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Critical Care, Trauma, and Resuscitation: Research Report

Current Use of Pain Scores in Dutch Intensive Care Units

A Postal Survey in the Netherlands

van der Woude, Margaretha C. E. MD*; Bormans, Laura RN*; Hofhuis, José G. M. RN, PhD; Spronk, Peter E. MD, PhD, FCCP

Author Information
doi: 10.1213/ANE.0000000000000972

Pain is a common problem for patients admitted to the intensive care unit (ICU) and can cause patient discomfort and agitation.1,2 Unrelieved pain may also evoke a stress response characterized by tachycardia, increased myocardial oxygen consumption, hypercoagulability, immunosuppression, and persistent catabolism.1,2 In addition to preexisting diseases, wounds, drains, the presence of an endotracheal tube, and bed rest, routine nursing procedures such as airway suctioning and positioning are common causes of pain in ICU patients.3,4 Data suggest that the severity of pain is often underestimated in critical care patients, particularly those who are sedated or unable to self-report.5–7 Pain also has long-term consequences, including a higher risk of developing posttraumatic stress disorder, a greater incidence of chronic pain, and a decreased quality of life.2 Despite reviews and international and national guidelines,1,2,8 pain management in critically ill patients is frequently underappreciated.6,9–12 Treating pain not only improves patient quality of life but outcomes as well. Pain assessment in mechanically ventilated patients, for example, is associated with a reduction in ventilator support and in duration of ICU stay.9 For this reason, the recognition of pain and its severity is extremely important.

Many different validated pain scales are available for postoperative patients. These include the Visual Analog Scale (VAS, range 0–10) and Numerical Rating Scale (NRS, range 0–10), which can be used in awake ICU patients.13

With the VAS, patients are asked to rate their pain intensity by putting a mark on a 10-cm line, where 0 represents “no pain” and 10 represents the “worst imaginable pain.” The score is measured from zero to the point of the patient’s mark in millimeters. With the NRS patients, a number is assigned to their pain, which can be graphically (NRS-V) or verbally (NRS-O) delivered, where 0 is no pain and 10 is the worst imaginable pain. In postoperative patients able to self-report, the NRS is the tool of choice.1,2,7,13 However, critically ill patients are often unable to self-report because of severe illness, sedation, or mechanical ventilation.14 In such patients, pain may be assessed using scales based on nonverbal behaviors, such as the Behavioral Pain Scale (BPS)3,15–18 and the Critical Care Pain Observation Tool (CPOT, range 0–8).19

The BPS evaluates 3 behaviors: facial expression, movements of upper limbs, and compliance with mechanical ventilation. Each item can be scored from 1 to 4, where 4 indicates behaviors indicative of greater pain. The BPS overall produces a score from 3 to 12, where 3 correlates to no pain and 12 correlates to maximal pain. The BPS has been validated in deeply sedated, mechanically ventilated patients3,15–18 and also in patients who are awake but sedated.20 The CPOT has 4 sections with different behavioral categories: facial expression, body movements, muscle tension, and compliance with mechanical ventilation for intubated patients or vocalization for extubated patients. Each item has a range score of 0 to 2, where 2 indicates behavior indicative of greater pain. Overall, the CPOT produces a score where 0 points corresponds to no pain and 8 points corresponds to maximal pain. The CPOT has not yet been validated for different groups of ICU patients17,18 (Supplemental Digital Content, Appendix A for details of both scales,

The aim of this study was to describe current attitudes toward pain measurement in patients able and not able to self-report in adult ICU departments in the Netherlands.


The local ethics committee of the Gelre Hospitals Apeldoorn approved the study. In February 2011, a multicenter, exploratory survey using a standardized questionnaire was sent to the nursing manager of all adult ICUs in the Netherlands. After 3 months, all ICUs that had not yet responded to the questionnaire were contacted by telephone and, if required, the questionnaire was sent a second time. The questionnaires were sent to teaching hospitals (including university hospitals), as well as nonteaching hospitals to explore the differences between those 2 different types of hospitals. Survey reporting was checked as previously described.21 To account for larger or smaller ICUs, we weighted the survey results by the number of nurses working in each ICU.

