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Barriers to nurse-led pain management for adult patients in intensive care units: An integrative review

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    1 Twitter: @MajidAlien.
    Majid Alotni
    Correspondence
    Corresponding author. Tel.: +966554887744.
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    1 Twitter: @MajidAlien.
    Affiliations
    School of Nursing and Midwifery, College of Health, Medicine & Wellbeing, University of Newcastle, University Drive, Callaghan NSW 2308, Australia

    Department of Medical/Surgical nursing, Nursing College, Qassim University, Buraydah 52571, Saudi Arabia
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    2 Twitter: @MCGuilhermino.
    Michelle Guilhermino
    Footnotes
    2 Twitter: @MCGuilhermino.
    Affiliations
    School of Nursing and Midwifery, College of Health, Medicine & Wellbeing, University of Newcastle, University Drive, Callaghan NSW 2308, Australia

    John Hunter Hospital, Intensive Care Services, Hunter New England Local Health District, Australia
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    3 Twitter: @jed_duff.
    Jed Duff
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    3 Twitter: @jed_duff.
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    School of Nursing and Midwifery, College of Health, Medicine & Wellbeing, University of Newcastle, University Drive, Callaghan NSW 2308, Australia

    Centre for Healthcare Transformation, Queensland University of Technology, Centre for Nursing and Midwifery Research, Royal Brisbane and Womens Hospital, Herston QLD 4029, Australia
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    4 Twitter: @jennysim_1.
    Jenny Sim
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    4 Twitter: @jennysim_1.
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    School of Nursing and Midwifery, College of Health, Medicine & Wellbeing, University of Newcastle, University Drive, Callaghan NSW 2308, Australia

    School of Nursing and Australian Health Services Research Institute (AHSRI), University of Wollongong, NSW, Australia
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Open AccessPublished:November 01, 2022DOI:https://doi.org/10.1016/j.aucc.2022.09.002

      Abstract

      Objective

      This integrative review sought to identify and synthesise quantitative and qualitative evidence on barriers to pain management in adult intensive care units (ICUs).

      Background

      Pain is experienced by 58% of adult ICU patients, which leads to consequences such as decreased healing and delirium. Managing pain effectively is an integral part of the critical care nurse's role.

      Methods

      An integrative review was conducted based on Whittemore and Knafl's approach. Peer-reviewed research articles were sourced from five databases. Included articles were limited to those published in English and Arabic. The quality of included papers was evaluated using the Mixed Methods Appraisal Tool (MMAT). Identified barriers to pain management in adult ICUs were mapped onto the components of the COM-B model. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

      Results

      Nine hundred and ninety-one papers were identified; 19 studies met the inclusion criteria. Seventeen studies focused on pain management from the perspective of nurses, whereas the remaining two focused on the perspectives of patients and nurses. Using the MMAT, two studies were rated 5 stars (out of 5), nine studies were rated 4 stars, seven studies were rated 3 stars, and one study was rated 2 stars. Lack of knowledge and skills was found to be psychological capability barriers, while nurse dependency on following doctor's orders, poor staffing levels, lack of pain assessment skills, and lack of education were barriers mapped to physical capability. Opportunity was represented by three barriers: inadequate documentation of pain and shortage of nurses were mapped to the physical opportunity, and poor communication to the social opportunity. Nurses' beliefs towards pain assessment were mapped to reflective motivation.

      Conclusions

      The findings of this study suggest that knowledge, nursing beliefs, insufficient numbers of nursing staff, lack of documentation, and lack of communication commonly affect pain management in adult ICUs.

      Prospero registration

      CRD42020179913

      Keywords

      1. Introduction

      Pain is defined as an unpleasant sensory and emotional experience associated with, or resembling, actual or potential tissue damage.
      International Association for the Study of Pain
      IASP's proposed new definition of pain released for comment.
      Although pain relief is a fundamental right for patients, pain is experienced by 58% of patients in adult intensive care units (ICUs).
      • Alasad J.A.
      • Tabar N.A.
      • Ahmad M.M.
      Patients' experience of being in intensive care units.
      It can lead to decreased healing, delirium, and other adverse physiological and psychological outcomes.
      • Alasad J.A.
      • Tabar N.A.
      • Ahmad M.M.
      Patients' experience of being in intensive care units.
      Most ICU patients experience pain at some stage during their treatment,
      • Olsen B.F.
      • Valeberg B.T.
      • Jacobsen M.
      • Småstuen M.C.
      • Puntillo K.
      • Rustøen, T.
      Pain in intensive care unit patients—a longitudinal study.
      including during invasive and noninvasive procedures. ICU patients may not be able to report their pain verbally or through signalling for various reasons such as an altered level of consciousness, mechanical ventilation, or sedation.
      Systematic pain assessment is fundamental to achieving effective pain management. An ICU patient's inability to communicate his/her pain does not refute neither the existence of pain nor the need for appropriate pain treatment.
      International Association for the Study of Pain
      IASP's proposed new definition of pain released for comment.
      Despite this barrier, most pain assessment tools are usually dependent on a patient's ability to communicate. Therefore, ICU nurses must be capable of assessing pain using behavioural pain assessment methods so that a patient's impaired communication capabilities are considered. Devlin, Skrobik
      • Devlin J.W.
      • Skrobik Y.
      • Gélinas, C.
      • Needham D.M.
      • Slooter A.J.
      • Pandharipande P.P.
      • et al.
      Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
      propose that when patients cannot communicate, their behavioural reaction should be considered by ICU nurses and doctors as a surrogate measure of pain, providing their motor functions are working.
      This systematic review sought to explore the barriers to nurse-led pain management in ICUs globally. The Behaviour Change Wheel (BCW)
      • Michie M.M. Van Stralen
      • West R.
      The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
      was used as the guiding framework to analyse and interpret the findings within this review. The BCW is a behaviour change intervention framework that can be used to identify intervention functions and policies based on target behaviours.
      • Michie L. Atkins
      • West R.
      The model centred in the BCW is known as the Capability, Opportunity, Motivation, Behaviour (COM-B) model.
      • Michie M.M. Van Stralen
      • West R.
      The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
      These components are considered necessary for implementing behaviour change and apply to nurses' pain assessment processes in this review. The COM-B model, illustrated in Fig. 1, suggests that one's capability to accomplish the task, motivation to accomplish the task, and opportunity to perform the task, as well as circumstances beyond the individual's control, influence the desired behaviour (in this case, to assess patient pain). Capability and opportunity influence the relationship between behaviour and motivation, and they are the necessary prerequisites for behaviour change to occur. In addition, capability and opportunity influence someone's motivation to perform a behaviour.
      • West R.
      • Michie S.
      A brief introduction to the COM-B Model of behaviour and the PRIME Theory of motivation [v1].
      Figure 1
      Figure 1Capability, Motivation, and Opportunity components of Behaviour (COM-B), derived from Crowley et al. (2020).

