pain management case study nursing

Acute Pain Nursing Care Plan and Management

Feeling the sharp, stabbing pain of an acute injury or illness is a sensation that no one wants to experience. As nurses, it’s our job to help ease the suffering of our patients and provide the best possible care for those in pain. Creating a comprehensive care plan for acute pain nursing diagnosis can help relieve our patients’ discomfort and get them on the road to recovery. Whether it’s administering medication , providing emotional support, or teaching patients about pain management techniques, this care plan guide will help you utilize those tools on how to manage acute pain

Let’s take a closer look at how we can effectively care for patients experiencing acute pain. Use this guide to formulate your nursing care plans and nursing interventions for patients experiencing acute pain.

Table of Contents

What is acute pain, causes of pain, signs and symptoms, goals and outcomes, nursing diagnosis, related care plans, using the pqrst pain assessment mnemonic, determine factors that causes acute pain, determine patient’s response to pain, initiating nonpharmacologic pain management, provide pharmacologic pain management, recommended resources, references and sources.

The International Association for the Study of Pain (IASP) defined pain as “ an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage .” Another great and influential definition of pain is from Margo McCaffery, a nurse expert on pain, who defined it as “ pain is whatever the person says it is and exists whenever the person says it does .” The unpleasant feeling of pain is highly subjective in nature that may be experienced by the patient.

“Pain is whatever the person says it is and exists whenever the person says it does.” Margo McCaffery – Pain Management Nurse Pioneer

Acute pain is pain, as defined above, that has a duration of less than 3 months and relief can be anticipated or predicted. In contrast, chronic pain is has a duration of more than 3 months without an anticipated or predictable end. The physiological signs of acute pain emerge from the body’s response to pain as a stressor. Acute pain provides a protective purpose to make the person informed and knowledgeable about the presence of an injury or illness. The unexpected onset of acute pain reminds the patient to seek support, assistance, and relief.

Other factors such as the patient’s cultural background, emotions, and psychological or spiritual discomfort may contribute to acute pain. In older patients, assessment of pain can be challenging due to cognitive impairment and sensory-perceptual deficits. Assessment and management of the nursing diagnosis of acute pain are the main focus of this care plan.

Here are the common causes of pain:

• Tissue damage or break in tissue integrity such as in surgery , injury, fractures, and other conditions that breakdown or damage the body’s tissues.
• Inflammation is a normal immune response to injury or infection can also cause pain.
• Nerve damage or irritation that is commonly caused by sciatica, herniated disc, or infections such as shingles ( postherpetic neuralgia )
• Psychological conditions such as stress, depression , anxiety can all contribute to pain.

The following are the common manifestations that defines the characteristics of acute pain. Use these subjective and objective data to help guide you through the nursing assessment . Alternatively, you can check out the assessment guide for acute pain in the subsequent sections.

• Self-report of intensity using standardized pain intensity scales (e.g., Wong-Baker FACES scale, visual analog scale, numeric rating scale)
• Self-report of pain characteristics (e.g., aching, burning, electric shock, pins, and needles, shooting, sore/tender, stabbing, throbbing) using standardized pain scales (e.g., McGill Pain Questionnaire, Brief Pain Inventory)
• Guarding behavior or protecting the body part
• Facial mask of pain (e.g., grimaces)
• Expression of pain (e.g., restlessness, crying, moaning)
• Profuse sweating
• Alteration in BP , HR, RR
• Dilation of the pupils
• Proxy reporting pain and behavior/activity changes (e.g., family members , caregivers )

The following are the common nursing care planning goals and expected outcomes for Acute Pain:

• Patient demonstrates the use of appropriate diversional activities and relaxation skills.
• Patient describes satisfactory pain control at a level (for example, less than 3 to 4 on a rating scale of 0 to 10)
• Patient displays improved well-being such as baseline levels for pulse, BP , respirations, and relaxed muscle tone or body posture.
• Patient uses pharmacological and nonpharmacological pain-relief strategies.
• Patient displays improvement in mood, coping.

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with acute pain based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities. However, if you still find value in utilizing nursing diagnosis labels, here are some examples to consider:

• Acute Pain related to tissue injury from surgical incision AEB patient reporting a pain level of 8 on a 1-10 scale, facial grimacing, and guarding the surgical site.
• Acute Pain related to inflammation and swelling secondary to sprained ankle AEB patient’s verbal report of pain, observed limping, and inability to bear weight on the affected leg.
• Acute Pain related to musculoskeletal injury (e.g., fracture , sprain) as evidenced by patient describing pain as sharp or throbbing, limited range of motion, and swelling at the injury site.
• Acute Pain related to inflammation (e.g., appendicitis , pancreatitis ) as evidenced by patient reporting localized abdominal pain, pain intensity increasing with movement , and presence of nausea or vomiting .
• Acute Pain related to mucosal irritation and inflammation in the urinary tract (e.g., urinary tract infection ) as evidenced by patient reporting burning sensation during urination , frequent need to urinate, and abdominal discomfort.
• Acute Pain related to cervical dilation and uterine contractions during labor as evidenced by patient reporting contraction pains, expressing distress during contractions, and utilizing pain relief techniques.

Diseases, medical conditions, and related nursing care plans for Acute Pain nursing diagnosis:

• Surgery (Perioperative Client)
• Brain Tumor
• Hypertension
• Tonsillitis
• Click here for more sample nursing care plans for the acute pain nursing diagnosis .

Nursing assessment and rationales

Proper nursing assessment of acute pain is imperative for the development of an effective pain management plan. Nurses play a crucial role in the assessment of pain, use these techniques on how to comprehensively assess acute pain:

Perform pain assessment

1. Perform a comprehensive assessment of pain. Determine the location, characteristics, onset, duration, frequency, quality, and severity of pain via assessment. The patient experiencing pain is the most reliable source of information about their pain. Their self-report on pain is the gold standard in pain assessment as they can describe the location, intensity, and duration. Thus, assessment of pain by conducting an interview helps the nurse in planning optimal pain management strategies.

Alternatively, you can use the nursing mnemonic “PQRST” to guide you during pain assessment:

• Provoking Factors : “What makes your pain better or worse?”
• Quality (characteristic): “Tell me what it’s exactly like. Is it a sharp pain, throbbing pain, dull pain, stabbing, etc?”
• Region (location): “Show me where your pain is.”
• Severity : Ask your pain to rate pain by using different pain rating methods (e.g., Pain scale of 1-10, Wong-Baker Faces Scale).
• Temporal (onset, duration, frequency): “Does it occur all the time or does it come and go?”

2. Assess the location of the pain by asking to point to the site that is discomforting. Using charts or drawings of the body can help the patient, and the nurse determines specific pain locations. For clients with a limited vocabulary, asking to pinpoint the location helps in clarifying your pain assessment – this is especially important when assessing pain in children.

