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

Figures & data

Figure 1 PRISMA flow chart.

Note: Adapted from: Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of Clinical Epidemiology. 2009;62(10)e1-e34. Creative Commons..⁶²

Table 1 Summary of the Detailed Information of the Selected Studies

Authors/ Country	Design	Purpose	Response Rate	Participants	Instrument	Key Findings	LOE
Wang & Tsai,^Citation20 Taiwan	Prospective cross-sectional	To discuss pain management awareness & barriers from nurses’ perspective in critical care units.	97.9%	370 ICU nurses from 16 hospitals	Nurses’ Knowledge & Attitudes Survey-Taiwanese version	Nurses’ perceived barriers to pain management are affected significantly by nurses’ awareness & knowledge regarding pain management in critical care units.	IV
Topolovec-Vranic et al,^Citation22 Canada	Prospective cross-sectional	To examine the effect of a newly developed pain assessment tool for critically ill patients in a trauma/neurosurgery critical care unit.	89%	64 ICU patients	The Staff Satisfaction Questionnaire & Staff End-of-Study Questionnaire, The Patient Pain Management Questionnaire	Use of the Nonverbal Pain Scale improved nurses’ confidence while assessing nonverbal patients’ pain, documentation of findings, and rating of patients’ pain experience.	IV
Lindberg & Engström,^Citation15 Sweden	Qualitative	To describe critical care nurses’ experiences in assessing and managing postoperative ICU patients’ pain.	85.7%	6 ICU nurses	Semi-structured interviews	Establishing a good relationship between nurses and patients is essential for effective pain management.	VI
Rose et al,^Citation18 Canada	Prospective cross-sectional	To explore nurses’ skills & knowledge related to pain assessment & management among verbal & nonverbal critically ill patients in critical care settings.	57%	140 RN employed in five ICUs of a 600-bed university-affiliated hospital	Survey of assessment and management of pain for critically ill adults	Nurses had a lack of confidence in their abilities and less frequent use of formal assessment tools for nonverbal patients, although they reported equal importance in assessing pain among verbal and nonverbal patients.	IV
Subramanian et al,^Citation16 United Kingdom	Qualitative prospective exploratory	To discuss the challenges of effective pain management among critically ill patients from nurses’ point of view.	100%	21 critical care nurses from a teaching health care trust	Semi-structured interviews, using the critical incident technique	The quality of care and pain management in critical care units is influenced by nurses’ decision-making regarding pain control.	VI
Rose et al,^Citation19 Canada	Prospective cross-sectional	To explore critical care nurses’ perceptions & knowledge toward pain assessment and management in ICUs.	24%	842 ICU nurses	Survey of assessment and management of pain for critically ill adults	A large percentage of critical care nurses did not assess nonverbal pain using formal pain assessment tools and were unaware of published guidelines for critically ill patients’ pain management.	IV
Alasiry et al,^Citation13 Sweden	Qualitative	To discuss pain assessment & pain management in critically ill patients from nurses’ perspective.	100%	10 coronary care unit nurses	Semi-structured interviews	Adequate pain assessment and management needs more knowledge and improved practice among critical care nurses while dealing with pain in myocardial infarction patients.	VI
Machira et al,^Citation24 Kenya	Pre/posttest Quasi-experimental	To implement and examine the effect of an educational pain management program for critical care nurses	87.1%	27 nurses from 2 units in a single health institution	Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKASRP)	Significant knowledge deficits and poor attitudes towards pain management were identified among critical care nurses.	III
Schreiber et al,^Citation25 United States	Pre/posttest Quasi-experimental	To examine the effect of an educational intervention on pain management in a critical care unit.	100%	341 medical-surgical & critical care nurses	Brockopp-Warden Pain Knowledge/Bias Questionnaire [BWPKBQ])	A lack of knowledge among nurses regarding the basic concepts of pain control was identified. The implementation of the educational intervention led to major changes in pain management knowledge among the nurses in the selected institution.	III
