1.1 Background and Significance

Pain is a universal human experience, yet in the critical care setting, it represents a uniquely complex clinical challenge.(1) The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."(2) In intensive care units (ICUs), patients frequently experience moderate to severe pain at rest and during routine care activities such as suctioning, positioning, and wound care. Studies suggest that up to 77% of ICU patients experience significant pain during their stay, and undertreated pain is associated with adverse outcomes including hemodynamic instability, immunosuppression, prolonged mechanical ventilation, delirium, post-traumatic stress disorder, and chronic pain syndromes. (3, 4)

The challenge of pain assessment in the ICU is compounded by the fact that many critically ill patients are unable to communicate verbally due to sedation, mechanical ventilation, or underlying neurological impairment. In such patients, self-report—the gold standard of pain assessment—is impossible, necessitating the use of validated behavioral pain assessment tools.(5, 6) The Critical-Care Pain Observation Tool (CPOT) and the Behavioral Pain Scale (BPS) are the most widely recommended and validated tools for assessing pain in nonverbal ICU patients. For patients who can self-report, the Numeric Rating Scale (NRS) and Visual Analog Scale (VAS) remain the preferred instruments.(7)

Nurses are at the forefront of pain assessment in ICUs. They spend the most time at the bedside, perform the majority of painful procedures, and are responsible for ongoing monitoring and documentation of pain scores.(8) Effective pain assessment by nurses is the cornerstone of the ABCDEFGHI bundle—a comprehensive, evidence-based approach to ICU patient care that begins with "Assessment and management of pain". When nurses possess adequate knowledge and positive attitudes toward pain assessment tools, they are better equipped to recognize pain, communicate effectively with the interprofessional team, and advocate for timely analgesic interventions.(9)

However, studies from low- and middle-income countries (LMICs), including Pakistan, have consistently demonstrated gaps in nurses' knowledge and attitudes regarding pain assessment and management.(10) A study conducted in Pakistan found that baseline knowledge of the CPOT among ICU nurses was suboptimal, with significant improvement only after structured educational interventions. Similarly, research from Saudi Arabia reported that only 7.1% of ICU nurses demonstrated good knowledge of pain management, with 48.2% falling into the poor knowledge category.(11) In Colombia, a cross-sectional study found that professional nurses achieved only 30.7% correct responses on a pain knowledge survey, while nursing assistants scored even lower at 25.6%.(12)

Abbottabad, a city in the Khyber Pakhtunkhwa province of Pakistan, is home to several tertiary care hospitals serving a large population from both urban and rural areas.(13) Understanding the baseline knowledge and attitudes of nurses in this context is essential for developing effective, culturally appropriate educational programs and quality improvement initiatives.(14)