See also : Pain Perplex: 5 Things Nurses Need to Understand About Pain Management

3. Perform history assessment of pain Additionally, the nurse should ask the following questions during pain assessment to determine its history: (1) effectiveness of previous pain treatment or management; (2) what medications were taken and when; (3) other medications being taken; (4) allergies or known side effects to medications.

4. Determine the client’s perception of pain. In taking a pain history, provide an opportunity for the client to express in their own words how they view the pain and the situation to gain an understanding of what the pain means to the client. You can ask, “What does having this pain mean to you?”, “Can you describe specifically how this pain is affecting you?”.

5. Pain should be screened every time vital signs are evaluated. Many health facilities set pain assessment as the “fifth vital sign” and should be added to routine vital signs assessment.

6. Pain assessments must be initiated by the nurse. Pain responses are unique for each person, and some clients may be reluctant to report or voice out their pain unless asked about it.

7. Use the Wong-Baker FACES Rating Scale to determine pain intensity. Some clients (e.g., children, language constraints) may not relate to numerical pain scales and may need to use the Wong-Baker Faces Rating Scale. Pain assessment tools help translate the patient’s subjective experience of pain into objective numbers or descriptors.

 8. Investigate signs and symptoms related to pain. An accurate assessment of pain is crucial in providing an individualized plan of care. Bringing attention to associated signs and symptoms may help the nurse in evaluating the pain. In some instances, the existence of pain is disregarded by the patient.

9. Determine the patient’s anticipation for pain relief . Some patients may be satisfied when pain is no longer intense; others will demand complete elimination of pain. This influences the perceptions of the effectiveness of the treatment modality and their eagerness to engage in further treatments.

10. Assess the patient’s willingness or ability to explore a range of techniques to control pain. Some patients may be hesitant to try the effectiveness of nonpharmacological methods and may be willing to try traditional pharmacological methods (i.e., the use of analgesics). A combination of both therapies may be more effective, and the nurse has the duty to inform the patient of the different methods to manage pain.

11. Determine factors that alleviate pain. Ask clients to describe anything they have done to alleviate the pain. These may include, for example, meditation, deep breathing exercises, praying, etc. Information on these alleviating activities can be integrated into planning for optimal pain management.

12. Evaluate the patient’s response to pain and management strategies. It is essential to assist patients to express as factually as possible (i.e., without the effect of mood, emotion, or anxiety ) the effect of pain relief measures. Inconsistencies between behavior or appearance and what the patient says about pain relief (or lack of it) may reflect other methods the patient is using to cope with the pain rather than pain relief itself.

13. Provide ample time and effort regarding the patient’s report of their pain experience. Patients may be reluctant to report their pain as they may perceive staff to be very busy and have competing demands on their time from other nurses, doctors, and patients (Manias et al., 2002). Interruptions during pain management can prevent nurses from assessing and managing the patient’s pain experience.

14. Evaluate what the pain suggests to the patient. The meaning of pain will directly determine the patient’s response. Some patients, especially the dying , may consider that the “act of suffering” meets a spiritual need.

Nursing interventions for acute pain

Nurses are not to judge whether the acute pain is real or not. As a nurse, we should spend more time treating patients. The following are the therapeutic nursing interventions for your acute pain nursing diagnosis:

1. Provide measures to relieve pain before it becomes severe. It is preferable to provide an analgesic before the onset of pain or before it becomes severe when a larger dose may be required. An example would be preemptive analgesia, which is administering analgesics before surgery to decrease or relieve pain after surgery . The preemptive approach is also useful before painful procedures like wound dressing changes, physical therapy, postural drainage , etc.

2. Acknowledge and accept the client’s pain. Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.

3. Provide nonpharmacologic pain management. Nonpharmacologic methods in pain management may include physical, cognitive-behavioral strategies, and lifestyle pain management. See methods below: 

3.1. Provide cognitive-behavioral therapy (CBT) for pain management. These methods are used to provide comfort by altering psychological responses to pain. Cognitive-behavioral interventions include:

• Distraction. This technique involves heightening one’s concentration upon non-painful stimuli to decrease one’s awareness and experience of pain. Drawing the person away from the pain lessens the perception of pain. Examples include reading, watching TV, playing video games, and guided imagery.
• Eliciting the Relaxation Response. Stress correlates to an increase in pain perception by increasing muscle tension and activating the SNS. Eliciting a relaxation response decreases the effects of stress on pain. Examples include directed meditation, music therapy, and deep breathing .
• Guided imagery. Involves the use of mental pictures or guiding the patient to imagine an event to distract from the pain.
• Repatterning Unhelpful Thinking . Involves patients with strong self-doubts or unrealistic expectations that may exacerbate pain and result in failure in pain management.
• Other CBT techniques include Reiki, spiritually directed approaches, emotional counseling, hypnosis, biofeedback, meditation, and relaxation techniques.

3.2. Provide cutaneous stimulation or physical interventions Cutaneous stimulation provides effective pain relief, albeit temporary. The way it works is by distracting the client away from painful sensations through tactile stimuli. Cutaneous stimulation techniques include:

• Massage . When appropriate, massaging the affected area interrupts the pain transmission, increases endorphin levels, and decreases tissue edema . Massage aids in relaxation and decreases muscle tension by increasing superficial circulation to the area. Massage should not be done in areas of skin breakdown, suspected clots, or infections.
• Heat and cold applications. Cold works by reducing pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. Cold is best when applied within the first 24 hours of injury while heat is used to treat the chronic phase of an injury by improving blood flow to the area and through reduction of pain reflexes.
• Acupressure . An ancient Chinese healing system of acupuncture wherein the therapist applies finger pressure points that correspond to many of the points used in acupuncture.
• Contralateral stimulation . Involves stimulating the skin in an area opposite to the painful area. This technique is used when the painful area cannot be touched.
• Transcutaneous Electrical Nerve Stimulation (TENS). Is the application of low-voltage electrical stimulation directly over the identified pain areas or along with the areas that innervate pain.
• Immobilization . Restriction of movement of a painful body part is another nonpharmacologic pain management. To do this, you need splints or supportive devices to hold joints in the position optimal for function. Note that prolonged immobilization can result in muscle atrophy, joint contracture, and cardiovascular problems. Check with the agency protocol.
• Other cutaneous stimulation interventions include therapeutic exercises (tai-chi, yoga, low-intensity exercises, ROM exercises), and acupuncture.

4. Provide pharmacologic pain management as ordered. Pain management using pharmacologic methods involves using opioids (narcotics), nonopioids ( NSAIDs ), and co analgesic drugs. The World Health Organization (WHO) published guidelines on the logical usage of analgesics to treat cancer using a three-step ladder approach – also known as the analgesic ladder . The analgesic ladder focuses on aligning the proper analgesics with the intensity of pain.

