Pain Management Frameworks and Critical Care Nursing Competencies: An Evidence-Informed Integrative Review

Pain is a prevalent and complex challenge in intensive care units (ICUs). Although structured pain management frameworks, such as validated behavioral assessment tools and multimodal analgesia protocols, are widely recommended, implementation variability persists. Emerging evidence suggests that nursing competency and organizational context influence the fidelity of these frameworks. This review synthesized contemporary literature examining ICU pain management frameworks and the nursing competencies required for effective implementation. An evidence-informed integrative review was conducted using a structured search of PubMed, CINAHL, EMBASE, Cochrane Library, and PsycINFO for studies published between January 2020 and March 2025. Empirical, validation, and guideline-based studies conducted in adult ICUs were included. The literature search yielded 10 studies, and data were extracted and thematically synthesized to identify pain management frameworks, nursing competency domains, and contextual determinants influencing practice. Findings indicate that ICU pain management is structured around validated behavioral assessment tools, including the Behavioral Pain Scale and the Critical-Care Pain Observation Tool, multimodal analgesia strategies, and protocol-driven monitoring. However, evidence demonstrates variability in nurses' pharmacological knowledge, assessment proficiency, clinical decision-making behaviors, and attitudes toward analgesia. Organizational factors, including workload pressures, staffing and patient factors, and institutional protocol reinforcement, moderate implementation consistency. The synthesis informed a three-level conceptual model linking frameworks, competency domains, and organizational determinants. Effective ICU pain management requires alignment between standardized frameworks, multidimensional nursing competencies, and supportive organizational systems. Integrated competency development and protocol reinforcement may enhance consistency and improve patient outcomes in critical care settings.