title: Expert clinical reasoning and pain assessment in mechanically ventilated patients: A descriptive study.
abstract: BACKGROUND
  Pain assessment in mechanically ventilated patients is challenging, because nurses need to decode pain behaviour, interpret pain scores, and make appropriate decisions. This clinical reasoning process is inherent to advanced nursing practice, but is poorly understood. A better understanding of this process could contribute to improved pain assessment and management.
  
  
  OBJECTIVE
  This study aimed to describe the indicators that influence expert nurses' clinical reasoning when assessing pain in critically ill nonverbal patients.
  
  
  METHODS
  This descriptive observational study was conducted in the adult intensive care unit (ICU) of a tertiary referral hospital in Western Switzerland. A purposive sample of expert nurses, caring for nonverbal ventilated patients who received sedation and analgesia, were invited to participate in the study. Data were collected in "real life" using recorded think-aloud combined with direct non-participant observation and brief interviews. Data were analysed using deductive and inductive content analyses using a theoretical framework related to clinical reasoning and pain.
  
  
  RESULTS
  Seven expert nurses with an average of 7.85 (±3.1) years of critical care experience participated in the study. The patients had respiratory distress (n=2), cardiac arrest (n=2), sub-arachnoid bleeding (n=1), and multi-trauma (n=2). A total of 1344 quotes in five categories were identified. Patients' physiological stability was the principal indicator for making decision in relation to pain management. Results also showed that it is a permanent challenge for nurses to discriminate situations requiring sedation from situations requiring analgesia. Expert nurses mainly used working knowledge and patterns to anticipate and prevent pain.
  
  
  CONCLUSIONS
  Patient's clinical condition is important for making decision about pain in critically ill nonverbal patients. The concept of pain cannot be assessed in isolation and its assessment should take the patient's clinical stability and sedation into account. Further research is warranted to confirm these results.
authors.affiliation: Institute of Higher Education and Nursing Research, University of Lausanne, CHUV, Switzerland; Haute Ecole de Santé Vaud (HESAV), University of Applied Sciences Western Switzerland, Lausanne, Switzerland.
authors.forename: Anne
authors.initials: A
authors.lastname: Gerber
authors.affiliation: Institute of Higher Education and Nursing Research, University of Lausanne, CHUV, Switzerland; Institut et Haute Ecole La Source, School of Nursing, Lausanne, Switzerland.
authors.forename: Anne-Laure
authors.initials: AL
authors.lastname: Thevoz
authors.affiliation: Institute of Higher Education and Nursing Research, University of Lausanne, CHUV, Switzerland; Haute Ecole de Santé Vaud (HESAV), University of Applied Sciences Western Switzerland, Lausanne, Switzerland. Electronic address: Anne-Sylvie.Ramelet@unil.ch.
authors.forename: Anne-Sylvie
authors.initials: AS
authors.lastname: Ramelet
mesh_terms: D057179:Advanced Practice Nursing; D064648:Critical Care Nursing; D003657:Decision Making; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009730:Nursing Assessment; D010147:Pain Measurement / Q000451:nursing*; D012121:Respiration, Artificial / Q000451:nursing*; D013557:Switzerland
keywords: Clinical reasoning; Critical care; Decision-making; Intensive care; Nursing; Pain assessment