      1.1 Aim

      The aim of this integrative review was to identify and synthesise qualitative and quantitative evidence on the barriers to pain management practices for nurses working in adult ICUs.

      2. Methods

      2.1 Review methods

      This review followed the integrative review framework outlined by Whittemore and Knafl,
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      which comprises the following five stages: (i) identifying the aim of the review, (ii) searching the literature, (iii) assessing the data and then extracting the data, (iv) analysing the data, and (v) presenting the review results. This approach was selected to allow the researchers to synthesise the findings of both quantitative and qualitative studies and provide a comprehensive review of the literature regarding the barriers to nurse-led pain management in adult ICUs.
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.

      2.2 Search strategy

      The keywords used were barrier∗ OR limit∗ OR challeng∗ OR difficult∗ OR obstacle∗ AND pain management∗ OR pain manage∗ OR pain treatment OR pain relief OR pain control OR pain assessment AND nurs∗ AND intensive care unit OR ICU OR critical care AND adult. Five databases (CINAHL, EMBASE, Scopus, PubMed, and EMCare) were searched for peer-reviewed research articles that contained the key terms. These five databases were selected to ensure a wide-ranging search and sufficient breadth and depth in the retrieved papers. The search was conducted in two stages: an initial search to identify key terms and a comprehensive search using the identified key terms. The initial search was performed in EMBASE and EMCare. Following this, the identified terms were modified and used to search CINAHL, Scopus, and PubMed. An example of the search strategy in CINAHL is included in Supplemental File 1.
      Studies were included if they were written in English or Arabic, focused on nurses’ assessment and management of pain, and studied adult patients in the ICU setting. Therefore, studies that examined pain assessment and management of paediatric patients, pain assessment and management by doctors and/or health providers other than nurses, and pain management in non-ICU settings were excluded. Studies that had participants other than nurses such as doctors, respiratory therapists, and cardiac perfusionists were excluded. The titles and abstracts of all eligible studies were screened against the inclusion and exclusion criteria by one author (MA), and 10% of potential studies were reviewed by JD. Two authors (MA and MG) completed screening of all full-text studies. Any disagreements were resolved through discussion that was educative in nature and included input from an additional author (JD).

      2.3 Search outcome

      A systematic search of the literature was conducted in June 2021. A total of 991 articles were identified (986 identified through database search plus five through other sources) which included 296 duplicates. The 695 remaining articles underwent title and abstract review. After reviewing titles and abstracts, 501 studies were excluded because the study context was not ICU or the study did not examine adults. The 194 remaining studies underwent full-text review; 175 were excluded because either they focused on pain management in different settings or participants were not nurses. Finally, 19 articles met the inclusion criteria (Fig. 2).
      Figure 2
      Figure 2Flowchart showing the process of inclusion and exclusion of studies in this review.

      2.4 Critical appraisal

      The quality of papers included in this review was evaluated using the Mixed Methods Appraisal Tool (MMAT).
      • Hong Q.
      • Fàbregues S.
      • Bartlett G.
      • Boradman F.
      • Cargo M.
      • Dagenais P.
      • et al.
      The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers.
      The MMAT focuses on five fundamental quality criteria for five types of research designs: (i) qualitative research, (ii) randomised controlled trials, (iii) nonrandomised research, (iv) quantitative descriptive research, and (v) mixed methods. MA independently appraised the articles and discussed them with MG and JD as part of Doctoral supervision. MA and MG then independently appraised all articles using the MMAT (version 2018) prior to data extraction. During the independent appraisal, there was one minor disagreement which was resolved through discussion. The MMAT appraisal for each included study is available in Supplementary File 2.

      2.5 Data extraction

      Data were extracted independently by three authors (MA, MG, and JD). The data extraction form had subsections for research description (author, year of publication, study location, and paper title), methodology (study design, methods, sampling, and sample size), and findings.

      2.6 Data analysis and synthesis

      According to Kitchenham,
      • Kitchenham B.
      several steps were undertaken in data analysis: the data from the primary sources were ordered, coded, categorised, and summarised into a unified and integrated conclusion about the research problem. In this study, barriers were classified using the COM-B model. Data were subcategorised by the first author and were reviewed by all authors.

