Intensive & Critical Care Nursing 60 (2020) 102874

Contents lists available at ScienceDirect

Intensive & Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research Article

Comparison of the Zurich Observation Pain Assessment with the

Behavioural Pain Scale and the Critical Care Pain Observation Tool in
nonverbal patients in the intensive care unit: A prospective
observational study
Martin R. Fröhlich a,b,⇑, Gabriele Meyer b, Rebecca Spirig c, Lucas M. Bachmann d
a
Kantonsspital Aarau (Switzerland), Department of Clinical Nursing Science & Department of Perioperative Medicine
b
Martin Luther University Halle-Wittenberg (Germany), Institute for Health and Nursing Science
c
University of Basel (Switzerland), Institute for Nursing Science
d
Medignition AG, Zurich (Switzerland)

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To determine the concordance of Zurich Observation Pain Assessment (ZOPA) with the beha-
Received 7 January 2020 vioural Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT) to detect pain in nonverbal ICU
Revised 21 March 2020 patients.
Accepted 1 April 2020
Design: Prospective observational study [BASEC-Nr. PB_2016-02324].
Setting: A total of 49 ICU patients from cardiovascular, visceral and thoracic surgery and neurology and
neurosurgery were recruited. Data from 24 patients were analyzed.
Keywords:
Main Outcome Measurements: Three independent observers assessed pain with the BPS, the CPOT or ZOPA
Concordance
Intensive care unit
prior, during and after a potential painful nursing intervention. Tools were randomized concerning the
Nonverbal patients pain management after each pain assessment. Frequency of nine additional pain indicating items from
Observational study a previous qualitative, explorative study was calculated.
Pain assessment tool Results: ZOPA was positive in 32 of 33 measuring cycles (97.0%; 95%CI: 84.2-99.9%), followed by the CPOT
(28/33 cycles, 84.8%; 95%CI: 68.1–94.9%) and the BPS (23/33 cycles, 67.0%; 95%CI: 51.3–84.4%). In 22/33
cycles all tools were concordant (66.7%; 95%CI: 48.2-82.0%). Analgesics were provided in 29 out of 33
cycles (87.9%; 95%CI: 71.8–96.6%). Additional pain indicating items were inconsistently reported.
Conclusion: ZOPA is concordant with the BPS and the CPOT to indicate pain but detects pain earlier due to
the low threshold value. Inclusion of further items does not improve pain assessment.
Ó 2020 Elsevier Ltd. All rights reserved.

Implications for clinical practice

 Pain assessment in nonverbal patients in the ICU is important to prevent negative short- and long-term outcomes caused by unde-
tected pain.
 The German ZOPA instrument shows a high concordance with well-known pain assessments as BPS and CPOT.
 The ZOPA delivers valid and reliable results in patients from different clinical fields and induces an early pain treatment.

⇑ Corresponding author at: Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau (Switzerland), martin.froehlich@ksa.ch
E-mail address: martin.froehlich@ksa.ch (M.R. Fröhlich).

https://doi.org/10.1016/j.iccn.2020.102874
0964-3397/Ó 2020 Elsevier Ltd. All rights reserved.
2 M.R. Fröhlich et al. / Intensive & Critical Care Nursing 60 (2020) 102874