2.1 Study Design and Setting A descriptive cross-sectional study design was employed. The study was conducted in the multidisciplinary intensive care units (ICUs) of two tertiary care hospitals in Abbottabad, Pakistan: Ayub Teaching Hospital and Combined Military Hospital (CMH) Abbottabad. The study was carried out over a period of six months, from January to June 2025.Tertiary care hospitals were selected because they serve as referral centers for the region and manage the most critically ill patients, where pain assessment is of paramount importance. Multidisciplinary ICUs were chosen to capture a diverse range of patient conditions and nursing experiences. 2.2 Study Population and Sampling The target population comprised all registered nurses (RNs) working in the multidisciplinary ICUs of the selected hospitals. Inclusion criteria were: (a) registered nurses with a valid nursing license, (b) currently employed in a multidisciplinary ICU for at least six months, and (c) providing direct patient care. Exclusion criteria were: (a) nurses on leave during the study period, (b) nursing students or interns, and (c) nurses working in administrative or non-clinical roles.A convenience sampling technique was used to recruit participants. Based on the total number of eligible nurses (approximately 180), a sample size of 150 was calculated using the formula n = Z²pq/d², with a 95% confidence level (Z=1.96), expected proportion (p) of 50%, margin of error (d) of 5%, and a 10% non-response rate. All nurses who met the inclusion criteria and provided consent during the study period were invited to participate. 2.3 Data Collection Instrument Data were collected using a structured, pre-validated questionnaire adapted from the Knowledge and Attitudes Survey Regarding Pain (KASRP), originally developed by Betty Ferrell and Margo McCaffery and used extensively in similar studies. The questionnaire was modified to focus specifically on pain assessment tools used in the ICU context and to reflect the local clinical setting. The instrument consisted of three sections: Section A: Demographic and Professional Information This section collected information on age, gender, educational level (diploma, bachelor's, master's), years of experience in ICU, type of ICU (medical, surgical, mixed), attendance at pain management workshops or continuing education programs, availability of pain assessment tools in the ward, and existence of pain management protocols. Section B: Knowledge Assessment This section comprised 25 items in true/false and multiple-choice formats, designed to assess knowledge of: Pain physiology and pathophysiology Validated pain assessment tools for ICU patients (CPOT, BPS, NRS, VAS) Appropriate use of pain assessment tools in verbal and nonverbal patients Pain assessment frequency and documentation standards Barriers to effective pain assessment Each correct response was scored as 1, and incorrect responses as 0. Total knowledge scores ranged from 0 to 25, with scores categorized as: poor (<50% correct), moderate (50-74% correct), and good (≥75% correct). Section C: Attitude Assessment This section comprised 10 statements rated on a 5-point Likert scale (1 = Strongly Disagree to 5 = Strongly Agree), designed to assess attitudes toward: Importance of systematic pain assessment Confidence in using pain assessment tools Perceived barriers to tool use (time, complexity, lack of training) Integration of pain assessment into routine nursing care Interprofessional collaboration in pain management 2.4 Validity and Reliability The questionnaire was adapted from the validated KASRP, which has demonstrated reliability (Cronbach's alpha >0.70) in multiple international studies. For this study, face and content validity were established through review by three experts: two senior intensivists and one nursing educator with expertise in critical care. The instrument was pilot-tested on 15 ICU nurses (not included in the final sample), and minor adjustments were made for clarity and cultural appropriateness. The internal consistency of the knowledge section was assessed using Kuder-Richardson Formula 20 (KR-20 = 0.72), and the attitude section demonstrated acceptable internal consistency (Cronbach's alpha = 0.78). 2.5 Data Collection Procedure Permission was obtained from the hospital administrations and the respective nursing directors. Ethical approval was secured from the Institutional Review Board (IRB) of Ayub Teaching Hospital (Reference No. ATH/IRB/2025/042). Potential participants were approached during their shifts in the ICU. The purpose of the study was explained, and written informed consent was obtained. Participants were assured of confidentiality and anonymity; no identifying information was collected. The questionnaire was self-administered and took approximately 20-25 minutes to complete. Data collection was conducted during non-peak hours to minimize disruption to patient care. A designated drop box was used for completed questionnaires to ensure anonymity. 2.6 Data Analysis Data were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 26. Descriptive statistics (frequencies, percentages, means, and standard deviations) were calculated for demographic variables, knowledge scores, and attitude responses. Knowledge scores were categorized as poor, moderate, or good, and presented as frequencies and percentages. For attitude items, mean scores and standard deviations were calculated, and responses were dichotomized as "agree" (agree/strongly agree) versus "disagree" (disagree/strongly disagree/neutral) for simplified interpretation. Inferential statistics: Independent t-tests were used to compare mean knowledge scores between two groups (e.g., gender, workshop attendance), and one-way ANOVA was used to compare mean scores across three or more groups (e.g., education level, years of experience). Pearson correlation was calculated to examine the relationship between knowledge scores and years of experience. Statistical significance was set at p < 0.05. 2.7 Ethical Considerations This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Institutional Review Board (IRB) of Ayub Teaching Hospital (Reference No. ATH/IRB/2025/042). Permission was also obtained from the nursing administration of both participating hospitals. All participants provided written informed consent after receiving a detailed explanation of the study objectives, procedures, potential risks, and benefits. Participants were informed that participation was voluntary and that they could withdraw at any time without consequences. Confidentiality was maintained by ensuring anonymity in data collection and secure storage of data in a password-protected computer accessible only to the research team.

A total of 150 nurses participated in the study, yielding a response rate of 83.3% (150/180). The demographic and professional characteristics of the participants are presented in Table 1. The majority of participants were female (72.0%), and the mean age was 30.2 ± 6.8 years. Most held a diploma in nursing (60.0%), with 34.0% holding a bachelor's degree (BSN) and 6.0% holding a master's degree. The mean years of experience in the ICU was 4.3 ± 3.1 years, with 28.0% having less than 2 years of experience, 42.0% having 2-5 years, and 30.0% having more than 5 years. Only 32.0% reported having attended any formal training or workshop on pain assessment in the past two years. Pain assessment tools were reportedly available in 85.3% of ICUs, while a formal pain management protocol was present in only 46.7% of units.