Gerber et al,^Citation26 Western Switzerland	Descriptive observational	To discuss expert nurses’ perspective of the indicators that influence their clinical reasoning towards pain assessment among nonverbal critically ill patients.	100%	7 expert nurses/ medical-surgical and critical care nurses	3 methods of data collection: recorded think aloud, direct non-participant observations, and brief interviews	This study highlights the difficulty of providing care to critically ill patients, as well as the importance of comprehensive pain assessment which takes into account the patient’s complete clinical picture.	VI
Kizza & Muliira,^Citation30 Ugandan	Descriptive cross-sectional	To discuss pain assessment practice facilitators and barriers among critical care nurses in a resource-limited setting.	75%	170 nurses	Survey of Perceived Pain Assessment and Management Practices for Patients Able and Unable to Self-Report Pain	Several barriers were found to affect adequate pain assessment among critical care nurses in a resource-limited setting. The main barriers were nurses’ workloads; lack of awareness; and poor adaptation to pain assessment tools	VI
Lewis et al,^Citation23 United States	Quasi-experimental	To examine the efficacy of small group discussions on barriers to and knowledge of pain management among critical care nurses.	97%	32 critical care nurses	Brockopp & Warden Pain Knowledge Questionnaire	Improving nurses’ pain management knowledge and decreasing their bias towards particular patients can improve critically ill patients’ clinical outcomes.	III
Ufashingabire et al,^Citation31 Rwanda	Descriptive cross-sectional	To evaluate critical care nurses’ knowledge of & attitudes towards pain management among critically ill patients	100%	69 critical care nurses	Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKASRP)	Several factors negatively influenced effective pain management practices in ICUs. Continuous educational training & working area improvement are needed to improve nurses’ pain management practices.	VI
Deldar et al,^Citation14 Iran	Qualitative	To gain a better understanding of the current challenges faced by critical care nurses in using pain assessment tools with nonverbal patients.	100%	20 ICU nurses	Semi-structured interviews	Several factors could influence the adequate use of pain assessment scales, particularly for nonverbal patients. Identifying such factors can improve assessment & empower nurses in the use of nonverbal pain assessment tools.	VI
Khalil,^Citation29 Egypt	Descriptive exploratory	To evaluate the use of nonpharmacological management for pain control among ICU nurses	100%	60 ICU nurses	Nonpharmacological pain management checklist	A substantial proportion of critical care nurses did not use nonpharmacological intervention practices to control their patients’ pain.	VI
Hamdan,^Citation27 Jordan	Descriptive cross-sectional	To evaluate critical care nurses’ pain assessment practices.	60.1%	300 ICU nurses	The Pain Assessment and Management for the Critically Ill survey	The most valid and reliable tools for both verbal and nonverbal patients were not often used by nurses, and nurses were not aware of most behavioral pain indicators among critically ill patients.	VI
Asman et al,^Citation17 Israel	Prospective cross-sectional	To examine how nurses’ knowledge of pain in mechanically ventilated patients & self‐perceived collaboration between nurses & physicians affect pain management	84.67%	187 ICU nurses	The Strengthening the Reporting of Observational Studies in Epidemiology EQUATOR checklist	Improved knowledge among nurses of behavioral pain indicators and self‐perceived collaboration between nurses and physicians promote adequate pain management.	IV
Wøien,^Citation21 Norway	Prospective before/after study with a longitudinal design	To compare between the effect of regular care protocols & analog sedation on the levels of pain & sedation among critically ill patients.	81%	205 ICU patients	Numeric rating scale, Critical Care Pain Observational Tool	Systematic assessment & documentation succeeded in establishing effective pain management & sedation in critical care units.	IV
Khalil & Mashaqbeh,^Citation28 Jordan	Cross-sectional descriptive	To evaluate nurses’ attitudes towards & knowledge of pain	100%	417 ICU nurses	Nurses’ Knowledge and Attitudes Survey (NKAS)	Nurses have significant knowledge deficits and poor attitudes toward pain, specifically in certain areas (ie, pain assessment and pharmacological management).	VI
Roos-Blom et al,^Citation32 Netherland	Unadjusted and case-mix adjusted	To investigate the association between nurses’ heavy workloads & effective pain management in ICUs	15.7%	13 ICUs’ electronic health records (HER)	Unadjusted & case-mix adjusted mixed-effect logistic regression modeling	Lower nurse-to-patient ratios improve pain management, especially in critically ill patients.