• Step 1: For mild pain (1 to 3 pain rating), the WHO analgesic ladder suggests the use of nonopioid analgesics with or without coanalgesics. If pain persists or increases despite providing full doses, then proceed to the next step.
• Step 2: For moderate pain (4 to 6 pain rating), opioid, or a combination of opioid and nonopioid is administered with or without conanalgesics.
• Step 3: For severe pain (7 to 10), the opioid is administered and titrated in ATC scheduled doses until the pain is relieved.

4.1. Administer nonopioids including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen , as ordered.  NSAIDs work in peripheral tissues. Some block the synthesis of prostaglandins, which stimulate nociceptors. They are effective in managing mild to moderate pain. All NSAIDs have anti-inflammatory (except for acetaminophen), analgesic, and antipyretic effects. They work by inhibiting the enzyme cyclooxygenase (COX), a chemical activated during tissue damage, resulting in decreased synthesis of prostaglandins. NSAIDs also have a ceiling effect. Once the maximum analgesic benefit is achieved, additional amounts of the same drug will not produce more analgesia and may risk the patient for toxicity. Common side effects of NSAIDs include heartburn or indigestion. There is also a possibility of forming a small stomach ulcer due to platelet aggregation. To prevent these side effects, clients should be taught to take NSAIDs with food and a full glass of water. Common NSAIDs include:

• Aspirin. It can prolong bleeding time and should be stopped a week before a client undergoes any surgical procedure. Should never be given to children below 12 years of age due to the possibility of Reye’s syndrome. May cause excessive anticoagulation if the client is taking warfarin .
• Acetaminophen (Tylenol). May have serious hepatotoxic side effects and possible renal toxicity with high dosages or with long-term use. Limit acetaminophen usage to 3 grams per day.
• Celecoxib (Celebrex). Is a COX-2 inhibitor that has fewer GI side effects than COX-1 NSAIDs.

For the full list, please visit: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Related Agents

4.2. Administer opioids as ordered. Opioids are indicated for severe pain and can be administered orally, IV, PCA systems, or epidurally.

• Opioids for moderate pain. These include codeine , hydrocodone , and tramadol (Ultram) which are combinations of nonopioid and opioid.
• Opioids for severe pain. These include morphine , hydromorphone , oxycodone, methadone , and fentanyl . Most of these are controlled substances due to potential misuse. These drugs are indicated for severe pain, or when other medications fail to control pain.

For the full list, please visit: Narcotics, Narcotic Antagonists, and Antimigraine Agents

4.3. Administer coanalgesics (adjuvants), as ordered.  Coanalgesics are medications that are not classified as pain medication but have properties that may reduce pain alone or in combination with other analgesics. They may also relieve other discomforts, increase the effectiveness of pain medications, or reduce the pain medication’s side effects. Commonly used coanalgesics include: 

• Antidepressants . Is a common coanalgesic that helps in increasing pain relief, improving mood, and reducing excitability.
• Local Anes t hetics . These drugs block the transmission of pain signals and are used for pain in specific areas of nerve distribution.
• Other coanalgesics. Include anxiolytics, sedatives, and antispasmodics to relieve other discomforts. Stimulants, laxatives, and antiemetics are other coanalgesics that reduce the side effects of analgesics.

5. Manage acute pain using a multimodal approach.  A multimodal approach is based on using two or more distinct methods or drugs to enhance pain relief (rather than resorting to opioid use or other pain management strategies alone). Different combinations of analgesic medications, adjuvants, and procedures can act on different sites and pathways in an additive or synergistic fashion. Combining medications and techniques allows the lowest effective dose of each drug to be administered, resulting in reduced side effects. 

6. Administer analgesia before painful procedures whenever possible. Doing so will help prevent pain caused by relatively painful procedures (e.g., wound care , venipunctures, chest tube removal, endotracheal suctioning, etc.).

7. Perform nursing care during the peak effect of analgesics.  Oral analgesics typically peak in 60 minutes, and intravenous analgesics in 20 minutes. Performing nursing tasks during the peak effect of analgesics optimizes client comfort and compliance in care. 

8. Evaluate the effectiveness of analgesics as ordered and observe for any signs and symptoms of side effects. The patient’s effectiveness of pain medications must be evaluated individually since they are absorbed and metabolized differently.

For more interventions related to pain, please visit Chronic Pain Nursing Care Plan

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care  Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health   Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ! Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

Recommended resources to further your study for this acute pain nursing care plan .

• Hartrick, C. T. (2004). Multimodal postoperative pain management .   American Journal of Health-System Pharmacy ,  61 (suppl_1), S4-S10.
• Herr, K., Titler, M. G., Schilling, M. L., Marsh, J. L., Xie, X., Ardery, G., … & Everett, L. Q. (2004). Evidence-based assessment of acute pain in older adults: current nursing practices and perceived barriers.   The Clinical journal of pain ,  20 (5), 331-340.
• Hsieh, L. L. C., Kuo, C. H., Lee, L. H., Yen, A. M. F., Chien, K. L., & Chen, T. H. H. (2006). Treatment of low back pain by acupressure and physical therapy: randomized controlled trial .  Bmj ,  332 (7543), 696-700.
• Khan, K. A., & Weisman, S. J. (2007). Nonpharmacologic pain management strategies in the pediatric emergency department .  Clinical Pediatric Emergency Medicine ,  8 (4), 240-247.
• Loeser, J. D., & Treede, R. D. (2008). The Kyoto protocol of IASP basic pain terminology ☆.   Pain ,  137 (3), 473-477.
• Loggia, M. L., Juneau, M., & Bushnell, M. C. (2011). Autonomic responses to heat pain: Heart rate, skin conductance, and their relation to verbal ratings and stimulus intensity .  PAIN® ,  152 (3), 592-598.
• Manias, E., Botti, M., & Bucknall, T. (2002). Observation of pain assessment and management− the complexities of clinical practice .  Journal of clinical nursing ,  11 (6), 724-733.
• McCaffery, M. (1990). Nursing approaches to nonpharmacological pain control .  International Journal of nursing studies ,  27 (1), 1-5.
• Reid, C., & Davies, A. (2004). The World Health Organization three-step analgesic ladder comes of age .
• Urden, L. D., Stacy, K. M., & Lough, M. E. (2006).  Thelan’s critical care nursing: diagnosis and management  (pp. 918-966). Maryland Heights, MO: Mosby.
• Treede, R. D. (2018). The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes.   Pain reports ,  3 (2).
• Pasero, C., & McCaffery, M. (1999).  Pain: clinical manual  (Vol. 9). St. Louis: Mosby.
• Urba, S. G. (1996). Nonpharmacologic pain management in terminal care .  Clinics in geriatric medicine ,  12 (2), 301-311.
• Vargas-Schaffer, G. (2010). Is the WHO analgesic ladder still valid?: Twenty-four years of experience.   Canadian Family Physician ,  56 (6), 514-517.
• Voscopoulos, C., & Lema, M. (2010). When does acute pain become chronic?.  British journal of anaesthesia ,  105 (suppl_1), i69-i85.

