Critical Care; 5: 433–441. Tittle M, McMillan SC. (1994). Pain and pain related side effects in an ICU and on a surgical unit: nurses’ management. American Journal of Critical Care; 3: 25–30.
Would you like to join the BACCN and receive this journal free? Yes? - Then join thousands of others in accessing the largest organisation dedicated to the promotion of excellence in the provision and delivery of critical care nursing in the U.K. We currently have over 3,700 members enjoying the following benefits: • • • • • • • •
Six Editions of the journal ‘Nursing in Critical Care’ Reduced rates at all BACCN events Annual national and regular international conferences Study tour and conference awards Opportunities for members to engage themselves in regional activity Reduced course fees from some Critical Care education companies 5% reduction on Blackwell Science publications Centralised membership and administration
For more information about becoming a member of BACCN please contact Jo Brock, Highways, Down Lane, Braunton, North Devon EX33 2LE Tel: 01271 815572 or visit our website at www.baccn.org.uk
Nursing in Critical Care 2003 • Vol 8 No 2
67