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

Table 2 The Summary of the Measures Used in the Selected Quantitative Studies

Name of Tool	Number of Studies They Appear in	Purpose	Psychometric Properties
Nurses’ Knowledge and Attitudes Survey Regarding Pain (NKASRP)	4	To evaluate nurses’ knowledge of & attitudes towards pain assessment & pain management.	Cronbach’s alpha of 0.73, Test-retest reliability of > 0.80, Content and construct validity were established by pain experts
The Pain Assessment and Management for the Critically Ill survey	3	To assess nurses’ pain assessment practices among verbal & nonverbal patients.	Content validity, test-retest reliability, and comprehensiveness were tested by ten experts in pain.
The Pain Assessment and Management for the Critically Ill survey(modified)	1	To assess nurses’ pain assessment practices among verbal & nonverbal patients.	Cronbach’s alpha of the modified tool 0.71, content validity of 0.90
Brockopp-Warden Pain Knowledge/Bias Questionnaire [BWPKBQ])	2	To evaluate nurses’ knowledge of pain relief & biases towards certain patient groups.	Test and retest correlation coefficient 0.86
Numeric rating scale, Critical Care Pain Observational Tool	1	To assess pain levels among verbal & nonverbal patients, respectively	The authors only mentioned that all instruments used had been validated
The Strengthening the Reporting of Observational Studies in Epidemiology EQUATOR checklist	1	To evaluate nurses’ knowledge of pain indicators, nurse-physician collaboration & satisfaction, & adequacy of pain management.	Cronbach’s alpha of three sections 0.82, 0.94, 0.84 respectively
Nonpharmacological pain management checklist	1	To explore critical care nurses’ implementation of nonpharmacological pain interventions to control their patients’ pain.	Test and retest correlation coefficient of 0.7
The Staff Satisfaction Questionnaire and Staff End-of-Study Questionnaire	1	To investigate pain assessment & management from nurses’ perspective & their confidence level in assessing & managing pain in both verbal & nonverbal patients.	The authors did not evaluate the psychometric properties of the tools
The Patient Pain Management Questionnaire	1	To assess patients’ pain management from their point of view & their level of satisfaction during their experience in intensive care units	The authors did not evaluate the psychometric properties of the tool

Table 3 The Summary of the Measures Used in the Selected Qualitative Studies

Authors	Method	Purpose	Type of Analysis
Deldar et al^Citation18	Semi-structured interviews	To investigate a better understanding of the current challenges faced by critical care nurses in using pain assessment tools among nonverbal patients	Inductive approach based on the Graneheim and Lundman method.^Citation59
Alasiry et al^Citation13	Semi-structured, 20-minute interviews	To gain a better understanding of pain assessment and pain management in critically ill patients in cardiac care units from nurses’ perspectives.	Content analysis using manual analyzing based on the Graneheim and Lundman method.^Citation59
Subramanian et al^Citation16	Semi-structured interviews with nurses using the critical incident technique. Interviews lasted between 45 minutes-1.5 hours	To understand challenges related to effective pain management among critically ill patients from nurses’ perspective.	Content analysis using the framework analysis developed by the National Centre for Social Research.^Citation60
Lindberg & Engström^Citation15	Semi-structured interviews lasting between 20–70 minutes	To gain a better understanding of critical care nurses’ experiences in assessing and managing postoperative patients’ pain in an intensive care unit	Content analysis described by Downe-Wamboldt.^Citation61

Table 4 The Barriers to and Facilitators of Pain Assessment and Management

Barriers
Nurse-Related Barriers	Patient-Related Barriers	Physician-Related Barriers	System-Related Barriers
● Nurses’ lack of knowledge regarding the use of pain assessment tools ● Nurses’ poor knowledge regarding pharmacological pain management ● Nurses’ improper and infrequent use of behavioral pain assessment tools for nonverbal patients	● Patients’ inability to communicate ● Patients’ hemodynamic instability ● Patients’ history of substance abuse, alcoholism, or suicidal attempts	● Physicians’ prescription of analgesics being independent of evaluation pain scores ● Poor interaction of physicians with nurses regarding nonverbal patients’ pain ● Junior doctors’ lack of experience and senior doctors’ heavy workloads	● Absence of standardized guidelines and protocols for pain evaluation and control ● Inadequate training and education related to pain assessment and management ● Lack of standardized pain assessment forms and tools for verbal and nonverbal critically ill patients
Facilitators
Nurse-Related Facilitators	Patient-Related Facilitators	Physician-Related Facilitators	System-related facilitators
● Ongoing education and professional training related to pain assessment and management ● Nurses’ knowledge regarding pain behaviors and indicators ● High level of knowledge among nurses about the pharmacological management of pain ● Nurses’ realization of the importance of physiological indicators in pain assessment	● Self-reporting of pain	● Collaboration between physicians and nurses Prescription of adequate analgesics doses by physicians	● Reporting and discussing patients’ pain scores during nurse-to-nurse handovers ● Continuous education and professional training for critical care nurses

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