9 thoughts on “Acute Pain Nursing Care Plan and Management”

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Thanks for sharing this amazing post! Remember that acute pain management should be individualized based on the patient’s unique circumstances. Regular reassessment and communication are key components of effective acute pain management. Always adhere to your healthcare facility’s policies and protocols when implementing pain management interventions.

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Nurses’ Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review

Mohammad rababa.

1 Adult Health Nursing Department, Jordan University of Science and Technology, Irbid, Jordan

Shatha Al-Sabbah

Audai a hayajneh.

This review aims to examine nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients.

Pain is one of the worst memories among critically ill patients. However, pain among those patients is still undertreated due to several barriers that impede effective management. Therefore, addressing the perceived barriers and facilitators to pain assessment management among critical care nurses is crucial.

A systematic search of pain assessment and management in critical care patient-relevant literature from four databases was done, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

The barriers and facilitators were categorized into four groups: nurse-related, patient-related, physician-related, and system-related. The most frequently reported barriers in this study included nurses’ lack of knowledge regarding the use of pain assessment tools, patients’ inability to communicate, physicians’ prescription of analgesics being independent of pain scores evaluation, and absence of standardized guidelines and protocols for pain evaluation and control. For the facilitators, the most reported ones include ongoing education and professional training related to pain assessment and management, patients’ ability to self-report pain, effective collaboration between physicians and nurses, and productive discussion of patients’ pain scores during nurse-to-nurse handovers.

Various barriers and facilitators to pain assessment and management were identified and examined in this review. However, future research is still needed to further investigate these barriers and facilitators and examine any other potential associated factors among critical care nurses.

Relevance to Clinical Practice

The findings of our study could help hospital managers in developing continuous education and staff development training programs on assessing and managing pain for critical care patients. Also, our findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat pain in critical care patients.

Introduction

For intensive care unit (ICU) patients, pain experienced during ICU stay is one of the most upsetting memories. 1 According to Puntillo et al, more than half of ICU patients in 28 European countries were found to have experienced pain, whilst in the United States (US), about 60% of ICU patients reported that their pain persisted after discharge from the hospital. 1 In addition to various physiological sources of pain, routine nursing care procedures, such as position-changing and endotracheal suctioning, are major sources of intrinsic pain for ICU patients. 2 Untreated pain among critical care patients has many adverse effects, leading to serious physiological and psychological complications and increased length of critical care unit stay. 2 For example, the influence of unrelieved pain on the physiological condition of patients includes hemodynamic instability, such as blood pressure elevation, tachycardia, tachypnea, and hyperglycemia. Other associated negative physical consequences include the increase in catecholamine release, immunosuppression, urinary retention, and the increase in metabolic rate. 2 Furthermore, psychological and emotional distress may develop among patients who suffer from pain as a result of their inability to cope effectively with pain. In turn, this may lower patients’ quality of life. 2 As a result of pain symptoms, patients may often find themselves unable to accept certain job tasks and assignments, which may lead to them losing their jobs. This may have several negative consequences on the psychological status of patients. 3 Further, unrelieved pain may also negatively affect patients’ social interactions, as the decline in physical and mental functioning caused by persistent pain contributes greatly to impaired social relationships and interactions. 3 Thus, pain decreases individuals’ quality of life and markedly decreases their mental and physical health status. 3 Therefore, ICU patients require adequate pain assessment and management. However, there are several barriers to effective pain assessment and management among ICU patients. 4 For example, although pain is a highly subjective experience, ICU patients’ deteriorated level of consciousness and intubation limits their ability to communicate, which complicates their pain assessment and management. 4

In addition to patient-related barriers, other barriers related to healthcare providers and systems complicate pain assessment and management among adult critical care patients. 5 For example, studies have found nurses and physicians to have low levels of knowledge, poor attitudes, and inadequate training related to pain assessment and management for adult critical care patients. 6 Furthermore, heavy workloads, high patient-provider ratios, tight work schedules, and the unavailability of standard pain protocols in adult critical care units are factors that contribute to the issue of unrelieved pain. 5

Moreover, consensus is yet to be reached on the most effective pain assessment tools and pain management measures for adult critical care patients. The American Society for Pain Management Nursing recommends relying on pain-related behaviors to evaluate and treat pain among intubated patients or patients with communication deficits. 4 Several nonverbal scales have been approved as valid tools for pain assessment among adult critically ill patients, such as the Behavioral Pain Scale (BPS) and Critical-Care Pain Observation Tool (CPOT). 7 However, such tools have been limited by their low specificity and sensitivity for pain indicators, particularly in nonverbal patients, as well as nurses’ misunderstanding, misinterpretation, and underestimation of pain behaviors and nurses’ poor knowledge and attitudes related to the use of such tools. 7 Physiological measures, such as blood pressure, heart rate, and respiratory rate, are sometimes used as alternative pain indicators and can provide important clues for proper pain assessment. 8 However, the 2012 Society of Critical Care Medicine (SCCM) guidelines do not recommend the use of these measures alone for pain evaluation in critically ill adult patients; rather, these measures should be used in combination with the evaluation of behavioral indicators of pain. 2

Pain management for critically ill adult patients in ICUs is classified into pharmacologic and non-pharmacologic treatments. 1 Analgesics are the first-line therapy for pain. 9 However, the use of analgesics has many adverse effects, including dizziness, physical dependence, vomiting, intolerance, respiratory depression, delayed extubation, induced bowel dysfunction, increased length of hospitalization and healthcare costs, and increased morbidity and mortality. 9 According to Gaskin and Richard, 10 the extra annual costs of pain management on the healthcare system in the US were between $261-$300 billion in 2010. Several nonpharmacological therapies for pain are cost-effective, easy-to-use, and free of adverse effects. The guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) recommend the use of nonpharmacological interventions, such as music therapy/calming voice and massaging, to target pain among critically ill adults and minimize the harmful side effects of the recurrent and long-term use of analgesics. 11

Pain assessment and management in adult ICU patients has been gaining research attention for over 25 years. 1 However, pain is still a serious health problem around the world and is still untreated or undertreated among adult ICU patients. 1 , 2 Unfortunately, pain experienced by adult ICU patients remains widely underrecognized and undertreated due to various barriers. 2 Furthermore, there remains a wide gap between the findings of previous research and clinical practice. Moreover, there is no evidence in the nursing literature regarding the barriers and facilitators of pain assessment and management in adult critical care adult patients as perceived by nurses. Therefore, summarizing and synthesizing the existing research on pain assessment and management among adult critical care adult patients is needed to guide clinical practice and future research.

Accordingly, this review aims to identify nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients.

Materials and Methods

Study design.