      3. Results

      Nineteen articles met the inclusion criteria and were included in this review (Fig. 2). Seventeen studies focused on pain management from the perspective of nurses working in ICUs, whereas the remaining two focused on the perspectives of both ICU patients and ICU nurses. The MMAT was used to appraise all included studies (see Supplemental file 2). Two studies met 100% of the MMAT criteria and were rated 5 stars (∗∗∗∗∗), nine studies met 80% of the MMAT criteria and were rated 4 stars (∗∗∗∗), seven studies met 60% of the MMAT criteria and were rated 3 stars (∗∗∗), and one study was rated 2 stars (∗∗) as it met 40% of the MMAT criteria.
      Of the included studies, 14 used cross-sectional surveys at one point in time, two used a pre–post quasi-experimental design, and three used qualitative descriptive methods using semistructured interviews. Four studies were conducted in Saudi Arabia and Jordan, two studies were undertaken in the USA and Iran, and one study was undertaken each in Italy, Uganda, Egypt, Rwanda, Taiwan, UK, and Turkey (Table 1).
      Table 1Characteristics of the included studies.
      #Author/s [reference]Study locationParticipants/settingStudy designMMATFindings
      1Alasiry and Löfvenmark (2013)Saudi Arabia10 CCU nursesQualitative semistructured interviews∗∗∗
      • Pain assessment was perceived to be challenging because of the language barrier. It was difficult for patients to describe the quality of their pain.
      • ICU nurses lacked the knowledge of proper use of pain assessment scales.
      • Nurses lacked the skills and experience to assess patients who could not communicate.
      2Fatma et al. (2005)Turkey91 general ICU nursesQuantitative cross-sectional study∗∗∗∗
      • ICU nurses showed limited knowledge regarding pain assessment. Nearly half of nurses administered medication before assessing patients' pain.
      • 25% of nurses were unable to articulate what was a physiological response to pain.
      • Education and training would enhance nurses to provide better pain assessment and treatment.
      3Ayasrah et al. (2014a)Jordan301 adult ICU patientsQuantitative cross-sectional study∗∗∗
      • 65.2% of medical records contained no pain assessment in the nurse's documentation.
      • 63% of the pain episodes were not reassessed.
      • Pain management – pharmacological interventions were documented in 78% of the medical records
      • 45.9% nonpharmacological interventions to relieve pain were documented.
      4Deldar et al. (2018)Iran20 general ICU nursesQualitative semi-structured interviews∗∗∗∗The authors categorised the results into four groups;
      • Forgotten priority: The pain was not assessed and evaluated routinely; lack of physician–nurse interaction about pain management; and lack of pain assessment policies and regulations.
      • Organisational barriers: inadequate nurse-patient ratio and the presence of less experienced nurses.
      • Attitudinal barriers: nurses did not believe in pain assessment scales for non-verbal patients; and failed to comprehend pain in non-verbal patients.
      • Barriers to Knowledge: there was no awareness of how to use a non-verbal pain scale; and lack of training on pain assessment scales.
      5Eid et al. (2014)Saudi Arabia593 nurses from wards and adult ICUQuantitative cross-sectional study∗∗∗∗∗Nurses' Knowledge and Attitudes Survey Regarding Pain (KASRP) was used to test nurses' knowledge and attitude. The most prominent findings were as follows:
      • 25.5% of participants had attended training about pain.
      • Three out of 593 nurses achieved a “high” score.
      • 64.4% of participants underestimated the smiling patient's pain.
      • 4% answered the right dose of morphine.
      6Erkes et al. (2001)USA30 adult ICU nursesQuantitative, pre–post quasi-experimental study∗∗∗∗The KASRP was used pre and post study to determine the level of knowledge and attitude ICU nurses achieved.
      • Findings indicated inadequate pain management in hospital settings
      • Results revealed that knowledge and attitude improved from baseline to the post test (t = 9.60, p = ,0005)
      • Spearman's correlation analysis showed a significant correlation between scores and experience.
      7Hamdan (2019)Jordan300 adult ICU nursesQuantitative cross-sectional study∗∗∗∗
      • Low awareness among nurses about indicative pain behaviours.
      • Approximately 35% of nurses said that using pain tools to assess pain in patients unable to talk is either somewhat or moderately important.
      • Most valid and reliable pain assessment tools were not used often.
      8Hsiang-Ling and Yun-Fang (2010)Taiwan370 general ICUs nursesQuantitative cross-sectional study∗∗∗∗Taiwanese version of the KASRP was used to evaluate nurses' knowledge and attitude regarding pain in the adult ICU.
      • The average overall score was 53.4% which refers to poor pain management knowledge.
      • The top barrier was nurses were dependent on doctors' orders.
      • Education was recommended to enhance knowledge and correct attitude for nurses working in adult ICUs in Taiwan.
      9Issa et al. (2019)Saudi Arabia204 ICU nursesQuantitative pre-post quasi-experimental study∗∗∗∗
      • 60.3% of nurses believed patients should be encouraged to endure as much pain as possible before using an opioid.
      • 50% of nurses had poor knowledge regarding pain indicators and opioid doses.
      10Khalil and Mashaqbeh (2019)Jordan117 adult ICU nurses, 66 ED nurses, medical 70 nurses, surgical 90 nurses, oncology 74 nurses.Quantitative cross-sectional study∗∗∗∗
      • Nurses demonstrated lack of knowledge and attitude deficits as a result of the Bachelor of Nursing undergraduate curricula pain management gap.
      • 54% of nurses believed that ICU patients should be instructed to tolerate pain as much as they can.
      11Khalil (2018)Egypt60 ICU nurses in medical, neurosurgery, and emergency critical care unitsQuantitative cross-sectional study∗∗∗
      • Lack of nurses' knowledge, lack of time, nurses' workload, and patients' instability were barriers to nonpharmacological pain practices being used by nurses.
      12Kia et al. (2021)Iran224 ICU nurses from 14 general ICU and two cardiac surgery and burn ICU wardQuantitative cross-sectional design∗∗∗
      • The rate of nonpharmacological pain management methods among ICU nurses in Iran was not high due to various factors such as fatigue, multiple responsibilities, a heavy workload, and an insufficient number of nurses per shift.
      • The majority of the participants in this study had never attended a nonpharmacological pain management course.
      13Kizza and Muliira (2015)Uganda170 nurses from critical care unitsQuantitative cross-sectional study∗∗∗
      • The main perceived barriers to acute pain assessment practices were workload (84.1%), poor documentation and communication of pain assessment and management (77.6%), lack of education, lack of availability of assessment tools (74.1%), and lack of protocols and guidelines.
      14Latina et al. (2015)Italy286 nurses from ICU, SICU & ordinary wardsQuantitative cross-sectional study∗∗∗∗Italian Version of the KASRP was used to evaluate nurses' knowledge and attitude toward pain:
      • Nurses had never attended education course regarding pain management.
      • The mean correct responses for the knowledge survey were 55.5% (SD 6.33).
      • Surgical wards and ICU showed 62% to develop positive attitude and gain good understanding in combination with other wards.
      • Limited level of knowledge and poor attitudes towards pain management within the three different settings.
      15Puntillo et al. (2002)USA14 ICU nurses and 5 units (3 ICUs and two PACUs)Quantitative cross-sectional study∗∗After using the Pain Assessment and Intervetion notation (P.A.I.N.) tool, participants stated barriers to the use of the tool and to the pain assessment in the ICU such as
      • The inability of an ICU patient to communicate makes pain assessment difficult for ICU nurses.
      16Subramanian et al. (2012)UK21 adult critical care nursesQualitative semi-structured interviews∗∗∗∗
      • ICU nurses described four main challenges in managing pain: a lack of clinical guidelines, limited autonomy in decision-making, a lack of structured pain assessment tool, and the patient's condition itself.
      17Samarkandi (2018)Saudi Arabia247 nurses from adult ICU (49), oncology (34), medical surgical (59), ED (12), and others (93).Quantitative cross-sectional study∗∗∗∗∗The KASRP was used to assess the level of nurses' knowledge and attitude regarding pain, and the significant outcomes were as follows:
      • 50% of nurses stated no previous education about pain assessment and management.
      • The mean of correct answers was 18.5 out of 40 in the KASRP, and the range was 3–37
      • Spearman's correlation test showed a positive significant relationship with years of experience (r = 0.163, P = 0.022)
      18Ufashingabire et al. (2014)Rwanda69 adult ICU nursesQuantitative cross-sectional study∗∗∗KASRP was used to assess the level of nurses' knowledge and attitude regarding pain, and the significant outcomes were:
      • Nurses lack adequate knowledge and have poor attitudes toward pain management.
      • The level of nursing education (p < 0.008) and the hospital where nurses worked (p < 0.0001) significantly influenced nurses' attitudes toward pain management.
      • 42% believed that patients who can be distracted from pain do not have severe pain.
      19Younis et al., (2021)Jordan300 ICU nurses from 22 general ICUs.Quantitative cross-sectional study∗∗∗
      • Nurses noted that the most common impediments affecting pain assessment and management were nurse workload (84.6.3%), patient instability (54.4%), patient incapacity to speak (53.3%), and sedation interfering with pain assessment (50%).
      CCU, coronary care unit; ED, emergency department; ICU, intensive care unit; KASRP, Nurses' Knowledge and Attitudes Survey Regarding Pain; MMAT, Mixed Methods Appraisal Tool; PACU, postanaesthesia care unit; SICU; subintensive care unit.
      Data were analysed using the COM-B model
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: a guide to designing interventions.
      and themed into the broad categories of capability, opportunity, and motivation. Capability and opportunity included two subthemes, and motivation included one subtheme.

