Nurses' perceptions of pain management in non-communicative critically ill patients: A phenomenological study

Background: Despite ethical principles and standards of care aiming to ensure proper pain management, inadequate pain treatment is common. Aim: To explore ICU nurses’ beliefs, attitudes, and ethical perspectives regarding pain management in non-communicative critically ill patients, focusing on applying the bioethical principles of beneficence, non-maleficence, autonomy, and justice. Methods: This qualitative study used descriptive phenomenology. We conducted semi-structured interviews with 11 nurses with ≥3 years’ ICU experience selected through purposive sampling. Thematic and content elements were combined for the analysis. Our hospital's ethics committee approved the study, and all participants provided written informed consent. Findings: Nurses’ beliefs, attitudes, and ethical perspectives regarding pain management in non-communicative patients into 15 categories. Inequities in managing communicative and non-communicative patients arose mainly from professionals’ inadequate sensitivity, challenges of managing non-communicative patients, and personal beliefs. Nurses reported significant ethical dilemmas in managing pain of non-communicative patients, highlighting challenges in adequately applying principles of beneficence, non-maleficence, and justice. Findings indicate pain is often under-assessed and undertreated, partly due to misconceptions, high workload, and variability in pain assessment tools. Participants also expressed autonomy is frequently overlooked, as decisions are often made without patient or family input. Institutional factors like insufficient time and heavy workload, were identified as barriers to equitable pain management, limiting the consistent application of bioethical principles. Conclusions: Results underscore the need for standardized ICU pain assessment protocols incorporating validated non-verbal tools, alongside ongoing ethical decision-making training and pain management. Better institutional support, including clearer guidelines and improved resource allocation, could help ICU nurses deliver more consistent, ethical, and patient-centered care, addressing bioethical principles of justice, beneficence, non-maleficence, and autonomy.