Development of the Questionnaire

The questionnaire was developed for the purpose of the study (Supplemental Digital Content, Appendix B for full questionnaire, After analyzing the literature, and in consultation with colleagues, final questions were formulated and reviewed for clarity to reduce the chances of misinterpretation and to be understandable in only one way. This was accomplished using feedback from a small focus group of experienced ICU nurses.

The questionnaire contained 4 parts:

  1. Demographic questions regarding the hospital and ICU setting.
  2. Questions pertaining to the presence and implementation of pain assessment strategies.
  3. Questions addressing the clinical importance of pain treatment as judged by the ICU team.
  4. Questions regarding barriers to using pain assessment and protocols related to management.

Statistical Analysis

Categorical data were presented in percentages with 95% confidence intervals (CIs). Proportions were compared using the Fisher exact test. Mann-Whitney U test was used for differences between 2 groups (teaching and nonteaching hospitals) in not-normally distributed continuous variables. P < 0.05 was considered to indicate statistical significance. CIs were calculated using

The Bonferroni correction was used to adjust for multiple comparisons. P values were then compared with α′ = α/k with α = 0.05 and denominator k = according to the number of subquestions. The exact CIs for Bonferroni-corrected comparisons were calculated using, and the exact corrected CI could be found in each result section. The Bonferroni correction was used for pain assessment (7 subquestions for patients able to self-report, i.e., 99.3% CI, and 11 subquestions for patients unable to self-report, i.e., 99.5% CI), rating pain intensity (4 subquestions, i.e., 98.8% CI), the relevance of pain measurement (7 subquestions, i.e., 99.3% CI), and for obstacles to pain measurement and treatment (13 subquestions, i.e., 99.6% CI).

To be more representative of nursing opinion, weighted values were used for the final analysis to correct for the size of the ICU and the number of nurses involved in daily ICU care. Analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 14 (Chicago, IL).


Survey Response

Table 1
Table 1:
Characteristics of Participating Centers

Questionnaires were sent to all 107 adult ICUs in the Netherlands. Forty-three ICUs spontaneously returned the questionnaire, and an additional 41 responded after being contacted by telephone. This resulted in an overall response rate of 84 (79%) ICUs. (See Table 1 for the demographic characteristics of the participating ICUs.) The nonresponder group consisted of 10 teaching hospitals and 13 nonteaching hospitals.

Pain Assessment

In patients able to self-report, 94% (n = 79; 95% CI, 86.7%–98%) of the ICUs used routinely a standardized pain score. The VAS (57%; n = 48; 99.3% CI, 41%–72%) and NRS (48%; n = 40; 99.3% CI, 33%–64%) were the most frequently used scores. A minority used the Faces scale (5%; n = 4; 99.3% CI, 0%–16%). Some ICUs used >1 score. Nonteaching hospitals used pain assessment tools significantly more often than teaching hospitals (100% vs 87%, P = 0.012) in patients able to self-report pain.

In patients unable to self-report, standardized behavioral pain assessment tools were used in only 19% (n = 16; 95% CI, 0.2%–38.2%) of the ICUs. The CPOT and BPS were used in 6% (n = 5; 99.5% CI, 1.1%–17%) and 5% (n = 4; 99.5% CI, 0.1%–15%), respectively. The other 8% (n = 7; 99.5% CI, 2%–20.2%) used other tools. In this group of patients, no significant difference was found between the teaching and the nonteaching hospitals (P = 0.911).

Rating Pain Intensity

Although 94% (n = 79) of the ICUs used a standardized pain score in patients able to self-report, we found that nurses preferred to use unstructured patient self-reports to rate pain intensity. In 64% of ICUs (n = 54; 98.8% CI, 50%–77%), nurses felt that the patients themselves were the most accurate in rating pain. But in 36% of ICUs (n = 30; 98.8% CI, 23%–50%), nursing opinion was considered the gold standard assessment in patients able to self-report (Bonferroni denominator 4; α′ = 0.012). In patients not able to self-report, 98% of ICUs (n = 82; 98.8% CI, 89.7%–99.9%) felt that their assessment of pain was most accurate, regardless of whether a pain score was used. Patients’ relatives contributed to pain evaluation in only 1% (n = 1) of responding ICUs. Nurses did not identify a role for physicians in patients able or not able to self-report. No significant difference was found between the teaching hospitals versus the nonteaching hospitals in nursing preferences for pain assessment tools.