      3.1 Capability

      Capability is defined as the individual's psychological and physical capacity to engage in the activity concerned.
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: a guide to designing interventions.

      3.1.1 Psychological capability

      Psychological capability includes an individual's capacity to engage in the necessary thought processes, comprehension, and reasoning through education to perform the target behaviour. The COM-B model differentiates education and training. Education is focused on developing understanding and knowledge, whereas training is focused on developing skills.
      • Michie M.M. Van Stralen
      • West R.
      The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
      Ten studies examined a lack of knowledge related to pain management by nurses in adult ICUs.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      • Ayasrah S.M.
      • O’Neill T.M.
      • Abdalrahim M.S.
      • Sutary M.M.
      • Kharabsheh M.
      Pain assessment and management in critically ill intubated patients in Jordan: a prospective study.
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      • Wang H.L.
      • Tsai Y.F.
      Nurses' knowledge and barriers regarding pain management in intensive care units.
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      • Ufashingabire C.M.
      • Nsereko E.
      • Njunwa K.J.
      • Brysiewicz P.
      Knowledge and attitudes of nurses regarding pain in the intensive care unit patients in Rwanda.
      • Erkes E.B.
      • Parker V.G.
      • Carr R.L.
      • Mayo R.M.
      An examination of critical care nurses’ knowledge and attitudes regarding pain management in hospitalized patients.
      • Kia Z.
      • Allahbakhshian M.
      • Ilkhani M.
      • Nasiri M.
      • Allahbakhshian A.
      Nurses’ use of non-pharmacological pain management methods in intensive care units: a descriptive cross-sectional study.
      • Fatma A.
      How do intensive care nurses assess patient’s pain?.
      The two main types of knowledge that are necessary for effective pain management were categorised by researchers as basic knowledge and pharmacological knowledge. Basic knowledge was related to the understanding and knowledge of the physiology of pain, including the difference between acute and chronic pain, the evaluation of pain, and the risks associated with poor pain management. Pharmacological knowledge was related to the understanding and knowledge of pain medication dosage, complications, and their mechanism of action.
      Basic knowledge included assessing pain using vital signs and other physical cues as an indicator of pain, understanding the pathophysiology, and assessing pain. Some nurses believed that vital signs were always a reliable indicator of pain.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Fatma A.
      How do intensive care nurses assess patient’s pain?.
      Another study showed that nurses defined pain as a physical ailment and stressed the importance of looking for a pathological basis in pain assessment.
      • Fatma A.
      How do intensive care nurses assess patient’s pain?.
      Most nurses in the included studies had low levels of knowledge of effective techniques and processes for pain assessment, low levels of knowledge about assessing facial expressions during painful procedures;
      • Ayasrah S.M.
      • O’Neill T.M.
      • Abdalrahim M.S.
      • Sutary M.M.
      • Kharabsheh M.
      Pain assessment and management in critically ill intubated patients in Jordan: a prospective study.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      and the need to reassess pain following pain relief.
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      ,
      • Ufashingabire C.M.
      • Nsereko E.
      • Njunwa K.J.
      • Brysiewicz P.
      Knowledge and attitudes of nurses regarding pain in the intensive care unit patients in Rwanda.
      In addition, there was limited knowledge on the use of nonpharmacological pain management strategies.
      • Kia Z.
      • Allahbakhshian M.
      • Ilkhani M.
      • Nasiri M.
      • Allahbakhshian A.
      Nurses’ use of non-pharmacological pain management methods in intensive care units: a descriptive cross-sectional study.
      The nurses’ knowledge about the pharmacological treatment of pain in the ICU settings was also limited.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      • Ayasrah S.M.
      • O’Neill T.M.
      • Abdalrahim M.S.
      • Sutary M.M.
      • Kharabsheh M.
      Pain assessment and management in critically ill intubated patients in Jordan: a prospective study.
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      • Wang H.L.
      • Tsai Y.F.
      Nurses' knowledge and barriers regarding pain management in intensive care units.
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      • Ufashingabire C.M.
      • Nsereko E.
      • Njunwa K.J.
      • Brysiewicz P.
      Knowledge and attitudes of nurses regarding pain in the intensive care unit patients in Rwanda.
      Several studies identified that ICU nurses had poor knowledge regarding the best route and administration of opioids.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      ,
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      Nurses in ICU settings also had knowledge deficits about the possible complications of opioid administration, such as respiratory depression.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      • Ayasrah S.M.
      • O’Neill T.M.
      • Abdalrahim M.S.
      • Sutary M.M.
      • Kharabsheh M.
      Pain assessment and management in critically ill intubated patients in Jordan: a prospective study.
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      ,
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      Approximately 70% of ICU nurses reported that they withheld opioids due to concern that the patient could become addicted to opioids as a result of treatment.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      In some quantitative studies examining nursing knowledge, ICU nurses were unable to answer all questions about tolerance to opioids, which reveals a lack of knowledge in this area.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      Lack of education was another barrier that negatively impacted the psychological capability of ICU nurses concerning pain management.
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      ,
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      ,
      • Kia Z.
      • Allahbakhshian M.
      • Ilkhani M.
      • Nasiri M.
      • Allahbakhshian A.
      Nurses’ use of non-pharmacological pain management methods in intensive care units: a descriptive cross-sectional study.
      • Fatma A.
      How do intensive care nurses assess patient’s pain?.
      • Kizza I.
      • Muliira J.
      Nurses' pain assessment practices with critically ill adult patients.
      For instance, lack of education regarding pain assessment was a barrier to providing optimal pain management to ICU patients.
      • Latina R.
      • Mauro L.
      • Mitello L.
      • D’Angelo D.
      • Caputo L.
      • De Marinis M.G.
      • et al.
      Attitude and knowledge of pain management among Italian nurses in hospital settings.
      Pain assessment tools are enablers of psychological capability as they guide the process of pain assessment in ICUs. Two studies evaluated the Critical Care Pain Observation Tool (CPOT) and found it was easy to use, simple, and clear to understand, requiring minimal education and training and improving nurses' performance in achieving favourable outcomes regarding pain management.
      • Damico V.
      • Cazzaniga F
      • Murano L.
      • Ciceri R.
      • Nattino G.
      • Dal Molin A.
      Impact of a clinical therapeutic intervention on pain assessment, management, and nursing practices in an intensive care unit: a before-and-after study.
      ,
      • Hamdan K.M.
      Nurses'assessment practices of pain among critically ill patients.
      The first study stated that the CPOT is more sensitive to pain and valid than the Behavioral Pain Scale.
      • Puntillo K.A.
      • Stannard D.
      • Miaskowski C.
      • Kehrle K.
      • Gleeson S.
      Use of a pain assessment and intervention notation (PAIN) tool in critical care nursing practice: nurses’ evaluations.
      The second study investigated nurses' pain management strategies in 22 ICUs in Jordan and concluded that nurses do not use the best evidence-based pain scales such as the CPOT.
      • Alasiry S.
      • Löfvenmark C.
      Nurses' perceptions of pain assessment and pain management for patients with myocardial infarction in a coronary care unit.
      The Behavioral Pain Scale was evaluated and found to be effective in measuring the pain score of patients who cannot self-report.
      • Damico V.
      • Cazzaniga F
      • Murano L.
      • Ciceri R.
      • Nattino G.
      • Dal Molin A.
      Impact of a clinical therapeutic intervention on pain assessment, management, and nursing practices in an intensive care unit: a before-and-after study.
      Another study investigated the Pain Assessment and Intervention Notation (P.A.I.N.) tool and found that P.A.I.N. was effective in helping novice nurses to assess and manage pain experienced by ICU patients.
      • Puntillo K.A.
      • Stannard D.
      • Miaskowski C.
      • Kehrle K.
      • Gleeson S.
      Use of a pain assessment and intervention notation (PAIN) tool in critical care nursing practice: nurses’ evaluations.
      Similarly, Hamdan
      • Hamdan K.M.
      Nurses'assessment practices of pain among critically ill patients.
      concluded that the Adult Nonverbal Pain Scale increased nurses' self-confidence in the pain assessment of ICU patients.