The current study employed a systematic review design utilizing structured questions retrieved after reviewing the nursing literature relevant to pain among adult critical care patients. The researchers of the current review carefully evaluated and assessed the selected studies and compared their findings to reach consensus and avoid incongruities. This systematic review was guided by the following question: what are the patient-, nurse-, and system-related barriers and facilitators which impact pain assessment and management in adult critical care patients?

Inclusion Criteria

The studies included in the review were (1) peer-reviewed quantitative or qualitative studies, (2) published in English in the last ten years, (3) conducted among critical care nurses, and (4) related to the barriers and facilitators of adequate pain assessment and management in adult critical care patients.

Exclusion Criteria

Studies which were (1) dissertations, (2) book chapters, (3) conducted on target populations other than nurses, (4) conducted in clinical settings other than adult critical care units, or (5) written in languages other than English were excluded from this systematic review.

Search Strategy

An electronic search was performed by two of the researchers to identify all qualitative and quantitative published articles which discussed nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients. The review was conducted in April 2021. No search specifications related to publication date were set, and the researchers thoroughly searched the following databases: EBSCO, MEDLINE, CINAHL, and PubMed. The following keywords were used: “nurse”, “critical care nurses”, “pain”, “critically ill patients”, “adult”, “mechanically ventilated patients”, “critical care unit”, “intensive care unit”, “knowledge”, “attitude”, “pain assessment”, “pain management”, “barriers”, “facilitators”, “enablers”, and “challenges”.

The researchers used the Boolean operators “AND” and “OR” to expand the search options and search the literature in more depth. The search of articles was limited to qualitative and quantitative research studies published in English and with the abstract and reference list available, using “title/” or “abstract” in the search field. After an initial search using different combinations of the previously mentioned keywords, 1053 studies were identified, and after removing exact duplicates or overlapping studies, 290 articles remained. After applying the inclusion and exclusion criteria, the retrieved articles were reduced to 50. The reference lists of all 50 articles were reviewed to identify any other relevant studies not identified through the database searches. Then, after a careful review of the abstracts of the articles in order to determine the main objectives and keywords of the studies and whether pain assessment and management in critical care patients was the main theme, a total of twenty studies were selected for review. Figure 1 below shows the Preferred Reporting Items for Meta-Analysis (PRISMA) checklist and flowchart used as a method of screening and selecting the studies eligible for the current review.

PRISMA flow chart.

Quality of Evidence Appraisal Assessment

The researchers assessed the selected studies using the guidelines of Melnyk and Fineout-Overholt. 12 Two of the researchers carried out a detailed review of the guidelines and independently evaluated each study until an agreement on each study’s quality [level of evidence (LOE)]was reached.

Data Synthesis

The researchers developed an evidence-based table to summarize the detailed information of the selected studies ( Table 1 ). The following steps were taken to carry out data synthesis: (1) description of the selected studies in terms of the aims of the study, design, population, level of evidence, and major results; (2) identification of the limitations and strengths of the selected articles; and (3) investigation of the main study results to identify heterogeneity and homogeneity.

Summary of the Detailed Information of the Selected Studies

Abbreviations: ICU, intensive care unit; LOE, level of evidence.

Description of the Selected Studies

The selected 20 articles were found to employ different methodologies. Four studies were qualitative, 13–16 six were correlational, 17–22 three were quasi-experimental, 23–25 six were descriptive, 26–31 and one was longitudinal. 21 The included studies were conducted on critical care patients admitted to various clinical settings, including cardiac units, 13 , 18 oncology units, 28 emergency critical care units, 29 and neurosurgical units. 22 In addition to the abovementioned clinical settings, the majority of the studies also included other settings, such as medical-surgical units, medical units, and burn units. 21 , 27 Only Wang and Tsai 20 and Asman et al 17 were conducted in medical centers.

The proportion of female participants in the selected studies ranged from 40% to 99.7%, while the proportion of male participants ranged from 14.3% to 63.2%. Six of the studies were conducted in European countries. 13 , 15 , 16 , 21 , 26 , 32 Of the remaining studies, five were conducted in Asia, 14 , 17 , 20 , 27 , 28 five in North America, 18 , 19 , 22 , 23 , 25 and four in East Africa. 24 , 29–31 Critical care nurses’ pain assessment and management practices used among intensive care unit patients were measured using the Pain Assessment and Management for the Critically Ill survey in three of the studies. 18 , 19 , 27 In all three of these studies, a panel of experts had reviewed the instrument’s clarity, content validity, and reliability. To measure critical care nurses’ knowledge of and attitudes towards pain evaluation and management, four studies used the Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKASRP). 20 , 28 , 31 Knowledge of pain management and barriers to pain control were assessed using the Brockopp-Warden Pain Knowledge/Bias Questionnaire [BWPKBQ] in two studies. 23 , 25 Details regarding the measures used in the selected studies are summarized in Table 2 for quantitative studies and Table 3 for qualitative studies. Meanwhile, Table 1 presents a summary of the 20 reviewed studies.

The Summary of the Measures Used in the Selected Quantitative Studies

The Summary of the Measures Used in the Selected Qualitative Studies

Strengths and Limitations of the Selected Studies

Some of the strengths of the selected studies included the use of a large sample size, 19 , 25 , 28 multicenter analysis such as Roos-Blom et al, 32 and the recruitment of samples from several units. 14 , 27 , 29 , 31 Also, most of the studies reported using valid instruments to examine the study variables. However, the studies also had various limitations. For example, some studies had limited generalizability due to the use of convenience, consecutive, and purposive sampling techniques. 18 , 19 , 25 , 27–29 , 31 , 33 Also, in ten of the studies, most of the participants were female, and therefore, the results may not be representative of the targeted populations. 14 , 17 , 24 , 26 , 29 , 31 , 33 Other limitations included low response rates 18 , 19 , 32 and small sample sizes. 15 , 23 , 26 , 29 , 31 Additionally, the majority of the selected articles were descriptive correlational studies, which did not allow for causality inference to be established.

