critical care pain management

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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

Background Regular pain assessment can lead to decreased

incidence of pain and shorter durations of mechanical ventila-

tion 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 3753intensive care unit nurses identified through the 12 Canadian

provincial/territorial nursing associations responsible for pro-

fessional 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 communi-

cate (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 self-

report tools (703 nurses, 88%). Routine (>50% of the time) dis-

cussion of pain scores during nursing handover was reported

by 492 nurses (61%), and targeting of analgesia to a pain scoreor 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. Rou-

tine use of a behavioral pain tool was associated with aware-

ness 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 guide-

lines published by professional societies. (American Journal

of Critical Care. 2012;21:251-259)

CRITICALCARE NURSESPAINASSESSMENT ANDMANAGEMENTPRACTICES:

A SURVEY IN CANADA

www.ajcconline.org J AMERICAN JOURNAL OF CRITICAL CARE, July 2012, Volume 21, No. 4 2

2012 American Association of Critical-Care Nursesdoi: http://dx.doi.org/10.4037/ajcc2012611

Critical Care Evaluation

This article is supplemented by an AJCCPatient CarePage on page 260.


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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 nurs-

ing association to distribute surveys, the nurse man-

ager of 1 of the 2 ICUs in the remaining province

(Prince Edward Island) assisted with survey distri-

bution. In order to maximize response rates, surveywere 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. Partici-

pants were provided with a self-

addressed, postage-paid reply

envelope to return the survey to

the coordinating center.

Statistical MethodsTest-retest reliability was eval-

uated by using the Cohen statis-

tic; a value of 0.4 or greater was

considered to represent moderate

to good agreement.29 Because some surveys had miss-

ing data, item denominators varied. Categorical data

were summarized as proportions and 95% confi-

dence intervals. The five response categories (never,

seldom, sometimes, often, routinely) were

dichotomized as 50% of the time or less (never, sel-

dom, 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 pre-

emptive analgesia for various painful procedures24

and the importance of pain assessment for medical

vs surgical patients. Variability in the use of assess-

ment 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 guide-

lines, availability of tools, education on use of thetools, presence of protocols or

guidelines, years of ICU experience)

were examined by using multiple

logistic regression. All models were

assessed for collinearity and good-

ness 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.

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. Compari-

son of the 2 versions, by the primary and francoph-

one investigators (L.R. and C.G.), revealedalterations of meaning for some behavioral descrip-

tors, which were resolved through discussion.

Sampling and Study Population

The sample frame was 16 036 nurses who iden-

tified critical care in a hospital setting as their pri-

mary area of practice whose names were obtained

from the 12 provincial/territorial nursing associa-

tions 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 estimatedtotal 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 mis-

classification of nurses employment location, 3753

surveys were distributed. In order to obtain repre-

sentation 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 pedi-

atric 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.


A stratified,disproportionaterandom samplinstrategy was us

to include inten-sive care unit

nurses from allCanadian provincand territories.

A response rate24% yielded 802evaluable survey


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ResultsParticipants 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 North-

west 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 univer-

sity-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. How-

ever, nurses reported they were less likely to use a

behavioral pain assessment tool than a self-report

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

50% of the time for patients unable to communi-

cate, 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 assess-ment 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 nurse-

to-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 scale30was 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 assess-ment tools used were the Behavioral Pain Scale,23

used by 122 of 294 nurses (41%); the Adult Non-

verbal 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 com-

municate consisted of assessment of both behav-

ioral 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 fam-

ily 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 pub-

lished guidelines and clinical availability of a tool

when adjusting for education on pain assessmenttools, 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

Table 1

Participants demographics

Intensive care unit experience, y (n=801)5-10>10

Highest qualification (n= 802)Diploma in nursingBachelors degree in nursingMasters degree

Employment status (n =798)Full-timePart-timeCasuala

Shift rotation (n= 752)Rotating shiftsDays onlyNights or evenings only

Type of intensive care unit (n =799)CombinedCardiovascularMedical (only)Neuroscience (only)Surgical (only)Other

Hospital type (n= 782)University affiliatedLarge community (200 beds)Moderate community (50-199 beds)

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

389 (48.5)386 (48.1)

27 (3.4)

517 (64.8)226 (28.3)

55 (6.9)

544 (72.3)99 (13.2)

109 (14.5)

658 (82.4)92 (11.5)21 (2.6)14 (1.8)

9 (1.1)5 (0.6)

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

Characteristic No. (%)

a Casual nurses work on an as-needed basis.

