Pain is one of the most common problems in Intensive Care Units (ICUs) and in treating critically ill patients, regardless of their underlying diseases [1]. It is also considered one of the most significant stressors of critically ill patients [2]. It is reported that almost half of critical care inpatients experienced pain during rest and procedural interventions [3], that 45% to 82% of patients in ICU experienced moderate to severe pain [4], and that more than half experienced untreated and persistent pain after discharge [5]. In Jordan, ICU patients were found to have moderate pain at rest and severe pain during nursing procedures [6].

Pain is purely a subjective measure, so patient self-report is the most reliable method to assess and explore it. However, critically ill patients and those mechanically ventilated or unable to communicate are not able to report any pain that they may be experiencing. Consequently, there is a challenging and underestimated problem in estimating pain resulting from alteration of consciousness, sedation, invasive procedures [7], and mechanical ventilation [8]. Undertreated pain can result in unfavorable complications in respiratory and cardiac functions, thus augmenting morbidity, mortality, and healthcare costs [6] and lengthening hospital stays [4]. In contrast, pain assessment systematically improves patients’ outcomes, thus reducing duration of mechanical ventilator support and length of hospital stay [8].

Elimination of patients’ pain and suffering is an important responsibility of healthcare professionals (HCPs) [9, 10]. In ICUs, nurses play a key role in assessing and treating patients’ pain, by systematically monitoring pain levels, choosing and administering the appropriate treatment including non-pharmacological pain management interventions, educating patients and their families about pain, and advocating for patients [11]. Critically ill and mechanically ventilated patients rely strongly on nurses to alleviate their suffering and symptoms by understanding undesirable experiences including pain, anxiety, and delirium and by identifying the symptoms associated with pain [12]. Therefore, a principal aspect of nurses’ execution of the treatment plan for non-communicating or mechanically ventilated patients is to use the appropriate tools to assess their pain levels [6]. Moreover, accurate pain assessment improves its management, making assessment a key element of pain management in ICU patients. In summary, the use of appropriate pain assessment tools and documentation of pain levels help to improve understanding of pain levels in ICU patients, to enhance pain management, and to reduce undesired effects and complications [13].

Despite the attention of many researchers and healthcare institutions globally, however, pain management remains deficient, as about 50% of ICU patients continue to experience pain [3]. Among the factors obstructing ICU nurses in assessing and managing pain adequately are barriers related to patients, to nurses themselves, and to hospital policies, such as the persistence of traditional conceptions of pain and suffering, nurses having no authority to administer analgesia, the absence of special forms for assessing pain in intubated patients, lack of knowledge, physicians’ mistrust of nurses’ assessment, and inadequate psychosocial support services [14].

ICU patients in Jordan have been found to suffer moderate to severe pain and not be well satisfied with pain management [15]. Meanwhile, given nurses’ role as the HCPs most closely involved in pain management, their practices are key to its success. Furthermore, obtaining baseline data regarding nurses’ practices in Pain Assessment and Management (PAM) for ICU patients is a significant step in managing their pain effectively, thus enhancing their Quality of Life (QoL) and reducing hospitalization periods and emergency visits [16, 17].

Pain assessment and management is a topic of wide interest to HCPs and healthcare institutions not only because of its significant effect on the QoL of patients and their families, but also because it is considered an accreditation requirement. Moreover, improving HCPs’ practices in this field, participating in scientific research, and keeping up to date with modern science are all required to achieve optimal patient care [18, 19]. Thus, there is value in obtaining information about nurses’ PAM practices—both generally and in ICUs—and in exploring the factors that affect their success in this process, in addition to identifying their educational needs.

Identifying the current PAM practices, barriers and enablers from nurses’ point of view would help in exploring areas of deficit in order to guide healthcare administrators and policymakers in their planning and in seeking solutions to any such obstacles. Recognizing the great importance of nurses’ curricula and educational programs [9, 20], it is also hoped that this study will encourage nursing schools and in-service education departments to sharpen the focus of their curricula on pain-related topics and that it will shed light on specific areas of educational need.