Nurse-Related Barriers

Fifteen of the selected studies reported poor knowledge among nurses regarding critically ill patients’ pain as being a barrier to effective pain relief. Eight of the 15 studies reported nurses’ lack of knowledge regarding pain assessment, 13 , 14 , 18 , 19 , 25 , 27 , 33 five reported poor knowledge regarding pain management, 20 , 23 , 24 , 29 , 34 and only two reported both. 28 , 31 The remaining studies did not discuss the link between nurses’ knowledge and pain assessment and management in critically ill adult patients. Deficits in knowledge related to pain assessment and management were most frequently related to (1) behavioral pain indicators (eg facial expressions); 17 , 19 , 28 (2) perception of patient’s pain tolerance (eg patient with severe pain cannot be distracted); 28 , 31 (3) the use of verbal and nonverbal pain assessment tools; 13 , 14 , 18 , 27 , 33 (4) pharmacological pain management, 20 , 23 , 28 , 31 especially among post-operative patients 16 and those with terminal illnesses; 24 and (5) nonpharmacological management. 29

Among the selected studies, 13 discussed nurses’ poor attitudes as being a barrier to effective pain control. Five of these studies reported that the majority of critical care nurses had improper and infrequent use of behavioral pain assessment tools for nonverbal patients. 14 , 18 , 19 , 23 , 27 Also, four studies mentioned that nurses underestimate the importance of pain assessment for sedated patients or patients with a decreased level of consciousness. 14 , 18 , 19 , 23 , 27 Furthermore, most of the participating critical care nurses relied on measuring physiological parameters or observing odd behaviors when assessing critical care patients’ pain rather than using formal pain assessment tools. 18 , 19 , 26 , 28 , 33 Moreover, although self-reporting is the gold standard for pain assessment, three studies reported that nurses perceived self-reporting of pain to be an inaccurate measure of pain intensity among critically ill adult patients. 24 , 27 , 30 Another three studies found that nurses perceived there to be no need to assess pain or administer primitive analgesia before carrying out pain-inducing procedures. 19 , 21 , 30

Khalil and Mashaqbeh 28 reported that the majority of the participating nurses tended to encourage their patients to endure pain as much they could before offering analgesia. The study also reported that patients’ spiritual beliefs did not play a significant role in patients’ under-reporting of pain. Only Khalil 29 highlighted nurses’ misconceptions related to “fear of addiction” and how these misconceptions relate to the issue of pain under treatment or un-treatment in critically ill patients. According to Wang and Tsai 20 and Kizza and Muliira, 30 the majority of nurses perceived there to be no need for administering analgesics to sedated patients receiving pain-inducing procedures, as nurses perceived these patients to not feel pain. Moreover, in some cases, nurses were found to be unsure about the patient’s pain rating, which limited their administration of analgesics. 13 , 27 Also, Topolovec-Vranic et al 22 discussed analgesics misuse as being a barrier to pain management in critically ill patients.

Nurse-Related Facilitators

A limited number of the reviewed studies discussed improved knowledge among nurses as being a facilitator of optimal pain relief. 17 , 19 , 27 , 28 , 31 The most frequently reported facilitators of pain management in adult critically ill patients were (1) better understanding and interpretation of pain behaviors, 18 , 19 , 27 (2) sufficient knowledge of pharmacological interventions, 17 , 28 , 31 and (3) ongoing education and professional training related to pain assessment and management. 23 , 25 Furthermore, taking into account physiological indicators, in addition to verbal and nonverbal indicators, when carrying out pain assessment was found to facilitate pain management in adult critically ill patients. 18 , 19 Moreover, improved perception of patients’ pain among nurses was found to be another facilitator of pain management. 18

Patient-Related Barriers and Facilitators

Despite the relatively large number of research studies examining patient-related barriers to pain assessment and management, only eight of the reviewed studies discussed these barriers from the perspective of critical care nurses. The most frequently reported barrier was patients’ inability to communicate, 13 , 18 , 22 followed by hemodynamic instability. 18 , 29 Also, it was found that patient history of substance abuse, alcoholism, or suicidal attempts impeded proper pain management. 20 , 23 Only five of the 20 studies reported examples of patient-related facilitators of pain assessment and management. 13 , 20 , 22 , 24 , 28 The gold standard of pain assessment is self-reporting of pain by the patient. Thus, three studies reported patients’ self-reporting of pain as being the most accurate measure of pain and a facilitator of effective pain management. 20 , 24 , 28 In the study of Alasiry et al, 13 the participants emphasized the importance of using subjective assessment for critically ill conscious patients. With regard to the objective assessment of pain in critical care patients, the most commonly reported behavioral pain indicators were motor activity (eg, involuntary movements) and facial activity (eg, facial grimacing). 13 Even in cases where the patients were unable to verbalize their needs, the nurses used alternative methods in addition to behavioral indicators, such as helping patients write or draw their needs on paper. Moreover, in the study of Pollmann-Mudryj, 22 the participating nurses reported that if they continued to rely on behavioral indicators only to interpret patients’ pain, communication between nurses and patients would be lost.

Physician-Related Barriers and Facilitators

Only eight of the reviewed studies discussed physician-related barriers and enablers of pain management. The most frequently reported barrier was “physicians’ prescription of analgesics does not depend on the evaluation of pain scores”. 18 , 19 , 22 Also, Deldar et al, 14 reported that poor interaction between physicians and nurses regarding nonverbal patients’ pain impedes effective treatment. Moreover, Subramanian et al 16 reported junior doctors’ lack of experience and senior doctors’ heavy workloads as being significant barriers to effective pain assessment and management. As for the facilitators of pain assessment and management in critically ill adult patients, collaboration between physicians and nurses was the most frequently reported facilitator, 13 , 17 followed by “adequate analgesics doses prescribed by physicians”. 18 , 30

System/Organization-Related Barriers

Of the 20 selected studies, 12 articles discussed barriers to pain management associated with organizational factors. The barriers reported most frequently were (1) lack of standardized pain assessment forms and tools for verbal critically ill patients 16 , 30 and nonverbal patients, 14 , 19 , 20 (2) lack of standardized guidelines and protocols for pain evaluation and control, 14 , 16 , 19 , 30 , 32 (3) heavy workloads of nurses, 14 , 18 , 30 (4) nursing staff shortages, 13 , 29 (5) inadequate nurse-to-patient ratios, 14 , 32 (6) inadequate training and education related to pain assessment and management, 14 , 19 , 22 , 30 (7) nontherapeutic, ineffective, or complicated discussions about pain treatment during medical rounds, 18 (8) lack of documentation of pain assessment findings, 30 (9) lack of autonomous decision-making related to pain management, 16 , 20 and (10) poor hospital environments, such as shared rooms with only curtains between patients. 15 Also, only Hamdan 27 found a significant relationship between hospital type and adequate pain assessment by nurses, whereby nurses in private and governmental hospitals used pain assessment tools less often than did nurses in educational hospitals.

System/Organization-Related Facilitators

Only six studies discussed system-related facilitators of pain assessment and management among adult critically ill patients, and the most frequently reported facilitators were (1) continuous education and professional training for critical care nurses, 13 , 18–20 , 28 , 29 and (2) discussing and reporting patients’ pain scores during nurse-to-nurse handovers. 18 , 19 , 30 Furthermore, higher hospital accreditation was significantly associated with improved pain assessment practices. 20 Moreover, Wøien 21 reported that establishing evidence-based protocols for pain evaluation and documentation led to improved pain control plans. The perceived barriers and facilitators to pain assessment and management in critical care patients are summarized in Table 4 .