Table 1. Demographic and Professional Characteristics of Participants (N=150)

3.1 Knowledge of Pain Assessment Tools

The overall mean knowledge score was 14.6 ± 2.8 out of 25, corresponding to 58.4% correct responses. The distribution of knowledge scores is presented in Table 2. Most participants (54.0%) demonstrated moderate knowledge, 28.0% demonstrated poor knowledge, and only 18.0% demonstrated good knowledge (≥75% correct). The mean score for nurses who had attended a pain management workshop (16.2 ± 2.4) was significantly higher than for those who had not (13.8 ± 2.7), t(148) = 4.89, p < 0.001.Regarding specific knowledge items, only 42.7% correctly identified the CPOT as the recommended behavioral pain scale for nonverbal ICU patients. The NRS was correctly identified as the preferred tool for verbal patients by 52.0% of participants. A substantial proportion (40.7%) incorrectly believed that pain assessment is less important in sedated patients, and 36.7% were unaware that pain should be assessed at least every 4 hours in stable ICU patients. While 65.3% knew that vital signs should not be used as a sole indicator of pain, only 44.0% correctly recognized that behavioral pain scales are validated for use in mechanically ventilated patients.

Table 2. Knowledge Scores Regarding Pain Assessment Tools (N=150)

3.2 Attitudes toward Pain Assessment Tools

Participants' attitudes toward pain assessment tools are summarized in Table 3. Positive attitudes were observed regarding the importance of systematic pain assessment, with 68.0% agreeing or strongly agreeing that it is essential for quality patient care. Similarly, 62.0% agreed that routine pain assessment should be a standard of care for all ICU patients. However, significant attitudinal barriers were identified: 52.0% agreed or strongly agreed that pain assessment tools are time-consuming and add to their workload, and 47.3% lacked confidence in using the tools independently. Over half (54.0%) expressed a need for more training and education on pain assessment tools.A majority (56.7%) agreed that pain assessment tools improve communication with physicians regarding pain management, indicating recognition of the collaborative value of these tools. However, 34.0% still believed that their clinical judgment is more reliable than pain assessment tools, suggesting a potential resistance to protocol-based assessment.

Table 3. Attitudes toward Pain Assessment Tools (N=150)

3.3 Factors Associated with Knowledge and Attitudes

The association between demographic/professional factors and knowledge scores was examined using independent t-tests and one-way ANOVA. Years of ICU experience showed a significant positive association with knowledge scores (p = 0.021), with nurses having >5 years of experience demonstrating higher knowledge (mean = 16.1 ± 2.5) compared to those with <2 years (mean = 13.4 ± 2.9). Education level was also significantly associated with knowledge (p = 0.015), with BSN-prepared nurses achieving higher scores (15.4 ± 2.6) than diploma holders (13.9 ± 2.8). Attendance at a pain management workshop was the strongest predictor of both knowledge (p = 0.008) and positive attitudes (p = 0.013). Gender and type of ICU were not significantly associated with knowledge or attitudes (p > 0.05 for both).Attitude scores (aggregated) showed a weak but significant positive correlation with knowledge scores (Pearson r = 0.29, p = 0.021), suggesting that nurses with higher knowledge also tended to hold more positive attitudes toward pain assessment tools. No significant association was found between the availability of pain assessment tools or protocols and knowledge scores, though this may be due to self-reported availability rather than actual documented presence.