      3.1.2 Physical capability

      The second aspect of capability in the COM-B framework is physical capability which involves having the required skill, strength, and stamina to perform pain assessment. The studies suggested that workshops and training can help nurses improve their knowledge (psychological capability) and their strength, stamina, and skills (physical capability).
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: a guide to designing interventions.
      Three findings were subcategorised to physical capability in the included studies. Firstly, the lack of skills is an obstacle to pain assessment and management. Nurses need to increase their skill levels to be competent in pain management in the ICU. Secondly, the training gave the nurses the capability to provide the best pain care to ICU patients.
      • Alasiry S.
      • Löfvenmark C.
      Nurses' perceptions of pain assessment and pain management for patients with myocardial infarction in a coronary care unit.
      The number of nurses using nonpharmacological methods to manage pain in a cross-sectional study was not optimal due to many barriers, including fatigue.
      • Kia Z.
      • Allahbakhshian M.
      • Ilkhani M.
      • Nasiri M.
      • Allahbakhshian A.
      Nurses’ use of non-pharmacological pain management methods in intensive care units: a descriptive cross-sectional study.
      Thirdly, limiting the nurses' role to solely focusing on patient assessment, checking drug charts, and notifying the physician of patients’ pain reduces nurses' scope of practice and diminishes nurses' ability to manage pain using evidence-based guidelines that lead to optimum pain management.
      • Fatma A.
      How do intensive care nurses assess patient’s pain?.

      3.2 Opportunity

      Opportunity is defined as all the factors that lie outside the individual that make the behaviour possible or prompt it. The environment influences physical opportunity, while the social opportunity is influenced by language and culture.
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: a guide to designing interventions.

      3.2.1 Physical opportunity

      Documentation is critical to ICU nurses' assessment and management of pain. Insufficient and incomplete documentation of pain leads to limitations in assessing the patients’ pain status and recognising the need for reassessment and follow-up. There is a need to develop and implement hospital policies that promote compliance with comprehensive pain documentation processes by nurses. Nurses were interviewed about the barriers to the documentation of pain management. They found that nurses described organisational barriers such as lack of nurse staffing, insufficient time for quality patient care, and high workloads. Nearly half of all ICU nurses believed that the hospital where they worked did not have appropriate forms and electronic systems to document comprehensive pain assessments.
      • Alasiry S.
      • Löfvenmark C.
      Nurses' perceptions of pain assessment and pain management for patients with myocardial infarction in a coronary care unit.
      A lack of staff is another barrier related to physical opportunity. An inadequate patient-to-nurse ratio results in a high workload, which reduces the opportunity to assess and manage pain effectively, contributing to poor pain assessment and management among adult ICU patients.
      • Ayasrah S.M.
      • O’Neill T.M.
      • Abdalrahim M.S.
      • Sutary M.M.
      • Kharabsheh M.
      Pain assessment and management in critically ill intubated patients in Jordan: a prospective study.
      ,
      • Wang H.L.
      • Tsai Y.F.
      Nurses' knowledge and barriers regarding pain management in intensive care units.
      ,
      • Kia Z.
      • Allahbakhshian M.
      • Ilkhani M.
      • Nasiri M.
      • Allahbakhshian A.
      Nurses’ use of non-pharmacological pain management methods in intensive care units: a descriptive cross-sectional study.
      ,
      • Khalil N.S.
      Critical care nurses' use of non-pharmacological pain management methods in Egypt.
      ,
      • Younis M.B.
      • et al.
      Barriers and enablers toward pain assessment and management in nonverbal patients in the ICU.
      Two studies identified that one of the barriers to pain management was poor staffing levels leading to a high workload by nurses and suggested that healthcare managers had a role in overcoming this.
      • Wang H.L.
      • Tsai Y.F.
      Nurses' knowledge and barriers regarding pain management in intensive care units.

      3.2.2 Social opportunity

      The inability of patients to communicate or verbalise pain is a known barrier that leads to inadequate assessment and management of pain in adult ICU patients.
      • Ufashingabire C.M.
      • Nsereko E.
      • Njunwa K.J.
      • Brysiewicz P.
      Knowledge and attitudes of nurses regarding pain in the intensive care unit patients in Rwanda.
      ,
      • Deldar K.
      • Froutan R.
      • Ebadi A.
      Challenges faced by nurses in using pain assessment scale in patients unable to communicate: a qualitative study.
      The unstable patient is challenging to care for, and this is exacerbated further if the patient has a communication barrier.
      • Puntillo K.A.
      • Stannard D.
      • Miaskowski C.
      • Kehrle K.
      • Gleeson S.
      Use of a pain assessment and intervention notation (PAIN) tool in critical care nursing practice: nurses’ evaluations.
      The severity of illness that a patient experiences was documented as a communication barrier (53.3%) and contributed to the need for sedation (50%) among ICU patients in a cross-sectional study of 300 nurses in Jordan.
      • Younis M.B.
      • et al.
      Barriers and enablers toward pain assessment and management in nonverbal patients in the ICU.
      Therefore, being competent to assess pain in patients who are unable to communicate is a core skill requirement of ICU nurses.

      3.3 Motivation

      Motivation is defined as the processes that energise and direct behaviour and includes more than just goals and conscious decision-making. Reflective motivation involves an individual's evaluation and beliefs, while automatic motivation involves emotion and impulses.
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: a guide to designing interventions.