Importance of Pain Assessment

Table 2
Table 2:
Multifactorial Barriers to Pain Assessment and Management in ICU Patients
Figure 1
Figure 1:
Importance of pain assessment in several intensive care unit patient groups x-axis: percentage. GCS = Glasgow Coma Scale.

Respondents considered using pain assessment tools important in patients both unable to self-report (82%; n = 69; 95% CI, 72.3%–89.7%) and able to self-report (91%; n = 76; 95% CI, 82%–95.8%). In teaching hospitals, ICU teams considered it significantly more important to use pain assessment tools both in patients able to self-report (P = 0.002) and in patients unable to self-report (P = 0.002) than did nonteaching hospitals. According to nurses, pain measurement was considered as most relevant for specific ICU patient groups (Fig. 1). Pain measurement was considered most relevant for patients with burns (67%; n = 56; 99.3% CI, 51.5%–79.7%) or trauma (64%; n = 54; 99.3% CI, 49%–77.7%), end-of-life care patients (64%; n = 54; 99.3% CI, 49%–77.7%), and postoperative patients (57%; n = 48; 99.3% CI, 42%–71.5%). Teaching hospitals found pain measurement significantly more important for patients with burn wounds, end-of-life care patients, patients receiving sedatives, postoperative patients, trauma patients, medical ICU patients, and patients with a Glasgow Coma Scale < 8 compared with nonteaching hospitals (Bonferroni denominator 7; α = 0.007). Obstacles to pain measurement and treatment were multifactorial (Table 2). Unstable patients, patient inability to self-report, and the interference of sedation with pain assessment were the most important barriers. The teaching hospitals found this last barrier more important than nonteaching hospitals (P = 0.003). No significant other differences were found between the 2 groups of hospitals in this respect (Bonferroni denominator 13; α′ = 0.004).


The results of this survey reflected current ICU nursing attitudes toward the use of pain scores for pain assessment in Dutch ICUs. In the Netherlands, 94% of ICUs used standardized pain assessment tools in ICU patients who were able to self-report. However, a sizeable minority considered their own assessment of patient pain to be superior to standardized pain scales. In patients unable to self-report, nearly all ICU nurses considered their own assessment of patient pain to be superior to behavioral pain assessment tools, and only a minority of the ICUs used a pain assessment tool, despite the recommendations of international and national guidelines.1,2,8

Although the importance of using such pain assessment tools was considered equally important in both groups of patients, it was surprising to see that only a minority of Dutch ICUs used a validated pain score in patients unable to self-report. Current evidence1,2 suggests that critically ill patients frequently experience pain. Hence, appropriate pain assessment should be considered central to pain treatment protocols. Patel and Kress22 concluded, in a recent review of sedation and analgesia in ventilated patients, that objective assessments of sedation and pain can improve short- and long-term outcomes for ICU patients. Puntillo23 even suggested combining 2 pain assessment scales using the NRS to assess background information about pain and the BPS to assess current pain intensity. Recently, Dutch guidelines on pain in ICU patients were updated accordingly in an effort to improve pain awareness among caregivers in ICUs.8

One reason for poor implementation of pain measurements could be our finding that Dutch ICU nurses considered themselves the best judge of patients’ pain, even if patients were able to self-report. Both Puntillo23 and Ahlers et al.20 showed that nurses generally underestimated pain scores, especially when such scores are high. Nurses using their own estimate of patient pain would thus lead to less adequate pain treatment. To counteract this possibility, the patient’s own pain assessment should be used14,24 whenever possible. Furthermore, family members may be valuable in assessing patient pain after proper instruction.25 In the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT), these surrogates underestimated the pain 9.7% and overestimated the pain 16.8% of the time compared with the patients’ own judgment.

Our data suggest that changing behavior toward pain management in Dutch ICUs could improve the adequacy of pain treatment. However, successful implementation of new ICU clinical care strategies is difficult, even if the treatment is evidence-based.26,27 In principle, nonoptimal pain treatment can be attributed to the patient, the health care team, and the health care system and is potentially improved by protocols.28–31 Other factors contributing to improved daily measurement of pain include an enthusiastic and motivated staff, prioritizing pain assessment and management, and using standardized assessment tools according to the nursing staff (Table 3).