Introduction was originally intended for neurological and neurosurgical

patients, we believed that the instrument could be useful in other
Many patients describe the experience of pain during their stay clinical settings including cardiac, visceral, and thoracic surgery.
in the intensive care unit (ICU) (Abuatiq, 2015; Alasad et al., 2015; After the implementation of the ZOPA, a number of instruments
Chahraoui et al., 2015). Undetected pain and inadequate pain man- have been developed (Varndell et al, 2016; Gélinas et al., 2013;
agement result in negative short- and long-term outcomes: Pudas-Tähkä et al., 2009; Li et al., 2008). Among these, two instru-
increased sympathetic nervous system stimulation results in more ments, the behavioural Pain Scale (BPS) and the Critical Care Pain
stress for the heart, lung and circulation; increased metabolism Observation Tool (CPOT), have gained broad acceptance in the clin-
and decreased the immune response which is accompanied by an ical and research community (Payen et al., 2001; Gélinas et al.,
increased susceptibility to infection and risk of delayed wound 2006). Unlike ZOPA, the BPS and CPOT have been assessed in var-
healing (Lindenbaum and Milia, 2012; Middleton, 2003). Further- ious different clinical domains outside neurology and neurosurgery
more, pain can become chronic and is a risk factor for delirium, (Gélinas et al., 2013). Furthermore, the BPS was modified for use in
post-intensive care syndrome (PICS), and post-traumatic stress dis- non-intubated and ventilated patients (BPS-NI; Chanques et al.,
order (PTSD) (DGAI and DIVI, 2015; Mikkelsen et al., 2019; Elliott 2009). Thus, these instruments are ideal for comparison to the
et al., 2016; Timmers et al., 2011; Savaskan et al., 2016; Myhren ZOPA when used in clinical fields outside neurology and neuro-
et al., 2010). surgery. We hypothesized that the ZOPA could be used in settings
In 2003 a group of Swiss scientists and nurses developed and outside neurology and neurosurgery, if there was a high level of
validated the Zurich Observation Pain Assessment (ZOPA) for concordance between treatment decisions with the three
patients with neurosurgical and neurological illnesses and a instruments.
decreased level of consciousness and cognition (Handel, 2010).
Many of these patients are not able to communicate their pain Methods
experience to caregivers. As a result, there is a risk that pain will
be ignored and not appropriately managed. The ZOPA aims to elim- Objective
inate this problem. The assessment contains thirteen items in four
categories: vocalization, facial expression, body language and This study aimed to assess the concordance between the ZOPA,
physiological indicators, which are observed as present or absent CPOT and BPS / BPS-NI in ICU patients with reduced consciousness
(see Fig. 1). One positive item is interpreted as existing pain. The and cognitive impairment in the context of cardiovascular, visceral,
development and subsequent revision of the ZOPA followed and thoracic surgery. We also sought to learn if the ZOPA could be
recommendations from the literature (DeVellis, 2012; Pittman enhanced with additional items that would be appropriate for
and Bakas, 2010; Streiner and Norman, 2008; Hagino, 2002). The these patients.
instrument has been found to be valid and reliable in neurosurgical
and neurological patients (Fröhlich et al., 2016). While the ZOPA
Design

This study was designed as a prospective observational study.

Vocalization
Pain assessment and the administration of analgesics as an inter-
Groaning / Moaning vention were embedded in the research process with data col-
lected three times (see Fig. 2).
Grumbling

Facial expression Setting and participants

Distorted, affected facial expression The study had a projected sample size of 50 patients from three
Staring ICUs specializing in cardiovascular, visceral, and thoracic surgery
and neurology and neurosurgery in a University hospital in the
Gritting of teeth (on tube) German speaking part of Switzerland. Patients were eligible if they
Tightened eyes spoke German, were more than 18 years old and had reduced con-
sciousness and cognitive impairment. Patients were excluded if
Tears running from eyes they had a psychiatric diagnosis, chronic pain, complications dur-
ing their ICU stay such as delirium or hemorrhagic shock, or were
Body Language
in a terminal state. We did not calculate our sample size using a
Restless power analysis but estimated, that a sample size of 50 patients is
appropriate to detect a moderate to high concordance between
Kneading or touching part of the body
the ZOPA, the BPS and the CPOT (Fig. 3).
Tensed muscles
Ethical approval
Physiological Indicators

Change in vital signs: This study was approved by the Cantonal Ethic Commission (ref
number KEK-ZH 2014-0104; BASEC-Nr. PB_2016-02324].). Accord-
- Blood pressure / heart rate
ing with current legislation patients’ relatives gave a proxy consent
- Breathing (presumed patient will) for their loved one to be included in the
study. We had to obtain patients’ informed consent after discharge
Change in coloring:
from the ICU in order use and analyze their data for this study. We
- Facial rash / sweating conducted the study according to the guidelines of Good Clinical
Practice (International Conference on Harmonization of Technical
Fig. 1. English wording of ZOPA (provided for information only; the instrument was Requirements for Registration of Pharmaceuticals in Human Use,
administered in German). 1996).
 M.R. Fröhlich et al. / Intensive & Critical Care Nursing 60 (2020) 102874 3

Fig. 2. Study design.

