• Background Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally. • Objective To validate the Critical-Care Pain Observation Tool. • Methods A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation. • Results The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted κ coefficients. For criterion validity, significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. • Conclusions The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain.

• Background Little research has been done on pain assessment in critical care, especially in patients who cannot communicate verbally.• Objectives To describe (1) pain indicators used by nurses and physicians for pain assessment, (2) pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and (3) pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are intubated.• Methods Medical files from 2 specialized healthcare centers in Quebec City, Quebec, were reviewed. A data collection instrument based on Melzack’s theory was developed from existing tools. Pain-related indicators were clustered into nonobservable/subjective (patients’ self-reports of pain) and observable/objective (physiological and behavioral) categories.• Results A total of 183 pain episodes in 52 patients who received mechanical ventilation were analyzed. Observable indicators were recorded 97% of the time. Patients’ self-reports of pain were recorded only 29% of the time, a practice contradictory to recommendations for pain assessment. Pharmacological interventions were used more often (89% of the time) than nonpharmacological interventions (<25%) for managing pain. Almost 40% of the time, pain was not reassessed after an intervention. For reassessments, observable indicators were recorded 66% of the time; patients self-reports were recorded only 8% of the time.• Conclusions Pain documentation in medical files is incomplete or inadequate. The lack of a pain assessment tool may contribute to this situation. Research is still needed in the development of tools to enhance pain assessment in critically ill intubated patients.

Participation by health care workers and action plans targeting problematic aspects of the psychosocial work environment are key elements in interventions to improve their health. However, such interventions present challenges, such as the involvement of managers, involvement of all relevant participants, and re-establishment of trust within work teams. Recognition and respect must be re-established, and supervisors must engage with health care workers and give support at all stages of the intervention.

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Introducing incentives centred on all age groups provides an opportunity to create a healthy workplace for all generations of nurses.