Implementation strategies for a systematic pain assessment approach in the adult intensive care unit: Selection from members of the inter-professional team
CCCF ePoster library. Richard-Lalonde M. Nov 1, 2016; 150929; 50
Melissa Richard-Lalonde
Melissa Richard-Lalonde
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Topic: Survey or Interview (quantitative or qualitative)

Implementation strategies for a systematic pain assessment approach in the adult intensive care unit: Selection from members of the inter-professional team

Céline Gélinas, N, PhD1,2; Melissa Richard-Lalonde, BScN, MSc2; Madalina Boitor, N, PhD (c)1,2; Yannick Tousignant-Laflamme, pt, PhD3; Geraldine Martorella, N, PhD4; Jacki Raboy-Thaw, N, MScN, CNCC(C)5; Denny Laporta, MD5,6; Manon Choinière, PhD7
1 Ingram School of Nursing/Faculty of Medicine, McGill University, Montréal, Qc, Canada
2 Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montréal, Qc, Canada
3 Ecole de réadaptation, Université de Sherbrooke, Sherbrooke, Qc, Canada
4 College of Nursing, Florida State University, Tallahassee, FL, USA
5 Medical-Surgical Intensive Care Unit, Jewish General Hospital, Montréal, Qc, Canada
6 Respiratory Division/Faculty of Medicine, McGill University, Montréal, Qc, Canada
7 Department of Anesthesiology, Université de Montréal, CR-CHUM, Montréal, Qc, Canada



Grant acknowledgements:
This study was funded by the Louise and Elan Edwards Foundation (LAEF) and the Alan Edwards Centre for Research on Pain (AECRP).


The Society of Critical Care Medicine recommend regular pain assessments with appropriate tools (Numeric Rating Scale or NRS for patients able to self-report, and Behavioral Pain Scale/BPS or Critical-Care Pain Observation Tool/CPOT for those unable to self-report) in all intensive care unit (ICU) patients.1 The lack of inter-professional (IP) collaboration was identified as a major barrier to the implementation process.2

To develop and prioritize implementation strategies for the uptake of a systematic pain assessment approach integrating self-report (NRS) with the CPOT3 in a pain intervention algorithm (Figure 1) by the IP team in the adult ICU. 

A descriptive design was selected for this study conducted in a medical-surgical ICU of Montreal. A purposive sample of ICU nurses, physicians, and other clinicians involved in ICU patient care was recruited. The nominal group technique was used to describe and prioritize implementation strategies as it allows the generation of ideas from all participants, facilitates communication and group decision-making.4 Participants were asked to individually generate ideas on the following questions: 'What are the best strategies for the implementation of a pain assessment approach with validated tools (i.e. 0-10 NRS and CPOT) to ensure the uptake by the IP ICU team? For each strategy, what are the potential barriers to overcome and the facilitating factors to enhance?' Ideas were collected using a round-robin process, and promoted input from all participants until no further new ideas were found. Similar ideas were grouped into strategy themes, and strategies were prioritized using a voting system from 1 (least important) to 7 (most important). A summation of votes for each strategy was obtained, and weighted scores (i.e. summed votes divided by the number of participants) were calculated. No consensus was required. The Theoretical Domains Framework (TDF)5 developed to guide clinical behaviour change which includes 12 domains was utilized to classify implementation strategies. 

A total of 25 ICU clinicians (i.e., 9 nurses, 7 respiratory therapists/RT, 3 physicians, 1 physiotherapist, the clinical nurse specialist, the nurse and RT educators, the nurse and medical managers) participated in four nominal groups in which at least two disciplines were represented. Fourteen implementation strategies were described (Table 1), and three strategies were consistently described in all nominal groups. Top one was training of all clinicians of the IP team (mean=5.27) and related to knowledge/skills/support TDF domains. Because of difficulty releasing staff for training, short in-service sessions in small groups were favored, and the use of champions was identified as a facilitator. Surprisingly, online training was prioritized in only one group.  Top two was discussing pain assessments at daily rounds (mean=3.32) to optimize IP collaboration and related to goals/decision processes TDF domains. Top three was the systematic use of pain assessment tools by all clinicians (mean=3.15) to ensure common language and related to skills/support TDF domains.

Although electronic applications are gaining in popularity, ICU clinicians favored strategies that would enhance face-to-face interactions, IP communication and collaboration in ICU daily practice. Our findings also suggest that implementation strategies must be tailored to the clinicians' preferences, resources and context. 




1. Barr J, Fraser G, Puntillo KA et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263-306.
2. Gélinas C, Ross M, Boitor M et al. Nurses' evaluations of the CPOT use at 12-month post-implementation in the intensive care unit. Nurs Crit Care 2014;19:272-80.
3. Gélinas C, Fillion L, Puntillo KA et al. Validation of the Critical-care Pain Observation Tool in adult patients. Am J Crit Care 2006;15:420-7.
4. Potter M, Gordon S, Hamer P. The nominal group technique: A useful consensus methodology in physiotherapy research. NZ J Physiother 2004;32:126-30.
5. French SD, Green SE, O'Connor DA et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci 2012;7:38.

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