      3.3.1 Reflective motivation

      Several studies examined how nurses' attitudes, influenced by personal beliefs and behaviours, were barriers to pain management in ICUs.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      ,
      • Ufashingabire C.M.
      • Nsereko E.
      • Njunwa K.J.
      • Brysiewicz P.
      Knowledge and attitudes of nurses regarding pain in the intensive care unit patients in Rwanda.
      ,
      • Erkes E.B.
      • Parker V.G.
      • Carr R.L.
      • Mayo R.M.
      An examination of critical care nurses’ knowledge and attitudes regarding pain management in hospitalized patients.
      ,
      • Alasiry S.
      • Löfvenmark C.
      Nurses' perceptions of pain assessment and pain management for patients with myocardial infarction in a coronary care unit.
      ,
      • Deldar K.
      • Froutan R.
      • Ebadi A.
      Challenges faced by nurses in using pain assessment scale in patients unable to communicate: a qualitative study.
      ,
      • Samarkandi O.A.
      Knowledge and attitudes of nurses toward pain management.
      Multiple studies identified that more than half of the nurses working in ICUs felt that patients should be encouraged to endure pain as much as possible before opioids are administered.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      ,
      • Samarkandi O.A.
      Knowledge and attitudes of nurses toward pain management.
      Similarly, more than half of the ICU nurses did not believe patients' self-reports regarding pain,
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      ,
      • Samarkandi O.A.
      Knowledge and attitudes of nurses toward pain management.
      and approximately 50% of the nurses assumed that distraction could be effective in relieving pain.
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      ,
      • Ufashingabire C.M.
      • Nsereko E.
      • Njunwa K.J.
      • Brysiewicz P.
      Knowledge and attitudes of nurses regarding pain in the intensive care unit patients in Rwanda.
      ,
      • Samarkandi O.A.
      Knowledge and attitudes of nurses toward pain management.
      The ICU nurses’ views included that sleeping patients or patients with decreased levels of consciousness were not experiencing pain.
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      ,
      • Deldar K.
      • Froutan R.
      • Ebadi A.
      Challenges faced by nurses in using pain assessment scale in patients unable to communicate: a qualitative study.
      ,
      • Samarkandi O.A.
      Knowledge and attitudes of nurses toward pain management.
      Some ICU nurses reported that patients with stable vital signs should not be given analgesia
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      and expressed that if patients were smiling, they were not experiencing pain.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      These subjective judgements were also identified in settings where nurses did not want to use a pain assessment tool and preferred using their instincts.
      • Deldar K.
      • Froutan R.
      • Ebadi A.
      Challenges faced by nurses in using pain assessment scale in patients unable to communicate: a qualitative study.

      3.3.2 Automatic motivation

      From the selected studies, there were no identified data that mapped to automatic motivation.

      4. Discussion

      This integrative review aimed to synthesise evidence on the barriers to pain management practices by nurses working in adult ICUs. The review found various barriers, including lack of knowledge, nurses’ attitude, and lack of documentation and skills. Such barriers negatively affect the pain assessment and management process for nurses in ICU. To the best of our knowledge, this study is the first to map the barriers to nurse-led pain management in the ICU using the COM-B model (11).
      Our findings indicate that the most common barrier to nurse-led pain management in adult ICUs is the lack of knowledge. The impact of lack of theoretical and pharmacological knowledge on optimal pain management was examined in eight studies.
      • Issa M.R.
      • Awajeh A.M.
      • Khraisat F.S.
      • Rasheed A.M.
      • Amirah M.F.
      • Hussain A.
      • et al.
      Impact of an educational program on the knowledge and attitude about pain assessment and management among critical care nurses.
      ,
      • Eid T.
      • Bucknall T.
      • Almazrooa A.
      Nurses’ knowledge and attitudes regarding pain in Saudi Arabia.
      ,
      • Khalil H.
      • Mashaqbeh M.
      Areas of knowledge deficit and misconceptions regarding pain among Jordanian nurses.
      ,
      • Ufashingabire C.M.
      • Nsereko E.
      • Njunwa K.J.
      • Brysiewicz P.
      Knowledge and attitudes of nurses regarding pain in the intensive care unit patients in Rwanda.
      ,
      • Kia Z.
      • Allahbakhshian M.
      • Ilkhani M.
      • Nasiri M.
      • Allahbakhshian A.
      Nurses’ use of non-pharmacological pain management methods in intensive care units: a descriptive cross-sectional study.
      ,
      • Alasiry S.
      • Löfvenmark C.
      Nurses' perceptions of pain assessment and pain management for patients with myocardial infarction in a coronary care unit.
      ,
      • Deldar K.
      • Froutan R.
      • Ebadi A.
      Challenges faced by nurses in using pain assessment scale in patients unable to communicate: a qualitative study.
      • Samarkandi O.A.
      Knowledge and attitudes of nurses toward pain management.
      • Watt-Watson J.
      • et al.
      Relationship between nurses' pain knowledge and pain management outcomes for their postoperative cardiac patients.
      • Rose L.
      • Smith O.
      • Gélinas C.
      • Haslam L.
      • Dale C.
      • Luk E.
      • et al.
      Critical care nurses’ pain assessment and management practices: a survey in Canada.