Data collection and pain management first author and two clinical nurse specialists from two different
ICUs) used one of three instruments for pain assessment. To avoid
We observed patients’ behaviors and changes in physiological order effects, ZOPA, BPS and CPOT were randomized to determine
parameters related to pain while carrying out routine, necessary the instrument that leads the pain treatment (additional bolus of
nursing interventions which have been described as painful in analgesics) for each patient. Pain treatment was provided if the
the literature (Vázquez et al., 2011; Aslan et al., 2010). Pain was assessment indicated that the patient experienced pain during
assessed before, during, and after position changes in bed or endo- the nursing intervention (T1 in Fig. 2). The ICU nurse administered
tracheal suctioning (see Fig. 2). The ZOPA, the BPS / BPS-NI and an analgesic bolus. The time interval was from 5 to 8 min between
CPOT were used to assess pain. Three independent observers (the medication administration and final pain assessment (T2 in Fig. 2).
4 M.R. Fröhlich et al. / Intensive & Critical Care Nursing 60 (2020) 102874

Fig. 3. CONSORT Flow chart.

For this study we intended to assess whether the ZOPA could be patients with 557 measurements. From this, an instrument with
enhanced with additional items. In a previous qualitative part of a 13 items was finalized.
mixed methods study, we used the think aloud method with 16
critical care nurses to identify patient-related and pain indicating
Preparatory work
items (Fröhlich et al., 2019). We identified nine items not included
We asked the developers of the BPS and BSI-NI to translate their
in the current ZOPA: ‘‘rip open the eyes", ‘‘nose wrinkling", ‘‘tighten
original version into German and used a systematic approach for in
the cheeks", ‘‘rip open the mouth", "stick out the tongue", ‘‘defend",
the translation process (Maneesriwongul and Dixon, 2004). We
‘‘pinch the butt", ‘‘press against the ventilator", and ‘‘changes in
received the German version of the CPOT from our research col-
pupil size". All observers assessed these items independently
leagues at the University Hospital in Basel/Switzerland (Emsden
before, during and after the nursing intervention.
et al., 2016). Additionally, we added the nine additional items that
were identified in the previous qualitative, explorative study
(Fröhlich et al., 2019).
Observers participating in the pain assessment received a
Instrument development
description of the three instruments and practical training to use
and interpret the assessment instruments on six patients. For the
The development of the ZOPA was prompted after identifying a
nine additional items, we specified how to operationalize them
lack of appropriate pain assessment instruments for neurosurgical
with training on the same six patients.
and neurological patients (Handel, 2010). Based on a systematic lit-
erature search an initial pool of 43 items was compiled. To reduce
this pool an expert panel of nurse researchers and clinical nurse Data analyses
specialists rated the relevance and importance of each item. The Continuous variables are reported with means, standard devia-
reduced pool was used for 182 assessments resulting in a final pool tions and interquartile range, dichotomous variables with percent-
of 32 items. To determine the reliability, data from 390 measure- ages. We performed parametric or non-parametric tests as
ments were analyzed and showed a Cohen’s Kappa between appropriate. A p-value of less than 5% was considered statistically
0.450 and 0.795. Construct validity was estimated in 40 patients significant. We assessed the rate of concordance to perform or
with 249 measurements at two different times. After administra- withhold pain treatment between the three instruments.
tion of analgesics no positive items in ZOPA were observed in The Sign Test testing for the equality of matched pairs of obser-
182 measurements (75.3%, p = less than 0.001). Furthermore, vations (Snedecor and Cochran, 1989) by calculating the differ-
frequency and combination of all items was analyzed in 47 ences between two parameters was used to assess concordance
 M.R. Fröhlich et al. / Intensive & Critical Care Nursing 60 (2020) 102874 5

Table 1
Sociodemographic and clinical characteristics.