This study reveals a significant knowledge deficit among ICU nurses in Abbottabad regarding pain assessment tools, with only 18% demonstrating good knowledge. The overall mean knowledge score of 58.4% is comparable to findings from similar settings. In a Pakistani study evaluating the impact of an educational course on CPOT use, Siddiqui et al. reported a mean baseline pre-test score of 57.83% among critical care physicians and nurses—remarkably similar to our findings. This consistency suggests that knowledge gaps regarding ICU pain assessment are systemic in Pakistan's healthcare system and not unique to a single region. The finding that only 42.7% of participants correctly identified the CPOT as the recommended behavioral pain scale for nonverbal ICU patients is particularly concerning. The CPOT has been extensively validated in multiple languages and clinical contexts and is recommended by the Society of Critical Care Medicine (SCCM) as the preferred behavioral pain scale for critically ill adults.(15) Its low recognition rate suggests that CPOT may not be widely adopted or taught in the study hospitals, despite its availability in 85.3% of units. This disconnect between tool availability and nurse knowledge points to a lack of formal training or implementation support.(16) Similarly, the low awareness of appropriate pain assessment frequency (only 36.7% knew that pain should be assessed every 4 hours) reflects a gap in understanding of pain management standards.(17) This finding is consistent with research from Saudi Arabia, where critical care nurses demonstrated inadequate knowledge of pain assessment practices despite expressing positive attitudes.(18) The attitudinal findings reveal a paradox: while most nurses (68%) recognize the importance of systematic pain assessment, many also perceive significant barriers to its implementation.(17) Over half (52%) viewed pain assessment tools as time-consuming, and 47.3% lacked confidence in using them independently.(19) These findings align with a realist evaluation study that identified time constraints and workflow disruptions as key barriers to pain management intervention implementation in ICUs. The lack of confidence expressed by 47.3% of participants is particularly noteworthy, as it suggests that mere availability of tools is insufficient—nurses need structured training and supervised practice to build competency.(20) In our study, workshop attendance was the strongest predictor of both knowledge and positive attitudes, reinforcing the critical importance of continuing education. The significant association between years of ICU experience and knowledge scores (p = 0.021) suggests that experiential learning plays a role in building pain assessment competency.(21) However, the finding that even experienced nurses had knowledge gaps (mean score 16.1/25, or 64.4%) indicates that experience alone is insufficient—deliberate education is needed.(22) The strongest predictor of both knowledge and positive attitudes was attendance at pain management. This finding has important implications for practice: the significant improvement observed in the Pakistani CPOT educational course (pre-test 57.83% vs. post-test 67.43%, p < 0.01) demonstrates that even relatively brief, targeted interventions can substantially improve nurses' pain assessment knowledge. The fact that only 32% of our participants had attended such workshops suggests missed opportunities for professional development. The findings of this study have several important implications. First, there is an urgent need for structured, ongoing pain assessment education for ICU nurses in Abbottabad. As the SCCM emphasizes, pain assessment is the "cornerstone to optimal pain management". Educational interventions should focus on the practical application of validated tools, particularly the CPOT for nonverbal patients, and should include hands-on training with case scenarios to build confidence. Such education should be mandated as part of ICU orientation and reinforced through regular in-service training.(23) The Colombian study by Bonilla-Marciales et al. provides an interesting comparator, as it was also conducted in a tertiary care institution that had implemented clinical practice guidelines for pain management for six years.(24) Despite this institutional commitment, professional nurses achieved only 30.7% correct responses on the KASRP, and nursing assistants scored even lower at 25.6%. The authors concluded that "specific weaknesses were identified in knowledge and attitudes" and highlighted the need for systematic education.(25) This suggests that the mere presence of guidelines is insufficient—active strategies for dissemination, education, and reinforcement are necessary.

This cross-sectional study assessed the knowledge and attitudes of 150 ICU nurses regarding pain assessment tools in tertiary care hospitals in Abbottabad, Pakistan. The findings reveal that while most nurses hold positive attitudes toward the importance of systematic pain assessment, significant knowledge deficits exist, particularly regarding the appropriate use of validated behavioral pain scales such as CPOT for nonverbal patients. The overall mean knowledge score of 58.4% indicates that many nurses lack the foundational knowledge needed to assess pain accurately and consistently. Attitudinal barriers, including perceptions that pain assessment tools are time-consuming and a lack of confidence in their use, further impede effective pain assessment. Years of ICU experience, higher education level, and attendance at pain management workshops were significantly associated with better knowledge and attitudes, highlighting the importance of formal training and professional development. These findings underscore the urgent need for targeted educational interventions, organizational support, and policy reforms to improve pain assessment practices and ultimately patient outcomes in ICUs.

6. RECOMMENDATIONS

Based on the study findings, the following recommendations are proposed: First, the nursing administration and hospital leadership should develop and implement structured, mandatory continuing education programs on pain assessment, focusing on the practical application of validated tools such as CPOT and BPS, with hands-on training and simulation-based learning. Second, standardized pain management protocols should be developed and adopted across all ICUs, specifying assessment tools, frequency of assessment, documentation requirements, and a clear escalation pathway for inadequate pain control. Third, organizational support should be enhanced by reducing nurse-to-patient ratios where possible, integrating pain assessment into electronic health records, and designating pain champions or resource nurses to provide ongoing mentorship and support. Fourth, nursing education curricula at the diploma and bachelor's levels should incorporate comprehensive pain management content, with a specific emphasis on assessment tools for critically ill patients and the importance of systematic pain assessment as a quality metric. Finally, policymakers and hospital administrators should mandate pain assessment documentation as a quality indicator and support regular audits to ensure consistent implementation of pain management standards.

7. LIMITATIONS

This study has several limitations that should be considered when interpreting the findings. First, the cross-sectional design precludes establishing causality or assessing changes in knowledge and attitudes over time. Second, the use of convenience sampling in two tertiary care hospitals in Abbottabad may limit the generalizability of the findings to other hospitals, regions, or healthcare settings. Third, reliance on self-reported data may introduce social desirability bias, potentially overestimating positive attitudes and underestimating knowledge deficits. Fourth, the use of a modified KASRP instrument may affect comparability with studies using the original version, despite validation efforts. Fifth, this study assessed knowledge and attitudes but did not directly observe clinical practice, limiting the ability to confirm whether self-reported intentions translate into actual pain assessment behaviors. Finally, the low attendance at pain management workshops in the sample (32%) highlights the need for future research to explore barriers to continuing education participation among ICU nurses.