254 J AMERICAN JOURNAL OF CRITICAL CARE, July 2012, Volume 21, No. 4 www.ajcconline.org


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recommendations for pain assessment and manage-

ment. 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 recom-

mendations 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.14Awareness of pub-

lished guidelines or practice rec-

ommendations was higher in

Ontario (138 of 221 nurses; 62%)

than in other regions: 59 of 312nurses (19%) in Alberta, British

Columbia, and Quebec; and 38 of

258 nurses (15%) in all other provinces and territo-

ries (P< .001). When nurses familiar with the best-

practice 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 guide-

lines, P= .57; American Society of Pain Manage-

ment Nursing guidelines, P= .09).

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 phys-

iological indicators moderately to extremely impor-tant 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 oxygena-

tion status (47 nurses, 9%) were the physiological indi-

cators 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

Table 2

Variables associated with use of behavioral pain assessment tools

Aware of guidelines

Pain tool available

Received education on pain tools

Protocol available

Intensive care experience, y5-10>10

Hospital typeUniversity affiliatedCommunity, 200 bedsCommunity, 50-199 beds

Provincea

Quebec

OntarioAlbertaNewfoundlandNova ScotiaBritish ColumbiaManitobaNew Brunswick

Saskatchewan

2.5 (1.7-3.7)

2.6 (1.6-4.3)

1.3 (0.9-1.9)

1.6 (0.9-2.6)

11.2 (0.6-2.3)0.8 (0.4-1.6)1.0 (0.6-1.9)

11.2 (0.8-1.9)1.4 (0.9-2.1)

1

1.5 (0.8-2.6)2.8 (1.5-5.3)1.6 (0.6-4.6)2.1 (1.0-4.7)1.4 (0.7-2.7)1.1 (0.5-2.5)1.5 (0.7-3.1)

0.4 (0.1-1.3)

3.1 (2.3-4.3)

3.9 (2.8-5.4)

2.3 (1.7-3.3)

3.6 (2.6-5.0)

11.3 (0.7-2.3)1.0 (0.5-1.8)1.4 (0.8-2.3)

10.7 (0.5-1.0)0.9 (0.6-1.5)

1

2.5 (1.5-4.1)2.3 (1.3-4.0)1.4 (0.5-3.7)1.7 (0.9-3.5)2.1 (1.1-3.8)0.9 (0.4-2.0)1.4 (0.7-2.7)

0.4 (0.2-1.2)

52 (46-58)

48 (43-52)

40 (35-44)

47 (42-52)

29 (20-40)35 (28-42)29 (22-36)36 (31-41)

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

23 (16-31)

42 (36-49)40 (32-50)29 (15-49)34 (23-47)38 (28-49)22 (13-34)30 (21-41)

11 (5-24)

122/235

193/406

206/522

190/406

22/7662/17948/168

135/378

135/44661/16963/167

28/122

96/22644/109

7/2418/5332/8412/5522/74

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

Variable n/N % (95% CI) Univariate Multivariate

Odds ratio (95% CI)Use of pain tools >50%


Just 42% ofnurses targetadministration oan analgesic to pain score orother assessme


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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 neuropathophysiol-ogy (504 of 794 nurses; 63%). Fewer nurses had educa-

tion 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 assess-

ment as moderately to extremely important for surgical

(801 of 801 nurses; 100%), medical (761 of 801

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 ofconsciousness 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 suc-

tioning than for drain removal, placement of an inva-

sive catheter, repositioning, and wound care (Table 4).

Discussion

Pain assessment and management are core

competencies of ICU nurses. To our knowledge, our

Table 3

Nurses ratings of behaviors suggestive of pain

Not following commands

Striking staff

Trying to climb out of bed

Closing eyes

Sighing

Attempting to sit up

Seeking attention through movements

Pulling endotracheal tube

Retraction of upper extremities

Thrashing extremities

Slow cautious movements

Resistance to passive movements

WithdrawingRepetitive touching of area of the body

Arching

Restlessness

Rigidity

Splinting

Fighting ventilator/activation of alarms

Brow lowering/frowning

Vocalization

Clenching fists/teeth

Guarding

Wincing

Grimacing

53 (6.8)

62 (7.9)

51 (6.5)

54 (7.2)

51 (6.6)

71 (9.0)

100 (12.9)

132 (16.8)

122 (15.8)

128 (16.3)

147 (18.6)

181 (22.9)

200 (25.3)183 (23.1)

224 (28.5)

244 (30.6)

209 (26.5)

388 (49.6)

