# Nurses' Pain Assessment and Attitudes: A Qualitative Study in a Neurointensive Care Unit

## TL;DR

This study explores how nurses in neurointensive care units assess and perceive pain in patients who cannot easily communicate their discomfort.

## Contribution

The study reveals that nurses rely heavily on physical indicators and personal judgment for pain assessment, which can be influenced by biases.

## Key findings

- Nurses in neuro-ICUs find pain assessment challenging due to communication and consciousness impairments.
- Nurses rely on physical parameters and interpretive judgment when assessing pain in patients.
- Continuity of care is essential for interpreting subjective pain cues in neuro-ICU patients.

## Abstract

As analgo‐sedation gains prominence, a significant portion of adult ICU patients—including those in neurointensive care units (neuro‐ICUs)—remain awake and conscious throughout their stay. Despite this, neuro‐ICU patients frequently experience moderate to severe pain, highlighting the critical need for enhanced pain assessment.

This study aimed to explore nurses' assessments and attitudes towards pain in critically ill patients in the neuro‐ICU.

A qualitative, exploratory and inductive study was conducted, inspired by Ricoeur's phenomenological‐hermeneutic approach. Data were gathered at a neuro‐ICU in Copenhagen, Denmark via four focus group interviews and five semi‐structured individual interviews with nurses. The Consolidated Criteria for Reporting Qualitative Research guided the reporting process.

Four key themes were identified in the qualitative analysis: Subjective pain perception, exclusive nursing responsibility for pain assessment, continuity for interpreting lived pain and attitudes undermining pain care in the neuro‐ICU. Nurses viewed neuro‐ICU patients with brain injury as unable to self‐assess pain due to cognitive and communication deficits, irrespective of sedation level, leaving pain assessment dependent on the nurses' interpretive judgement.

Nurses in neuro‐ICU found pain assessment challenging due to impaired communication and fluctuations in consciousness, independent of sedation level. Nurses' dependence on physical parameters and tacit interpretive judgement placed clinical decision‐making in their hands when medical input was absent. Under these conditions, continuity of care became vital for interpreting patients' subjective pain cues. This need for continuity was further amplified by nurses' perception of holding sole responsibility for pain assessment in the neuro‐ICU.

The findings emphasize the need for structured pain assessment approaches that combine standardized tools with nurses clinical judgment in analgo‐sedated neuro‐ICU patients. Continuity of care appears essential for recognizing individual pain expressions and supporting consistent clinical decision‐making. Stronger interdisciplinary collaboration may reduce the burden on nurses and improve shared responsibility for pain management. Reflective practice and education are needed to address implicit biases, particularly toward patients with substance use histories. Together, these initiatives may reduce variation in analgo‐sedation practices and better protect patient comfort.

What is known about the topic
○Delirium is a common and serious complication among ICU patients worldwide.○International guidelines highlight the gaps in evidence for pain assessment, especially for neuro‐ICU patients.○Neuro‐ICU patients can exhibit atypical signs of pain challenging pain assessment.
What this paper adds
○Nurses in the neuro‐ICU find pain assessment challenging Nurses’ reliance on physical indicators and tacit interpretive judgments guide their pain assessment○Nurses paternalistic preunderstanding limit their access to the patients’ lived and expressed signs of pain.

What is known about the topic
○Delirium is a common and serious complication among ICU patients worldwide.○International guidelines highlight the gaps in evidence for pain assessment, especially for neuro‐ICU patients.○Neuro‐ICU patients can exhibit atypical signs of pain challenging pain assessment.

Delirium is a common and serious complication among ICU patients worldwide.

International guidelines highlight the gaps in evidence for pain assessment, especially for neuro‐ICU patients.

Neuro‐ICU patients can exhibit atypical signs of pain challenging pain assessment.

What this paper adds
○Nurses in the neuro‐ICU find pain assessment challenging Nurses’ reliance on physical indicators and tacit interpretive judgments guide their pain assessment○Nurses paternalistic preunderstanding limit their access to the patients’ lived and expressed signs of pain.

Nurses in the neuro‐ICU find pain assessment challenging Nurses’ reliance on physical indicators and tacit interpretive judgments guide their pain assessment

Nurses paternalistic preunderstanding limit their access to the patients’ lived and expressed signs of pain.