The Barriers to and Facilitators of Pain Assessment and Management

This review included 20 studies published over the previous 10 years and focused on the barriers and facilitators related to pain assessment and management in critical care units from the perspective of nurses. A limited number of relevant studies were identified. Nurse-related barriers were studied more than other forms of barriers (ie, patient- and system-related barriers), with insufficient education and training related to pain assessment among nurses being the most commonly reported nurse-related barrier. This particular finding is consistent with the findings of a recent systematic review which found nurses’ knowledge deficiencies and poor skills to be significant barriers to pain assessment among nursing home residents. 35

Nurse-Related Barriers and Facilitators

Given that they spend most of their time caring for patients, nurses play a major role in pain assessment in critically ill patients. 36 However, limited studies have explored nurse-related barriers to pain assessment. According to the literature review of McAuliffe et al, 36 nurses have deficient knowledge related to pain assessment in people with dementia (PWD). This is consistent with our review results regarding nurses’ lack of knowledge related to pain assessment, as PWD share some characteristics with critically ill patients, such as difficulty self-reporting pain. Also, in the current review, poor knowledge of nurses regarding pain management among ICU patients was found to be a barrier to effective pain relief. Similarly, several previous studies have reported that nurses’ lack of knowledge regarding postoperative pain management impeded the achievement of optimal pain control. 37

A previous systematic review emphasized the importance of using behavioral pain indicators for pain assessment in patients with communication deficits, as opposed to relying only on self-reporting to assess pain. Similar to our findings, the most commonly reported behavioral pain indicators were motor activity (eg involuntary movements) and facial activity (eg facial grimacing). 38 In our review, nurses were found to misunderstand these behavioral indicators, thus complicating the effective assessment and prompt management of pain in critical care patients. 17 , 19 , 28 This misunderstanding may be due to inconsistency in these behaviors between critical care patients and nurses’ lack of knowledge, in addition to poor formal nursing education and clinical training. 38

Tolerance of pain differs from one person to another. Several factors influence patients’ pain tolerance, including emotions and lifestyle factors. 39 According to Saifan et al, 39 nurses had several beliefs and misconceptions related to patients’ pain tolerance which act as barriers to effective pain management. For example, they believe that patients with severe pain cannot be distracted. These findings support the finding of our review that using both verbal and nonverbal pain assessment tools for critical care patients is essential for optimal pain evaluation because it provides a holistic and comprehensive assessment of pain and allows nurses to feel more confident. By using both verbal and nonverbal pain assessment tools for critical care patients, nurses capture affective and physiological components of the pain experience and become certain regarding suspected pain in critical care patients. 19 , 28 Several studies are consistent with our review findings, indicating that nurses’ lack of knowledge regarding how to use verbal and nonverbal pain assessment tools is a major barrier to pain relief. 40 For example, a review of the literature related to pain in PWD found nurses to have poor knowledge and practices related to the use of pain assessment tools. 40

Adequate administration of pharmacological interventions, specifically opioids, plays an important role in effective pain management. 39 However, only three of the selected studies reported sufficient knowledge among nurses regarding pharmacological management as being a facilitator of adequate pain relief. Consistent with this finding, several published studies reported nurses’ lack of knowledge regarding pharmacological management of pain as being a significant barrier to pain management. 40 This includes lack of knowledge regarding opioids usage, dosage, and routes of administration. 39 Moreover, there is limited evidence regarding nurses’ knowledge of pharmacological pain management and how it relates to effectively assess and promptly treat pain among critical care patients.

Prolonged use of analgesics has many adverse effects on patients’ health status. 9 For that reason, nonpharmacological interventions may be an effective alternative for pain control among critically ill patients. 11 There is limited evidence related to nurses’ knowledge of and attitudes towards the use of nonpharmacological interventions among adult critically ill patients. In the present review, only one study was found to explore this issue, and this study reported insufficient knowledge among nurses regarding the use of nonpharmacological interventions. 29 Despite the limited evidence in the literature, there are conflicting findings regarding nurses’ levels of knowledge and attitudes related to nonpharmacological interventions in general. According to Puntillo et al, 1 nurses working in medical and surgical wards had a satisfactory level of knowledge regarding nonpharmacological pain interventions. Conversely, the study of Munkombwe et al, 41 which was conducted to investigate nurses’ palliative care practices, showed nurses to have inadequate knowledge and poor attitudes related to nonpharmacological management.

Nurses’ attitudes and beliefs related to pain may influence nurses’ provision of proper pain management. 2 More than half of the reviewed studies reported such attitudes and beliefs as being either facilitators of or barriers to pain assessment and management. For example, although behavioral pain assessment tools have limitations, frequent observing or monitoring of pain behaviors using validated and reliable assessment tools is an essential pain assessment practice in the case of patients who have difficulty self-reporting pain. 2 However, some of the reviewed studies reported infrequent use of behavioral pain assessment tools by critical care nurses when caring for nonverbal patients. Similarly, Samarkandi 42 found ICU nurses to have poor attitudes towards behavioral pain assessment. However, these poor attitudes were found to improve after nurses were taught how to use the Critical-Care Pain Observational Tool (CPOT) for nonverbal patients. Also, a scoping review conducted to explore the issue of pain management in pediatric intensive care units reported poor attitudes among nurses regarding the use of valid nonverbal pain assessment tools. 43 Furthermore, several studies conducted in different countries and settings reported negative attitudes among nurses towards pain assessment and management. 42 Moreover, Devlin et al 11 explored the beliefs of nurses regarding sedation and found the misconception that “sedated patients don’t feel pain at all” to be a major barrier to adequate pain management. This finding supports the findings of about one-third of the reviewed studies.

In the current review, two studies reported that nurses emphasized monitoring physiological and behavioral indicators as being an important aspect of pain assessment, which facilitates pain management in adult critically ill patients. However, overreliance on measuring physiological parameters or observing odd behaviors rather than using formal pain assessment tools to assess critical care patients’ pain was identified as being a major barrier to pain management in the present review. Although physiological parameters such as blood pressure and heart rate can be used to evaluate patients’ pain and provide important clues for effective pain assessment, 8 it is not recommended that formal pain assessment tools are replaced with these parameters when evaluating pain in critically ill adult patients. 2

A systematic review study conducted to review pain education interventions for nurses working in acute hospital settings reported that different types of education interventions had improved nurses’ attitudes towards and knowledge of pain and increased their confidence in their abilities to assess and manage patients’ pain. 44 This finding is consistent with the findings of our review regarding the impact of education programs on improving nurses’ knowledge of and attitudes towards pain in adult critically ill patients. However, future interventional research studies are recommended to bridge the knowledge gap in the literature regarding the role of ongoing education and professional training related to pain for critical care nurses as facilitators of pain management.

