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Pain in intensive care: assessments and patients’ experience
Malmö University, Faculty of Health and Society (HS), Department of Care Science (VV).
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of the thesis was to translate, psychometrically test, and further develop the Behavioral Pain Scale for pain assessment in intensive care and to analyze if any other variables (besides the behavioral domains) could affect the pain assessments. Furthermore, the aim was to explore the patients’ experience of pain within the intensive care.

The Behavioral Pain Scale (BPS), consisting of the domains “facial expression,” “upper limbs,” and “compliance with ventilator/vocalization,” was translated andculturally adapted into Swedish and psychometrically tested in a sample of 20 patients(study I). The instrument was then further developed within one of the domains and tested for inter-rater reliability, discriminant validity, and criterion validity (study II). The method for analysis in both study I and II was a method specifically developed for paired, ordered, and categorical data. To describe and analyze the process of pain assessment, a General Linear Mixed Model was used to investigate what variables, besides the behaviors, could be associated with the observers’ own assessment of the patients’ pain (study III). Further, the patients’ experiences of pain when being cared for in intensive care were explored (study IV) through interviews with 16 participants post intensive care. Qualitative thematic analysis with an inductive approach was used for the analysis.

The first psychometric tests of the BPS (study I) showed inter-rater reliability with agreement of 85%. For the discriminant validity, all domains, except “compliance with ventilator,” indicated discriminant validity.

Therefore, in study II, a developed domain of “breathing pattern” was tested alongside the original version. The BPS showed discriminant validity for both the original and the developed version and an inter-rater reliability with agreement of 76-80%. Wheninspecting the respective domains there was a difference in discriminant validity between the original domain of “compliance with ventilation” and the developed domain of “breathing pattern,” showing higher values on the scale for the developed domain during turning. For criterion validity, the BPS showed a higher sensitivity than the observers, who on the contrary had a higher specificity.The General Linear Mix Model (study III) showed that heart rate could be associated with the observers’ assessments of pain. For the behavioral signs, the result indicated that breathing pattern was most associated with the observers’ pain assessment, whilst facial expression did not show any impact on the observers’ assessments.

The patients’ experiences of pain (study IV) in intensive care were described as generating a need for control; they experienced a lack of control when pain was present and continuously struggled to regain control. The experience of pain was not only related to the physical sensation but also to psychological and social aspects, along with the balance in the care given, which was important to the participants.

In conclusion, the translated and developed version of the Swedish BPS showed promising psychometric results in assessing pain in the adult intensive care patients. Still, other signs, besides behavioral, is possibly used when pain assessing and therefore information about and training in pain assessment are needed to enhance the assessments that are made. Also, the patients’ own experiences highlight the importance of individualizing and adapting pain assessment and treatment to the needs of each patient. Making them a part of the team could enhance their feeling of control, thereby supporting them in facing the experience of pain.

Place, publisher, year, edition, pages
Malmö: Malmö universitet, 2021. , p. 108
Series
Malmö University Health and Society Dissertations, ISSN 1653-5383 ; 2021:1
National Category
Nursing
Identifiers
URN: urn:nbn:se:mau:diva-40867DOI: 10.24834/isbn.9789178771424ISBN: 978-91-7877-141-7 (print)ISBN: 978-91-7877-142-4 (electronic)OAI: oai:DiVA.org:mau-40867DiVA, id: diva2:1531175
Public defence
2021-03-19, 09:00
Opponent
Note

Due to copyright reasons, the articles are not included in the fulltext online

Available from: 2021-02-25 Created: 2021-02-25 Last updated: 2024-03-07Bibliographically approved
List of papers
1. Behavioral Pain Scale - translation, reliability, and validity in a Swedish context
Open this publication in new window or tab >>Behavioral Pain Scale - translation, reliability, and validity in a Swedish context
2016 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 60, no 6, p. 821-828Article in journal (Refereed) Published
Abstract [en]

Background: Assessing pain in the intensive care unit (ICU) is challenging. Due to intubation and sedation, communication can be limited. International guidelines recommend assessing pain with instruments based on behavioral parameters when critically ill patients are unable to self-report their pain level. One of the recommended instruments, the Behavioral Pain Scale (BPS), has shown good validity and reliability in international studies. The aim of this study was to translate and adapt the BPS for critically ill intubated and non-intubated patients in a Swedish ICU context and to assess inter-rater reliability and discriminant validity. Methods: The BPS (both for intubated and non-intubated patients) was translated and adapted into Swedish using a translation method consisting of ten steps. The Swedish version was then tested for inter-rater reliability and discriminant validity on 20 critically ill patients (10 intubated and 10 non-intubated) before and directly after a potentially painful procedure (repositioning Results: The Swedish version of the BPS showed inter-rater reliability with a percentage agreement of 85% when tested on a sample of critically ill patients. The instrument also showed discriminant validity between assessments at rest and after repositioning Conclusion: Results of the Swedish version of the BPS support its use in critically ill patients who cannot self-report their pain level. Still, additional studies are needed to further explore its reliability and validity in the Swedish ICU context