It must be borne in mind that pain perception is culturally sensitive and that nurses’ behaviors and practices in PAM are influenced by culture [21, 22]. Therefore, researchers recommend that exploring HCPs’ knowledge of and attitudes to pain in multiple countries is required in order for any conclusions to benefit from a variety of perspectives. In particular, this study addresses the perspective of Jordanian nurses on PAM in ICUs, by investigating their practices, their perceptions of barriers and enablers, and their related educational needs.

Of the 210 questionnaires distributed, 171 were returned and included in the analysis, a response rate of 81.4%. The age of the participants ranged from 23 to 45 years, with a mean of 30.3 (SD=4.7). Their general experience ranged between 3 months and 20 years with a mean of 6.8 (SD=4.2) and their ICU experience ranged from 3 months to 18 years with a mean of 4.8 (SD=3.6). There were slightly more males (n=94; 55%) than females. The majority of participants had bachelor’s degrees (n=142; 83%). Precisely two-thirds (n=114; 66.6%) had no PAM training and 151(88.3%) had no experience in a pain management team. More than half of participants (n=98; 57.3%) were recruited from public hospitals. Nearly two-thirds (n=106; 62%) were working in mixed ICUs and the most frequent (n=117; 68.4%) nurse-to-patient ratio in the participating units was 1:>2. Table 1 gives details of participants’ characteristics.

3.2. Barriers to and Enablers of Pain Assessment and Management

Nurses perceived there to be marginally more enablers of PAM (mean=3.4; SD=.8) than barriers to it (mean=3.3; SD=.6). The two highest scores for enablers were for physicians’ prescribing of analgesics (mean=3.6; SD=1) and nurses’ belief about the priority of PAM (mean=4.5; SD=1.1), whereas the lowest were for hospital policy and services regarding pain consultation in the ICU (mean=3.1; SD=1.2) and using pain management guidelines (mean=3.2; SD=1.1). As to barriers, the highest scores were for high workload and time constraints (mean=3.6; SD=1), followed by unavailability of pain management guidelines (mean=3.5; SD=1.1), while the lowest were for the absence of a specific section for pain assessment in the nursing chart (mean=3.1; SD=1.3) and the fact that ICU professionals did not prioritize pain management (mean=3.1; SD=1.1). Table 3 gives details concerning PAM enablers and barriers.

Table 3. Enablers and barriers in pain assessment and management N=171.

-	Mean(SD)
Enablers	-
Pain assessment and management is a unit priority	3.5(1.1)
Enthusiastic and motivated staff	3.4(1)
Standardized assessment tools are in use	3.4(1.1)
Protocols and guidelines are in use	3.2(1.1)
Physicians prescribe adequate doses of analgesia	3.5(1)
Ongoing education on pain is provided	3.3(1.2)
Advanced practice nurse(s) are employed by the ICU	3.3(1.1)
Hospital pain service consults in the ICU	3.1(1.2)
Barriers	-
Workload and lack time	3.6(1)
Lack of availability of pain assessment tools	3.2(1.1)
Lack of education/familiarity with assessment tools	3.2(1)
Patient instability e.g. unstable hemodynamics	3.3(.98)
Patient inability to communicate	3.4(1.1)
Lack of protocols/guidelines for pain assessment	3.3(1.1)
Low priority of pain management by ICU team	3.1(1.1)
No designated area for charting pain	3.1(1.3)
Sedation interfering with pain assessment	3.4(1.1)
Poor documentation of pain assessment and management	3.2(1)
Poor communication of pain and analgesic management priorities within ICU team	3.2(1)
Lack of protocols/guidelines for pain management	3.2(1.1)
Insufficient analgesia dosage prescribed	3.2(1.2)

Fig. (1). Nurses' perception about importance and frequency in pain assessment based on the procedure.

