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Pain management in the intensive care unit (ICU) is an evolving practice but understudied. Paula Mickelson, BN’11, MN’23, says she chose to make this topic the focus of her Master of Nursing (MN) research because it’s all about making practices better in the ICU.

“ICU is like a completely different world. The way you manage pain in the ICU is not the same as the way you manage pain in other areas,” she says. Mickelson has been working at the Foothills Medical Centre ICU since 2014 and currently also works in the FMC catheterization lab.

“T���re's a lot of things we do in ICU that you don't do other places but it's hard to know what is pain management: there's no definition out there and it involves a lot of different people. It’s also done in many different ways in many different hospitals.”

For her MN course-based program, Mickelson looked into the Critical Care Pain Observation Tool (CPOT), an observational pain assessment and pain scale that allows for the detection of significant pain in adult patients who can’t reliably communicate.

“If you can imagine being a patient in ICU and you have a critical injury, very often, these people can't communicate for themselves…they are experiencing pain, so we have to advocate for them and essentially be their voices."

In her research, Mickelson found a lot of room for improvement around the use of the CPOT. The CPOT is routinely performed by bedside ICU nurses in all critical care settings within Alberta Health Services (AHS), yet there is little education available for the ICU staff on the appropriate use of the tool. Brief education is provided to nurses during their ICU orientation, but unfortunately, nurses are being taught to use the tool incorrectly.

“Pain management should be based on pain assessment. This is fundamental. If the CPOT is not accurately incorporated into clinical practice, there is no way to prove that we are providing appropriate pain management interventions to a very vulnerable population of ICU patients."

“What I ended up finding out about this pain scale is that it is a great pain scale in and of itself, but the authors haven't done a great job of putting educational material out into the world,” she says. With different versions of the CPOT assessment published across multiple peer-reviewed journals, and a unique pain scale whose interpretation has changed over time, finding accurate information about the CPOT is no small feat. Further complicating the situation are numerous misinterpretations of the CPOT in peer-reviewed articles.

Mickelson wanted to take a practical step toward better patient care, so after reviewing the literature and doing informal interviews with colleagues, she ended up creating a and for the CPOT that can be used alone as reference material or incorporated into a larger teaching context.

She’s working to get these materials added to the Department of Critical Care website and is collaborating with ICU educators to integrate accurate information about the CPOT into OPACCA (Orientation Program for Adult Critical Care in Alberta) and into the provincial charting system EPIC.

“Essentially, I created educational tools that I'm putting out into the world and they're accurate and they're well referenced, and they're easy to find. I'm working with AHS to improve how we use it.”

Mickelson says nurses are in a unique position to improve pain management practices. Nurses are responsible for routine pain assessments, implementing non-pharmalogical pain management interventions like early mobilization, for general patient comfort measures like cleanliness, as well as routine pain assessments and analgesic administration.

“Pain is something that people experience over time. If a physician has five minutes to assess a patient who can’t verbally report pain, and that patient is lying in bed quietly, it would be reasonable for the physician to think that this patient is not experiencing pain.

"As a bedside nurse, I might spend my entire 12-hour shift with one patient. During that time, a patient may lay quietly in bed for five minutes and then have very different behaviour for the other 11 hours and 55 minutes. It takes time to get to know a patient’s pain-related behaviours.

“I think it’s hard for physicians to hear nurses saying [patients are] in pain and not actually be able to observe it themselves because they don't have 11 hours to spend with the patient. But it’s a part of our job as nurses to see these things and advocate for appropriate care.”

Mickelson says while she understands the caution and hesitation on the part of physicians or residents in not wanting to overprescribe opiates given the ongoing opioid crisis, there is an important distinction between a ‘low dose’ and the ‘lowest effective dose.’ She wants to change the bias toward disbelief around pain.

“T��� first step is that we are all well informed, we are well educated, and we are doing appropriate standardized, repeated tests with results that we all understand. It enables communication, accuracy, and safety.”