Place, publisher, year, edition, pages
Wiley-Blackwell, 2016
Keywords
Anesthesiology
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:mau:diva-4648 (URN)10.1111/aas.12688 (DOI)000379932900015 ()27251598 (PubMedID)2-s2.0-84958212294 (Scopus ID)23039 (Local ID)23039 (Archive number)23039 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-01-22Bibliographically approved
2. To assess patients pain in intensive care: developing and testing the Swedish version of the Behavioural Pain Scale
Open this publication in new window or tab >>To assess patients pain in intensive care: developing and testing the Swedish version of the Behavioural Pain Scale
2019 (English)In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 52, p. 28-34Article in journal (Refereed) Published
Abstract [en]

Objectives: The Behavioural Pain Scale has previously been translated into Swedish and psychometrically tested. One of the domains- 'compliance with ventilation'- did not show equally as good psychometric proprieties as the other domains, which led to the question whether a development of that domain would be beneficial. This study aimed to develop the domain of 'breathing pattern' in the Swedish version of the Behavioural Pain Scale and then test the instrument for discriminant validity, inter-rater reliability and criterion validity. Method: The domain 'breathing pattern' was developed and included when the Swedish version of the Behavioural Pain Scale was psychometrically tested in 360 paired assessments. Results: The instrument showed discriminant validity through a significant positive change on the scale before and during turning and inter-rater reliability with an absence of significant disagreement on the scale between the paired assessments. The developed domain had a better result in discriminant validity than the original domain. The instrument also showed higher sensitivity in discriminating pain compared to assessment without an instrument. Conclusion: The Swedish version of the Behavioural Pain Scale, with a developed domain for 'breathing pattern' showed to be a reliable instrument for pain assessment in the adult intensive-care patient. (C) 2019 Elsevier Ltd. All rights reserved.

Place, publisher, year, edition, pages
Elsevier, 2019
Keywords
Behavioural Pain Scale, Critical care, Intensive care, Pain assessment, Person-centred care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:mau:diva-14588 (URN)10.1016/j.iccn.2019.01.003 (DOI)000463611200006 ()30826170 (PubMedID)2-s2.0-85062105810 (Scopus ID)30048 (Local ID)30048 (Archive number)30048 (OAI)
Available from: 2020-03-30 Created: 2020-03-30 Last updated: 2024-02-05Bibliographically approved
3. Patient characteristics and vital signs that could affect pain assessments in the ICU
Open this publication in new window or tab >>Patient characteristics and vital signs that could affect pain assessments in the ICU
Show others...
2021 (English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:mau:diva-40898 (URN)
Available from: 2021-02-26 Created: 2021-02-26 Last updated: 2024-01-16Bibliographically approved
4. Patients´ experiences of pain in the intensive care - The delicate balance of control.
Open this publication in new window or tab >>Patients´ experiences of pain in the intensive care - The delicate balance of control.
2020 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 76, no 10, p. 2660-2669Article in journal (Refereed) Published
Abstract [en]

AIM: To explore the patients´ experiences of pain when being cared for in the intensive care.

DESIGN: An exploratory, qualitative design was chosen.

METHOD: Interviews were performed with patients (October 2015-March 2017) within a week of post-intensive care (N = 16). Thematic analysis was used as method for analysis.

RESULTS: The findings generated two themes - a lack of control and to struggle for control. Pain was described as overwhelming, both in body and mind and generating the experience of a lack of control, with feelings of incapacitation, isolation, and having their needs unmet. Feeling in control of the pain and thus in control of the situation was experienced as a constant struggle. Well-planned care, finding ways to handle the pain and good communication were all helpful in this struggle.

CONCLUSION: The participants recalled their experience of pain in the ICU and control seems to be crucial for how pain is experienced. They experienced a lack of control due to not only the pain but also the treatment, which can be avoided by the nurse continuously evaluating and individualising the care. Balanced care, meeting the patients' needs and good communication helps the patient feel more in control when experiencing pain.

IMPACT: The experience of pain is dependent on control for the intensive care patient. The nurse may help them gain control and thereby handle the experience of pain through including the patient, striving for better communication and implementing individualised care that continuously assesses and treats pain.

Place, publisher, year, edition, pages
John Wiley & Sons, 2020
Keywords
critical care nursing, intensive care nursing, nursing, pain, pain experience, pain management, patient experience
National Category
Nursing
Identifiers
urn:nbn:se:mau:diva-18363 (URN)10.1111/jan.14503 (DOI)000567067200001 ()32808692 (PubMedID)2-s2.0-85089531459 (Scopus ID)
Available from: 2020-09-23 Created: 2020-09-23 Last updated: 2024-03-28Bibliographically approved

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