Socio-demographic and clinical characteristics

n (%) Mean SD Range IQR
Age (in years)* 61.1 11.0 41 to 76 53.5 to 70
Sex*
Man 16 (66.7)
Woman 8 (33.3)
Clinical field*
cardiovascular surgery 18 (75.0)
visceral and thoracic surgery 2 (8.3)
neurosurgery and neurology 4 (16.7)
Mechanical ventilation*
yes 23 (95.8)
no 1 (4.2)
Glasgow-Coma-Scale* 4.4 2.1 3 to 10 3 to 6
Richmond-Agitation-Sedation-Scale* 3.5 0.8 4 to 1 4 to 3
SAPS II 39.9 15.9 18 to 80 26 to 51.5
TISS-10 16.3 5.9 9 to 31 13.5 to 18
NEMS 35.0 7.8 18 to 50 32.5 to 39.5
Administration of analgesics before and during study*
Paracetamol 5 (20.8)
Methimazole 7 (29.2)
Fentanyl 6 (25.0)
Sufentanil 20 (83.3)
Morphine 4 (16.7)
Ketamine 3 (12.5)
Administration of sedatives before and during study*
Propofol 16 (66.7)
Pethidine 1 (4.2)
Dexmedetomidine 5 (20.8)
Clonidine 2 (8.3)
Sevoflurane 1 (4.2)
Nursing intervention**
change patient’s position 21 (63.6)
endotracheal suctioning 12 (36.4)
Administration of analgesics T1** 29 (87.9)

*n = 24 patients.
**n = 33 measuring cycles.

between the test results of the three instruments. The Sign Test from 24 patients with 33 measuring cycles were analyzed (see
tests the null hypothesis that the median of the differences is zero; Fig. 3). The characteristics of the sample are shown in Table 1.
no further assumptions are made about the distributions. This, in All but one patient was receiving mechanical ventilation. Of 33
turn, is equivalent to the hypothesis that the true proportion of measuring cycles, ZOPA was treatment decisive in 17 cycles
positive (negative) signs is one-half. A non-significant p-value indi- (51.5%), CPOT in 9 cycles (27.3%) and BPS in 7 cycles (21.2%). The
cates that the null hypothesis cannot be rejected. differences occurred due to patients dropping out after entering
We used Landis and Koch’s description and classification of the study.
kappa to describe the thresholds for concordance (Landis and
Koch, 1977). Values from 0 to 20 percent indicate slight concor- Positive assessment results and concordance
dance, 21 to 40 percent indicate poor concordance, 41 to 60 per-
cent indicate moderate concordance, 61 to 80 percent indicate Among the three instruments, we observed different probabili-
substantial concordance, and 81 to 100 percent indicate almost ties for a positive test result. ZOPA was positive in 32 out of 33
perfect concordance. cycles (97.0%; 95%CI: 84.2 to 99.9%), followed by the CPOT
In a secondary assessment we investigated whether nine addi- (28/33 positive results, 84.8%; 95%CI: 68.1 to 94.9%). The BPS
tional items improved the ZOPA to assess pain. Statistical analyses showed a positive test result in only 23 out of 33 cycles (67.0%;
were performed using the Stata 14.2 statistics software package 95%CI: 51.3 to 84.4%). In 22 out of the 33 cycles all three tests
(StataCorp. 2015. Stata Statistical Software: Release 14. College showed a positive test result (66.7%; 95%CI: 48.2 to 82.0%)
Station, TX: StataCorp LP.) (Table 2). In the 17 cycles, where the ZOPA is the classifier and
determined the treatment, the two other instruments where con-
Results cordant in 10 cycles (58.8%; 95%CI: 32.9 to 81.6%). In the 9 cycles
where CPOT determined the treatment, the two other instruments
From November 2017 to December 2018, 480 patients were where concordant in 6 cycles (66.7%; 95%CI: 29.9 to 92.5%, p-value
assessed for eligibility; 49 patients met the inclusion criteria. Data against ZOPA = 0.517). Finally, in the 7 cycles where BPS deter-

Table 2
Concordance between ZOPA, CPOT and BPS in T1.

CPOT / BPS Total

No pain / No pain No pain / Pain Pain / No pain Pain / Pain
ZOPA: No Pain 0 0 1 0 1
ZOPA: Pain 4 1 5 22 32
Total 1 6 22
6 M.R. Fröhlich et al. / Intensive & Critical Care Nursing 60 (2020) 102874

Table 3
Frequency of additional pain indicating items.