      According to the BCW intervention framework, a suitable solution for lack of knowledge and skills is education and training.
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: a guide to designing interventions.
      Some studies have implemented educational programs to enhance ICU nurses' knowledge of pain management, and the outcomes showed significant improvement in the nurses' knowledge of pain management.
      • Machira G.
      • Kariuki H.
      • Martindale L.
      Impact of an educational pain management programme on nurses' pain knowledge and attitudes in Kenya.
      A study was conducted to measure nurses’ knowledge pre and post the intervention. The evidence shows significant changes in knowledge scores (t = 9.60, p = 0.0005) post test
      • Erkes E.B.
      • Parker V.G.
      • Carr R.L.
      • Mayo R.M.
      An examination of critical care nurses’ knowledge and attitudes regarding pain management in hospitalized patients.
      and concluded that education is crucial for nurses' pain management in critical care. In addition, nurses should be responsive and integrate evidence-based pain management guidelines to provide pain relief and optimal care. In a quasi-experimental pre–post design, nine (out of a total of 27) nurses were allocated and received 7 h of education.
      • Machira G.
      • Kariuki H.
      • Martindale L.
      Impact of an educational pain management programme on nurses' pain knowledge and attitudes in Kenya.
      Nurses who participated in the educational intervention improved their post-scores on the Knowledge and Attitude Survey Regarding Pain (preintervention mean = 18.44; postintervention mean = 27.56).
      • Machira G.
      • Kariuki H.
      • Martindale L.
      Impact of an educational pain management programme on nurses' pain knowledge and attitudes in Kenya.
      Despite the small sample size (9 nurses), it highlights the significance of educating ICU nurses to enhance knowledge and correct attitudes.
      This integrative review shows that a lack of documentation is an obstacle to pain management.
      • Michie S.
      • Atkins L.
      • West R.
      The Behaviour Change Wheel: a guide to designing interventions.
      ,
      • Ayasrah S.M.
      • O’Neill T.M.
      • Abdalrahim M.S.
      • Sutary M.M.
      • Kharabsheh M.
      Pain assessment and management in critically ill intubated patients in Jordan: a prospective study.
      ,
      • Kizza I.
      • Muliira J.
      Nurses' pain assessment practices with critically ill adult patients.
      ,
      • Asadi Noghabi A.A.
      • et al.
      Effect of application of critical-care pain observation tool in patients with decreased level of consciousness on performance of nurses in documentation and reassessment of pain.
      According to the COM-B framework, physical opportunity can be improved using suitable pain assessment tools (such as the CPOT) that emphasise the importance of documentation. Gelinas et al.
      • Gélinas C.
      • Ross M.
      • Boitor M.
      • Desjardins S.
      • Vaillant F.
      • Michaud C.
      Nurses’ evaluations of the CPOT use at 12-month post-implementation in the intensive care unit.
      evaluated the CPOT and found that after 12 months of use, nurses perceived it was quick to use, simple to comprehend, and easily used in practice. Similarly, Mascarenhas et al.
      • Mascarenhas M.
      • Beattie M.
      • Roxburgh M.
      • MacKintosh J.
      • Clarke N.
      • Srivastava D.
      Using the model for improvement to implement the critical-care pain observation tool in an adult intensive care unit.
      implemented the CPOT and found that 4-hourly pain assessment increased in 89% of participants.
      Communication between patients and nurses is another way for nurses to assess and manage pain. Three studies reported that poor nurse–patient communication is an obstacle to pain management in ICUs and leads to improper pain assessment and treatment.
      • Alasiry S.
      • Löfvenmark C.
      Nurses' perceptions of pain assessment and pain management for patients with myocardial infarction in a coronary care unit.
      ,
      • Puntillo K.A.
      • Stannard D.
      • Miaskowski C.
      • Kehrle K.
      • Gleeson S.
      Use of a pain assessment and intervention notation (PAIN) tool in critical care nursing practice: nurses’ evaluations.
      ,
      • Gelinas C.
      • Arbour C.
      • Michaud C.
      • Robar L.
      • Côté J.
      Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management.
      Lack of communication is mapped as social opportunity, and the intervention is enablement. Enabling a patient's family to assist nurses to comprehensively assess pain as a family member can help in the identification of pain-related behaviours
      • Gelinas C.
      • Arbour C.
      • Michaud C.
      • Robar L.
      • Côté J.
      Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management.
      and assist in overcoming the communication barrier. Including a patient's family in their pain management is both an individual nurse decision
      • Alasiry S.
      • Löfvenmark C.
      Nurses' perceptions of pain assessment and pain management for patients with myocardial infarction in a coronary care unit.
      ,
      • Puntillo K.A.
      • Stannard D.
      • Miaskowski C.
      • Kehrle K.
      • Gleeson S.
      Use of a pain assessment and intervention notation (PAIN) tool in critical care nursing practice: nurses’ evaluations.
      ,
      • Gelinas C.
      • Arbour C.
      • Michaud C.
      • Robar L.
      • Côté J.
      Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management.
      and an administrative decision.
      • Gelinas C.
      • Arbour C.
      • Michaud C.
      • Robar L.
      • Côté J.
      Patients and ICU nurses’ perspectives of non-pharmacological interventions for pain management.