The aims of this study were to assess ICU nurses’ practices in pain assessment and management, to explore the factors that they perceived as hindering and enabling PAM, and to identify their PAM-related educational needs. Analysis of the data reveals that half of participating nurses wrongly believed that in the case of a patient able to self-report pain, the severity of that pain would be more accurately reported by physicians, nurses and relatives. This unfounded belief contradicts the fact that pain is purely subjective and can most reliably be reported by the patient, as indicated in the definition of McCaffery [23]. Participants in this study were more likely to hold this erroneous view than those in a recent study of Jordanian nurses working in an oncology unit, 74% of whom agreed that the patient would most accurately report pain [24]. Regarding patients unable to report their own pain, the proportion of participants (around three-quarters) who agreed that nurses offer the most accurate assessment was smaller than in two previous studies conducted among Jordanian [5] and Canadian [25] ICU nurses, of whom 84% and 94% respectively reported this belief. The percentage of nurses in the present study stating that they used pain assessment tools for patients able to report pain (60%) was higher than for those unable to report pain (50%), both figures being below the optimal level and much lower than the results of other studies [25-28]. All of these findings indicate the need to encourage nurses to improve their knowledge and skills and to be more expert in pain assessment.

The pain assessment tools most commonly reported as being used in this study were NRS and VAS when patients were able to report pain and CPOT and FLACC when they were unable to do so. These results are similar to those of previous studies [25, 26], indicating that nurses were using valid and reliable tools, so it is recommended that further studies be conducted to ensure their compliance in using these tools appropriately. In addition, it is recommended that these tools be added to nursing assessment charts in ICUs, because nurses in this study identified the absence of a pain tool from nursing charts as one of the most common barriers to assessing pain in ICU patients.

One of the inappropriate practices revealed by this study is the failure to routinely discuss pain scores and pain management plans during medical rounds. As generally understood, pain management is the responsibility of all healthcare professionals, all of whom, including nurses, should therefore be required to assign a higher priority to it; indeed, an earlier study identified the low priority given to pain management as an obstacle to successful pain management in ICUs [10]. It is further recommended that a study be conducted to assess physicians’ PAM practices for ICU patients, especially because such studies are missing from the Jordanian literature [9].

When factors affecting ICU nurses’ practice were assessed by asking them about barriers and enablers to PAM, they identified insufficient time and workload as the most common barrier. A previous qualitative study of the challenges facing ICU nurses in pain assessment identified workload as an organizational barrier and the inappropriate nurse-to-patient ratio was felt to be its main cause [27]. Similarly, the current study found nurse-to-patient ratios to be incompatible with international recommendations that each nurse should have care of no more than two patients [28]. The ratio of 1:>2 in most of the participating hospitals suggests that decision makers in Jordan should highlight this problem to improve the quality of care for ICU patients, as it has been proven that an improved nursing work environment, with reduced workload, impacts positively on the quality of patient care and reduces mortality [17]. As a first step, research is recommended into the impact of nursing workload on patients’ safety and quality of care in a Jordanian context. A final barrier identified by this study is the unavailability of PAM guidelines, which was also reported by Ugandan nurses, about 73% of whom perceived it to be a barrier [10]. Thus, it is important for hospitals to have valid and reliable PAM guidelines and to integrate them with a special practice policy in ICUs as a requirement for obtaining international accreditation.

It has been clearly demonstrated that Jordanian nurses are in need of further education regarding PAM in ICU settings. Results indicate that most participating nurses did not know any PAM guidelines and that they had not read any recommendations in this regard. Furthermore, they were found to need further education regarding the physiological and psychological consequences of untreated pain, a finding consistent with other studies. This could be explained by the failure to include the topic of pain in curricula, as reported by nursing students [27, 29] or by the inadequate attention given by hospitals’ in-service training units to this topic and the consequent insufficient training given to nurses [24]. Therefore, the inclusion of this topic in nursing school curricula and in training for nurses in hospitals is highly recommended.

Although participating ICU nurses in Jordan reported that they performed pain assessment for patients in ICU using proper pain assessment tools, their practice was found to be below the optimal level. Further attention is required to training nurses about how and when to assess pain in ICU patients. Priority should also be given to including discussion of PAM during nursing and medical rounds. Finally, healthcare professionals, organizations, schools of nursing, administrators, and policymakers should work together to take serious action to improve nurses’ knowledge and practices in PAM.

The validity and reliability of the tool which nurses were asked to complete, the Survey of Perceived Pain Assessment and Management Practices for Patients Able and Unable to Self-Report Pain, is considered a strength, whereas low sample size is considered a limitation of the study.