Frequency of new items (n = 33 measuring cycles)

T0 T1 T2
Items (Frequency) Observer 1 Observer 2 Observer 3 Observer 1 Observer 2 Observer 3 Observer 1 Observer 2 Observer 3
rip open eyes 0 0 0 6 7 5 0 1 1
nose wrinkling 0 0 0 3 9 9 0 0 0
tighten the cheeks 0 0 0 5 4 5 0 0 0
rip open the mouth 0 0 0 1 3 3 0 0 0
stick out the tongue 0 0 0 1 1 0 0 0 0
defend 0 0 0 5 6 7 0 0 0
pinch the butt 0 0 0 0 2 0 0 0 0
press against the ventilator 0 0 0 8 8 3 0 0 0
changes in pupil size 0 0 0 17 17 17 1 1 1

mined the treatment, the two other instruments agreed in 6 cycles play an important role in pain assessment (Rose et al., 2012).
(85.7%; 95%CI: 42.1 to 99.6%, p-value against ZOPA = 0.218). The Besides ZOPA, some other instruments include behavioural and
three instruments were never concordant to withhold treatment. physiological indicators (Odhner et al., 2003; Blenkharn et al.,
In total, treatment was provided in 29 out of 33 cycles (87.9%; 2002; Puntillo et al., 1997). The ZOPA includes changes in vital
95%CI: 71.8 to 96.6%). Results of the Sign Test for the classification signs and facial colors. Therefore, it works well for ICU nurses when
at T1 showed, that the ZOPA and the BPS were significantly differ- they have to decide about existing pain and whether to administer
ent (p = 0.039), while the ZOPA and the CPOT were not (p = 0.219). analgesics.
The BPS and the CPOT were also concordant (p = 0.125). We intended to assess whether the ZOPA was comprehensive or
if it needed to be enhanced with further items. The results of
Gerber et al. (2014) indicated that ICU nurses use other indicators
Adaptations of ZOPA threshold and additional items
besides those available in a pain assessment. Therefore, we wanted
to identify relevant items that could be added to the existing
As the ZOPA indicates pain comparatively early due to low
instrument. Interestingly, of the nine items that were added, some
threshold value, we calculated concordance with an increased
of them were never observed and others were complementary to
value from 1 to 3 and with an adapted instrument without the cat-
the ZOPA. This study shows that changes in pupil size is an indica-
egories of ‘‘vocalization” and ‘‘physiological indicators.” However,
tor for exiting pain. The literature describes similar results
this did not result in a better performance for the ZOPA. From
(Lukaszewicz et al., 2015; Aïssaoui et al., 2015; Paulus et al.,
new items observers discovered changes in pupil size most fre-
2012). Since the ZOPA indicates pain early and is sensitive, we
quently but not or rarely the other items (Table 3). Detecting items
found that including further items is not necessary.
were highly correlated with positive ZOPA results and associated
For sufficient pain management in the ICU, guidelines recom-
moderately with the administration of analgesics.
mend awareness of causes for pain, use observation tools for pain
assessment, and administer analgesics systematically (DGAI and
Discussion DIVI, 2015; Barr et al., 2013). In addition to the existing instru-
ments for pain assessment in ICU patients, the ZOPA is a German
Main findings instrument that in its current version is able to assess pain in
patients in critical care units.
Our results show that all instruments matched highly in the
ability to indicate pain. Although the ZOPA was developed for neu- Strengths and limitations
rosurgical and neurological patients, the concordance was high,
especially with the CPOT, which indicates that it is valid and reli- We identified some important aspects that influenced our
able with patients from different areas (Gélinas et al., 2013). How- results. First, patient dropouts caused a heterogeneous distribution
ever, ZOPA showed no superiority over BPS and CPOT, but detected of the instrument used for the decision to administer analgesics.
pain earlier due to the lower threshold value for a positive test The ZOPA was the most frequently used instrument to guide treat-
result. Although this value was adjusted and potentially sensitive ment. Second, the personal preferences of the observers could have
items were eliminated, there was no improvement in the agree- an influence on the fact that certain items were rarely evaluated
ment among instruments. Consequently, the probability adminis- positively. Despite the fact that all observers were trained with
tering analgesics was higher, if the ZOPA result determined the all instruments before doing the study, they may not have felt
treatment. Compared to the CPOT und the BPS, there are advan- completely comfortable when using them. Third, as the structure
tages for the ZOPA: First, the construction and the operationaliza- of ZOPA is convenient for the raters, it may have delivered positive
tion of the instrument with dichotomous items that make it easier results more often.
to use by critical care nurses. Second, ZOPA comprises not only Our study clarifies the relevance to detect pain in a vulnerable
behavioural signs but also physiological parameters, which are patient population. For this purpose, we chose a rigorous study
sensitive and contribute to earlier pain detection. design with strong inclusion criteria in order to eliminate
Physiological indicators such heart rate and blood pressure are patient-related factors, such as delirium, that could influence our
controversial as indicators of pain (Boitor et al., 2016; Chen and results. In daily clinical practice, participants suffer from different
Chen, 2015; Kapoustina et al., 2014; Arbour et al., 2014). Neverthe- illnesses and co-morbidities. Therefore, we had to exclude eligible
less, they play a crucial role for ICU nurses in pain assessment. patients during the study process because they developed compli-
Although a pain measurement instrument was implemented, ICU cations or their therapy changed. In addition, we did not obtain a
nurses rely on vital sign measurements to decide whether pain subsequent informed consent from included patients because they
exists or not. (Gerber et al., 2014). Moreover, a survey among ICU died after discharge or were not able to confirm participation. We
nurses revealed that they considered physiological parameters to could not enroll others to account for these dropouts, therefore the
 M.R. Fröhlich et al. / Intensive & Critical Care Nursing 60 (2020) 102874 7