      4.1 Strengths and limitations

      A strength of this study is its systematic search strategy enabling a large number of articles to be included. The use of the COM-B model enhanced mapping the barriers of nurse-led pain management with the implementation enablers to assist readers in overcoming common barriers found in the literature. A limitation of this study is that a grey literature search was not conducted, and five databases were searched, so some relevant studies may have been missed. The review included studies that used different research designs, populations, and outcomes, and the quality of included studies was varied, with most consisting of descriptive quantitative and qualitative studies. Data analysis and synthesis was conducted using the approach described by Kitchenham,
      • Kitchenham B.
      but it is acknowledged that there are limitations in the strength of findings generated from integrative reviews. In addition, one author undertook the title and abstract review of potential papers which may have limited the reliability of this process; however, an experienced researcher audited 10% of all potential papers to support knowledge and skill development of the primary author and three authors participated in full-text review, critical appraisal, and data extraction.

      5. Conclusion

      The findings of this study suggest that a deficiency in knowledge, nursing beliefs, insufficient numbers of nursing staff, lack of documentation, and poor communication are common barriers to effective pain management in adult ICUs. Based on the COM-B model, barriers and interventions were mapped, providing strategies to enable nurses to improve pain assessment and pain management in the ICU. Educational and training interventions are the most suitable way of enhancing nurses’ knowledge of pain assessment and medication, correcting negative attitudes, educating nurses about documentation, and communication between nurses and patients. Pain assessment tools can effectively support nurses in assessing pain in the ICU.

      Conflict of interest

      No conflicts of interest have been declared by the authors.

      Funding

      The authors received no specific funding for completing this review. The first author holds a PhD scholarship from the Government of Saudi Arabia. The funding body was not involved in the writing of the report and the decision to submit the review for publication.

      CRediT authorship contribution statement

      Majid Alotni: Data curation, Writing- Original draft preparation, Writing- Reviewing and Editing, Jed Duff.: Visualisation, Supervision, Conceptualisation, Methodology, Validation Michelle Guilhermino: Supervision Visualisation, Investigation, Validation. Jenny Sim: Writing- Reviewing and Editing, Supervision, Validation.

      Protocol registration

      This systematic review was registered in PROSPERO 2020 under the ID: CRD42020179913 by the International Prospective Register of Systematic Reviews (PROSPERO).

      Availability of data and materials

      All data in this study are included in this published article (and its supplementary information files).

      Consent for publication

      Not applicable.

      Acknowledgement

      The authors want to acknowledge the support of the University of Newcastle, Australia. The authors want to thank Debbie Booth, University of Newcastle librarian for her expertise in refining the search strategy.

      Appendix A. Supplementary data

      The following are the Supplementary data to this article:

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