Pain self-reporting is considered the best way to assess patients’ pain, due to the high subjectivity of the pain experience. 20 Only three of the reviewed studies reported the patient’s ability to self-report pain as being a facilitator of pain evaluation. According to Kizza et al, 33 a significant proportion of nurses do not trust or believe in patients’ self-reporting of pain. Two of the studies selected in our review reported that nurses did their best to encourage critically ill conscious patients to self-report their pain using different methods. However, this is not always possible, especially for patients with severe cognitive impairments or communication deficits. 20 A systematic review conducted to explore cancer patient-related barriers to pain management reported patients’ inability to communicate as being one of the major barriers to effective pain management. 45 Also, several studies reported similar findings among different patient groups and in different clinical settings. 46 These findings are similar to our finding that the most commonly reported patient-related barrier, as perceived by critical care nurses, was patients’ inability to communicate.

Physiological and behavioral indicators are significant pain clues and should be used in addition to other assessment tools to optimize pain management. 8 However, there is a lack of consistency and specificity regarding the use of these indicators, which may complicate the assessment and management of pain in critically ill patients. Consistent with our finding, Reardon et al 47 found hemodynamic instability to be a perceived barrier to pain assessment and management.

Though uncommon, drug addiction during the management of pain may occur. 9 Therefore, aberrant drug behaviors should be closely monitored to detect addiction and potential drug abuse, especially in patients with a history of substance abuse or alcoholism, when administering opioids to manage pain in such patients. 48 According to Passik et al, 48 patients with a history of substance abuse and those receiving opioids have more serious aberrant drug behaviors as compared to patients with no history of drug abuse. Consistent with our review findings, Paice 49 revealed having a history of misuse of opioids or alcoholism to be a major barrier to pain management in cancer patients.

A recent systematic review, which explored physician-related barriers to effective cancer pain management revealed several barriers as perceived by physicians, including deficiencies in knowledge regarding the use of opioids in cancer pain management, fear of addiction, concerns related to the side effects of opioids, inadequate pain assessment, and inadequate analgesics prescription. 50 In our review, physicians’ adequate prescription of analgesics was perceived by nurses to be a facilitator of effective pain management. Also, both our review and the review of Jacobsen et al 50 found physicians’ workloads and improper interpretation of pain scores as being barriers to adequate pain management. Our review found that insufficient interaction between physicians and nurses impedes effective pain treatment, while improved collaboration between physicians and nurses was found to be a major facilitator. Several previous studies have also reported that poor collaboration between nurses and physicians impedes optimal pain relief. 6 , 51 , 52

System-Related Barriers and Facilitators

The presence of standardized protocols and guidelines for pain evaluation and management is essential for optimal pain management. 53 Consistently, our review found that the most frequently reported system-related barrier to effective pain management in critical care unit patients was the lack of standardized pain assessment tools and guidelines and pain management protocols. Wøien 21 also reported that establishing evidence-based protocols for pain evaluation and documentation is essential for facilitating pain control. Similar findings were also reported by a recent integrative review conducted among hospitalized PWD, which found the lack of standardized pain assessment tools and guidelines to be a major barrier to pain management. 53

Heavy nurses’ workloads and high nurse-patient ratios are considered major barriers to optimal pain control. 5 However, there is limited evidence in the literature related to these barriers and their association with unrelieved pain in critically ill patients. According to previous studies, the quality of care provided to patients suffering from pain differed significantly according to the type of hospital (ie, public or private). 54 However, in our review, only a single study was found to have explored the association between hospital type and the tools used to assess pain in critically ill patients. 27

In the current review, it was found that most critical care nurses had a lack of education regarding pain management, and about half of the reviewed studies highlighted the importance of continuous and professional pain education for critical care nurses. Consistently, several previous studies have emphasized the importance of updating nurses’ information related to pain assessment and management in verbal and nonverbal patients. 54 Ineffective or complicated discussions about pain treatment during medical rounds were also identified as being a system-related barrier to effective pain management in this review. Similarly, three previous studies have reported that reporting and discussing the pain scores of patients during nurse-to-nurse handovers facilitates effective pain management. 54–56

Documentation of pain assessment and management is essential for ensuring the provision of good quality pain control, as it enhances communication between healthcare providers and leads to consistency in assessment data. 55 , 56 However, poor nursing documentation of pain assessment findings was identified in this review as being a barrier to pain management. Also, Rafati et al 56 revealed that nurses’ lack of documentation of postoperative pain management findings contributed to poor patient outcomes. Moreover, although limited studies in our review discussed the role of nurses’ autonomous decision-making in pain management, reporting it to be insufficient among critical care unit nurses, several published studies have reported that nurses’ lack of autonomous decision-making impedes effective pain management. 57

Providing adequate levels of privacy in hospital environments has also been found to facilitate nurses’ pain assessment and management practices. 55 , 58 This finding supports the finding of the current review that issues related to lack of patient privacy, such as shared rooms with no curtains between patients, were significant barriers to pain control among critical care patients. Other system-related barriers pertaining to the hospital environment, such as crowded wards, early discharge of patients, and nursing staff shortages were identified in a recent review. 58

Limitations of the Review

This review has several limitations. These limitations include the heterogeneity of the selected studies and the limited availability of relevant studies which examine the primary variables. Also, this review included studies published in English only, while there may be other studies written in other languages investigating the main study variables. Also, in comparison to other studies, some of the reviewed studies were conducted on small samples, which limits the generalizability of the findings of these studies. Further, the reviewed studies were conducted in different countries and regions around the world. Therefore, there may have been confounding variables which were not taken into consideration, but which may have impacted the results, therefore impacting the generalizability of the findings. Finally, another limitation is that most of the reviewed studies were cross-sectional and prospective cohort studies, which limits the determination of causality.

The findings of our study could help hospital managers in developing continuous education and staff development training programs on assessing and managing pain for critical care patients. Establishing continuous education, workshops, professional developmental lectures focusing on pain evaluation and treatment for both critical care nurses and physicians, as well as training courses on how to use pain assessment tools and other behavioral pain indicators, especially for nonverbal patients are highly recommended. Also, our findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat the pain of critical care patients and emphasizing the importance of alternative and complementary medicine of pain.

Adequate pain control barriers and facilitators among intensive care unit nurses remain insufficiently researched. Effective pain management in critical care units relies on nurses’ knowledge of and attitudes towards pain assessment and relief. Also, various barriers to and facilitators of effective pain relief, including patient-related, nurse-related, physician-related, and system-related were identified and examined in the reviewed studies. The most frequently reported barriers in this study included nurses’ lack of knowledge regarding the use of pain assessment tools, patients’ inability to communicate, physicians’ prescription of analgesics being independent of pain scores evaluation, and absence of standardized guidelines and protocols for pain evaluation and control. For the facilitators, the most reported ones include ongoing education and professional training related to pain assessment and management, patients’ ability to self-report pain, effective collaboration between physicians and nurses, and productive discussion of patients’ pain scores during nurse-to-nurse handovers.

Acknowledgments

We want to thank the librarians of Jordan University of Science and Technology for their help.

The authors declare no conflicts of interest for this work.