study sample was rather small. We did not calculate a precise activity and pain severity in patients with symptomatic irreversible pulpitis.
Restor. Dent. Endod. 38, 141–145. https://doi.org/10.5395/rde.2013.38.3.141.
study sample. Heterogeneous distribution of the classifier
Aïssaoui, M., Snauwaert, A., Dupuis, C., Atchabahian, A., Aubrun, F., Beaussier, M.,
restricted a comprehensive statistical analysis. 2015. Objective assessment of the immediate postoperative analgesia using
Further evaluation using the ZOPA are certainly warranted. pupillary reflex measurement. A prospective and observational study.
First, further studies in other patient groups, including post- Anesthesiology 116, 1006–1012. https://doi.org/10.1097/
ALN.0b013e318251d1fb.
surgery, trauma, and internal medicine would be useful. Second, Alasad, J.F., Abu Tabar, N., Ahmad, M.M., 2015. Patients’ experience of being in
less strict selection criteria for patient inclusion should be consid- intensive care units e7-11 J. Crit. Care 30, 859. https://doi.org/10.1016/j.
ered. Third, alternative validation procedures should be evaluated. jcrc.2015.03.021.
Aslan, F.E., Badir, A., Arli, S.K., Cakmakci, H., 2010. Patients’ experience of pain after
For example, biomarkers such as alpha amylase are described as an cardiac surgery. Contemp. Nurse 34, 48–54. https://doi.org/
opportunity to indicate pain (Ahmadi-Motamayel et al., 2013; Liu 10.5172/conu.2009.34.1.048.
et al., 2013; Uesato et al., 2010). Their levels could be obtained Arbour, C., Choiniére, M., Topolovec-Vranic, J., Loiselle, C.G., Gélinas, C., 2014. Can
fluctuations in vital signs be used for pain assessment in critically Ill patients
and correlated with the results of the instruments, as they seem with a traumatic brain injury?. Pain Res. Treat. 2014, 1–11. https://doi.org/
to provide additional insight into pain biology. As an alternative, 10.1155/2014/175794.
specialized software to scan face reaction could reduce rater Barr, J., Fraser, G.L., Puntillo, K., Ely, E.W., Gélinas, C., Dasta, J.F., Davidson, J.E.,
Devlin, J.W., Kress, J.P., Joffe, A.M., Coursin, D.B., Herr, D.L., Tung, A., Robinson, B.
dependent results and promote a systematic pain assessment. R., Fontaine, D.K., Ramsay, M.A., Riker, R.R., Sessler, C.N., Pun, B., Skrobik, Y.,
Guidelines recommend CPOT and BPS as the most valid and reli- Jaeschke, R., American Collegeof Critical Care Medicine, 2013. Clinical practice
able instruments. In this study we showed that the ZOPA can also guidelines for the management of pain, agitation, and delirium in adult patients
in the intensive care unit. Crit. Care Med. 41, 263–306. https://doi.org/10.1097/
deliver valid and reliable results. Selection of an appropriate
CCM.0b013e3182783b72.
instrument should be based on scientific and clinical factors. More Blenkharn, A., Faughnan, S., Morgan, A., 2002. Developing a pain assessment tool for
importantly however, teams should undergo sufficient training on use by nurses in an adult intensive care unit. Intensive Crit. Care Nurs. 18, 332–
the proper use of the instrument and continuously refine their 341. https://doi.org/10.1016/s0964-3397(02)00071-x.
Boitor, M., Fiola, J.L., Gélinas, C., 2016. Validation of the Critical-care pain
skills to use the instrument appropriately in their daily routine. observation tool and vital signs in relation to the sensory and affective
Continued training will also reduce differing results across differ- components of pain during mediastinal tube removal in postoperative cardiac
ent raters. surgery intensive care unit adults. J. Cardiovasc. Nurs. 31, 425–431. https://doi.
org/10.1097/JCN.0000000000000250.
Chahraoui, K., Laurent, A., Boy, A., Quenot, J.P., 2015. Psychological experience of
patients 3 months after a stay in the intensive care unit: a descriptive and
Conclusion qualitative study. J. Crit. Care 30, 599–605. https://doi.org/10.1016/j.
jcrc.2015.02.016.
We assessed the ZOPA in its present version and found it rea- Chanques, G., Payen, J.F., Mercier, G., de Lattre, S., Viel, E., Jung, B., Cisse, M., Lefrant,
J.Y., Jaber, S., 2009. Assessing pain in non-intubated critically ill patients unable
sonably concordant with other well-known pain assessments. to self-report: an adaptation of the behavioural Pain Scale. Intensive Care Med.