366 (46.0)

361 (45.8)

396 (50.6)

401 (50.3)

393 (49.2)

569 (71.5)

581 (72.4)

90 (11.5)

96 (12.3)

108 (13.8)

95 (12.7)

140 (18.0)

135 (17.1)

213 (27.4)

206 (26.2)

216 (27.9)

227 (28.9)

262 (33.2)

280 (35.4)

263 (33.3)293 (37.0)

286 (36.4)

339 (42.5)

388 (49.1)

246 (31.5)

304 (38.2)

305 (38.7)

274 (35.0)

298 (37.4)

322 (40.4)

203 (25.5)

205 (25.6)

641 (81.8)

624 (79.8)

621 (79.6)

600 (80.1)

588 (75.5)

583 (73.9)

464 (59.7)

449 (57.1)

436 (56.3)

431 (54.8)

381 (48.2)

331 (41.8)

327 (41.4)315 (39.8)

275 (35.0)

214 (26.8)

193 (24.4)

148 (18.9)

126 (15.8)

122 (15.5)

112 (14.3)

98 (12.3)

83 (10.4)

24 (3.0)

16 (2.0)

784

782

780

749

779

789

777

787

774

786

790

792

790791

785

797

790

782

796

788

782

797

798

796

802

Behaviora n Routinely>75%Often 51%-75%Never to sometimes 50%

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



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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 situatedwithin 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 proto-

cols should be developed that stip-

ulate 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 othercommonly occurring causes, such as hypoxia,

acidemia, agitation, and delirium.35

The facial expressions of grimacing and wincing

were universally considered indicative of pain. Accord-

ing to the Facial Action Coding System, a technique

that involves digital recording and coding of facial

actions, 4 core actionsbrow lowering, orbit tight-

ening, raising the upper lip and wrinkling the nose

(levator contraction), and eye closurehave been

associated with pain expression.36 Despite inclusion

results provide the largest and most diverse repre-

sentation of ICU nurses perceptions of pain assess-

ment 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 com-

municate and were unaware of practice recommen-dations published by professional societies for pain

assessment and management in critically ill adults.

Awareness of guidelines influenced use of behav-

ioral 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 prac-

tice, behavioral pain assessment tools were consid-

ered less useful than patient self-report tools.

Targeting of analgesia to a pain score also occurred

infrequently, although this finding may be moreindicative 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 ventila-

tion; analgesia was given without pain assessment

more than 50% of the time. In a single-center Cana-

dian 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 thatcreates a major barrier to adoption of the guidelines

into clinical practice. Despite the publication of 3

guidelines pertinent to pain assessment and man-

agement of critically ill patients, ICU nurses, the cli-

nicians 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

Table 4

Need for preemptive analgesiafor intensive care procedures

Wound care

Repositioning

Invasive catheter placement

Drain removal

Endotracheal suctioning

1

0.9 (0.9-1

0.9 (0.9-1

0.9 (0.9-0

0.7 (0.6-0

96 (94-97)

90 (88-92)

90 (88-92)

85 (82-87)

63 (59-66)

767/801

720/801

720/801

680/800

503/801

a Number of nurses rating need for the assessment of preemptive analgesia asmoderately to extremely important.

ProcedureRelative ris

(95% CI)% (95% CI)n/Na


A large number

of nurses do not

use pain assess

ment tools for

patients unable communicate.


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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 recom-mended 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.38As recommended by the Task Force

of the American Society for Pain Management Nurs-

ing,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 generaliz-

ability. 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 prac-

tices may represent the practices of nurses with more

knowledge and interest in pain assessment and man-

agement. Unknown confounding factors other than

those measured, such as tool availability and educa-

tion 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 generaliz-

ability to practice in other countries. As with all self-

report surveys, responses reflect the perceptions of

respondents and may not reflect actual practice.

ConclusionMost nurses do not use pain assessment tools

for patients unable to communicate and are unaware

of practice recommendations published by profes-

sional 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 commu-nicate pain. Educational and novel knowledge-

translation interventions are needed that will improve

compliance with recommendations for pain assess-

ment and management practices in adult ICUs.

ACKNOWLEDGMENTSThis study was conducted at the Lawrence S. BloombergFaculty of Nursing. We thank Ruxandra Pinto for her sta-tistical advice and assistance with data analysis andLeasa Knechtel for her input into the design of the survey.

FINANCIAL DISCLOSURESThis study was supported by a research grant from theAmerican Association of Critical-Care Nurses and theNursing Research Fund of St Michaels Hospital.

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