Critical care nurses' judgement of pain status: a case study design

In the performance of their professional activities, critical care nurses routinely make important judgements based on uncertain, fallible and inter-substitutable data. It is anticipated that this study will make visible the strategy by which critical care nurses use and combine multiple fallible cues, of which little is known, to reach a judgement about the pain status of the ventilated patient after coronary artery bypass graft (CABG) surgery. The study was conducted in one intensive care unit in a large university hospital with thirty critical care nurses and thirty ventilated patients. Nurses providing care for critically ill ventilated patients post CABG surgery were asked to think aloud, whilst the researcher simultaneously observed patient pain behaviours. For the purposes of this article, two contrasting pain episodes will be presented, namely, incident pain related to repositioning (initial hour) versus pain at rest (five hours later) post CABG surgery. Critical care nurses utilised different combinations of pain cues to make a judgement that the ventilated patient was either at 'risk for acute pain' during repositioning (initial hour) or was 'in acute pain' at rest (five hours) post CABG surgery. The combinations were: a 'primary preventative pain cue pattern' and a 'pain behaviour cue pattern', which were reliant on the critical care nurse's constant surveillance at the bedside linked with a theoretical and practical understanding of how pain, against a background of rapidly changing haemodynamics, could lead to a swift deterioration in a ventilated patient post CABG surgery.