The ZOPA has theoretical advantages because of its simple opera- 35, 2060–2067. https://doi.org/10.1007/s00134-009-1590-5.
tionalization and dichotomous item construction. Whether this Chen, H.J., Chen, Y.M., 2015. Pain assessment: validation of the physiologic
indicators in the ventilated adult patient. Pain Manag. Nurs. 16, 105–111.
simple use also improves clinical outcomes needs to be estab-
https://doi.org/10.1016/j.pmn.2014.05.012.
lished. In its current form, the ZOPA is calibrated towards early DeVellis, R.F., 2012. Scale Development. Theory and Applications. SAGE
pain treatment. Further research in other and larger patient groups Publications, Los Angeles.
is needed to confirm these results and assess the extent to which DGAI Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI),
Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin
ZOPA guided pain management has favorable effects on cardiovas- (DIVI) et al., 2015. S3-Leitlinie Analgesie, Sedierung und Delirmanagement in
cular and pulmonary outcomes. der Intensivmedizin. https://www.awmf.org/uploads/tx_szleitlinien/001-012l_
S3_Analgesie_Sedierung_Delirmanagement_Intensivmedizin_2015-08_01.pdf
(accessed 19.08.16).
Funding Elliott, R., McKinley, S., Fien, M., Elliott, D., 2016. Posttraumatic stress symptoms in
intensive care patients: an exploration of associated factors. Rehabil. Psychol.
61, 141–150. https://doi.org/10.1037/rep0000074.
We received funding from the Stiftung Pflegewissenschaft Sch- Emsden, C., Barandun Schäfer, U., Frei, I.A., 2016. Den Schmerz besser erfassen.
weiz, Schweizer Berufsverband der Pflegefachfrauen und Pflege- Intensiv 1/16, 16-20.
Fröhlich, M.R., Handel, E., Gnass, I., Sirsch, E., Rettke, H., Spirig, R., 2016.
fachmänner (SBK), and Mundipharma Medical Company
Standardisierte Schmerzfremdeinschätzung bei kognitiv und
Switzerland. bewusstseinsbeeinträchtigten Patient(inn)en mit dem Zurich Observation
Pain Assessment (ZOPAÓ) – Eine kritische Reflexion des
Entwicklungsprozesses. Pflegewissenschaft 11/12, 493–500.
Declaration of Competing Interest Fröhlich, M.R., Spirig, R., Meyer, G., Rettke, H., 2019. Welche patientenbezogenen
Parameter berücksichtigen Pflegende bei der Schmerzeinschätzung
bewusstseins-und kognitiv eingeschränkter Patienten auf der Intensivstation?
The authors declare that they have no known competing finan-
Eine qualitative explorative Studie. Pflegewissenschaft 1/2 (2019), 41–51.
cial interests or personal relationships that could have appeared Gélinas, C., Puntillo, K.A., Joffe, A.M., Barr, J., 2013. A Validated approach to
to influence the work reported in this paper. evaluating psychometric properties of pain assessment tools for use in
nonverbal critically Ill adults. Semin. Respir. Crit. Care Med. 34, 153–168.
https://doi.org/10.1055/s-0033-1342970.
Acknowledgements Gélinas, C., Fillion, L., Puntillo, K.A., Viens, C., Fortier, M., 2006. Validation of the
critical-care pain observation tool in adult patients. Am. J. Crit. Care 15, 420–
427.
The authors would like to thank the observers for their support Gerber, A., Thevoz, A.L., Ramelet, A.S., 2014. Expert clinical reasoning and pain
and their flexibility. assessment in mechanically ventilated patients. A descriptive study. Aust Crit
Care. https://doi.org/10.1016/j.aucc.2014.06.002.
Hagino, C., 2002. A brief overview of the development process for written, self-
References report, health-related surveys. J. Can. Chiropr. Assoc. 46, 11–21.
Handel, E. (Ed.), 2010. Praxishandbuch ZOPAÓ. Schmerzeinschätzung bei Patienten
Abuatiq, A., 2015. Patients’ and health care providers’ perception of stressors in the mit kognitiven und /oder Bewusstseinsbeeinträchtigungen. Huber, Bern.
intensive care units. Dimens. Crit. Care Nurs. 34, 205–214. https://doi.org/ Kapoustina, O., Echegaray-Benites, C., Gélinas, C., 2014. Fluctuations in vital signs
10.1097/DCC.0000000000000121. and behavioural responses of brain surgery patients in the Intensive Care Unit:
Ahmadi-Motamayel, F., Shahriari, S., Goodarzi, M.T., Moghimbeigi, A., Jazaeri, M., are they valid indicators of pain? J. Adv. Nurs. 70, 2562–2576. https://doi.org/
Babaei, P., 2013. The relationship between the level of salivary alpha amylase 10.1111/jan.12409.
8 M.R. Fröhlich et al. / Intensive & Critical Care Nursing 60 (2020) 102874