Table 3
Table 3:
Factors Improving Pain Assessment and Management in ICU Patients

Although pain management in teaching hospitals was discussed more often during nurse-to-nurse reporting and during medical rounds than in nonteaching hospitals, nonteaching hospitals used pain assessment tools more often than teaching hospitals (100% vs 87%). This observation suggests that the lack of use of pain assessment tools was not because of lack of knowledge.

Our study has several limitations. First, surveys were sent to head-nurses of the ICU, who were specifically asked in a cover letter and by phone (if they did not return the questionnaire spontaneously) to discuss the questionnaire with both the ICU nursing staff and the attending physicians to make sure that answers would reflect actual behavior and awareness pertaining to pain assessment in the ICU. Nevertheless, some answers may have been biased toward the nurse’s opinion; for example, questions addressing the clinical importance of treatment of pain judged by the ICU team and questions regarding barriers to using pain assessment and protocols related to management. Therefore, we weighted the survey results by the number of nurses in each ICU to decrease the likelihood and margin of error. Second, we did not query patients themselves about pain management strategies. Third, this survey contained a total of 84 ICUs (84/107) representing a response rate of 79%. For the first 2 parts of the questionnaire (demographic questions regarding the hospital and ICU setting and questions pertaining to the presence and implementation of some kind of pain assessment), this response rate suggested that the findings of the current study may be an accurate reflection of current pain assessment in adult ICUs in the Netherlands. Finally, this survey addressed only the awareness of and approach to pain in ICUs in the Netherlands. Although other countries may have produced different results, previous data have found that our results are not restricted to the Netherlands alone. For example, a 2006 German survey found the use of pain scales in only 21% of patients32 and a 2007 survey of all 54 Danish ICUs found that VAS was the only pain tool used routinely in 32% of patients.33 A 2009 study performed in 66 French adult ICUs found that analgesia monitoring was used in only 24% of eligible patients.34 More recently, Luetz et al.35 found that 80% of 101 European ICUs routinely used a validated pain tool but that only 30% used a behavioral pain assessment tool for patients unable to self-report—and actual use of pain assessment tools was only 43%, with 22% of the patients experiencing pain. A study on 842 Canadian ICU nurses further suggests that behavioral pain assessment tools were underused in patients unable to self-report, finding that 90% of the nurses used the NRS for patients able to self-report but that only 35% used a behavioral pain assessment tool for patients unable to self-report.36 Further international research should identify factors contributing to the inadequate use of pain scales in patients unable to self-report and develop strategies to increase their use.


Most Dutch ICUs measured pain routinely only in patients who are able to self-report. We demonstrated that, in Dutch ICUs, pain was not routinely measured in patients unable to self-report with a validated pain assessment tool. This occurred even while the importance of using such pain assessment tools was considered almost as important in both groups of patients. Therefore, it is possible that pain may be undertreated. Instead, Dutch nurses felt that they themselves were more accurate in rating the pain in this group of patients. In light of similar findings in other European countries, it might be possible that the poor use of pain scores may not be restricted to Dutch ICUs. ICU clinicians should consider a structured approach for pain management in ICU patients as a part of the sedation protocol, which should be introduced in all ICUs.


Name: Margaretha C. E. van der Woude, MD.

Contribution: This author helped design the study, conducted the study, helped to collect the data, helped analyze the data, and wrote the manuscript.

Attestation: Margaretha C. E. van der Woude attests to the integrity of the original data and the analysis reported in this manuscript and approved the final manuscript.

Name: Laura Bormans, RN.

Contribution: This author collected the data and helped analyze the data.

Attestation: Laura Bormans is the archival author, attests to the integrity of the original data and the analysis reported in this manuscript, and approved the final manuscript.

Name: José G. M. Hofhuis, RN, PhD

Contribution: This author analyzed the data.

Attestation: José G. M. Hofhuis attests to the integrity of the original data and the analysis reported in this manuscript and approved the final manuscript.

Name: Peter E. Spronk, MD, PhD, FCCP.

Contribution: This author conceived and coordinated the study, helped analyze the data, and assisted and approved the final draft of the manuscript.

Attestation: Peter E. Spronk attests to the integrity of the original data and the analysis reported in this manuscript and approved the final manuscript.

This manuscript was handled by: Avery Tung, MD.


The authors thank G. Poolmans for her contribution to the developing of the Dutch questionnaire.


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