Nurse Competencies, Patient Characteristics, and Pain Management Protocol Adherence in Intensive Care Units: A Multicenter Cross-Sectional Study Accounting for ICU Clustering

To examine the associations between nurse competencies (knowledge, self-efficacy, and attitude), patient characteristics, and pain management protocol adherence in adult intensive care units, while accounting for between-ICU clustering.

Adherence to pain management protocols remains suboptimal despite available guidelines. Nurse competencies are essential for evidence-based practice, yet their translation into clinical performance may depend on contextual factors. ICU-level organizational context has been described in recent reviews, but empirical examination of these relationships remains limited.

This multicenter cross-sectional study included 525 ICU nurses from seven hospitals in Tehran, Iran (July-October 2025). One index patient was assessed for each nurse. ICU-level organizational characteristics were assessed through unit observation and head nurse interviews. The intraclass correlation coefficient (ICC) for protocol adherence was computed from an empty mixed model. Multivariable linear regression with ICU entered as a fixed effect was used to identify individual-level factors associated with adherence. Organizational context was retained as a descriptive variable only.

Protocol adherence was moderate (mean 8.5/12; 32.4% good adherence). The ICC for protocol adherence was 0.02 (95% CI: 0.001-0.15), indicating minimal clustering. In the multivariable model with ICU as a fixed effect (18 predictors), knowledge (β = 0.311), self-efficacy (β = 0.290), and attitude (β = 0.276) remained independently associated with adherence (all p < 0.001). Patient characteristics remained significantly associated: substance use history (β = -0.138, p = 0.016), inability to communicate (β = -0.148, p = 0.010), GCS < 9 (β = -0.160, p = 0.008), and mechanical ventilation (β = -0.121, p = 0.028). The full model explained 53.4% of the variance in adherence. Organizational support across the seven ICUs ranged from 1 to 5 (weighted mean 3.42 ± 1.15).

Nurse competencies and patient characteristics are independently associated with pain management protocol adherence in this multicenter ICU sample. Between-ICU clustering was minimal (ICC = 0.02), suggesting that individual-level factors are the primary correlates of adherence in this sample. Given the small number of ICU clusters (n = 7), organizational findings are descriptive only and require confirmation in larger multilevel studies.

Nurse managers may consider competency-based pain management education and regular audits with feedback. Given the small number of ICU clusters (n = 7), these recommendations are hypothesis-generating and require validation in larger multilevel studies.