Landis, J.R., Koch, G.G., 1977. The measurement of observer agreement for Puntillo, K., Miaskowski, C., Kehrle, K., Stannard, D., Gleeson, S., Nye, P., 1997.
categorical data. Biometrics 33, 159–174. Relationship between behavioural and physiological indicators of pain, critical
Li, D., Puntillo, K., Miaskowski, C., 2008. A review of objective pain measure for use care patients’ self-reports of pain, and opioid administration. Crit. Care Med. 25,
with critical care adult patients unable to self-report. J. Pain 9, 2–10. https://doi. 1159–1166. https://doi.org/10.1097/00003246-199707000-00017.
org/10.1016/j.jpain.2007.08.009. Rose, L., Smith, O., Gélinas, C., Haslam, L., Dale, C., Luk, E., Burry, L., McGillion, M.,
Lindenbaum, L., Milia, D.J., 2012. Pain management in the ICU. Surg. Clin. North Am. Mehta, S., Watt-Watson, J., 2012. Critical care nurses’ pain assessment und
92, 1621–1636. https://doi.org/10.1016/j.suc.2012.08.013. management practice: a survey in Canada. Am. J. Crit. Care 21, 251–259. https://
Liu, H., Dong, W.Y., Wang, J.B., Wang, T., Hu, P., Wei, S.F., Ye, L., Wang, Q.W., 2013. doi.org/10.4037/ajcc2012611.
Association between salivary a-amylase activity and pain relief scale scores in Savaskan, E., Baumgartner, M., Georgescu, D., Hafner, M., Hasemann, W., Kressig, R.
cancer patients with bone metastases treated with radiotherapy. Chin. Med. J. W., Popp, J., Rohrbach, E., Schmid, R., Verloo, H., 2016. Empfehlungen zur
(Engl.) 126, 4444–4447. Diagnostik, Prävention und Therapie des Delirs im Alter. Praxis 105, 941–952.
Lukaszewicz, A.C., Dereu, D., Gayat, E., Payen, D., 2015. The relevance of Snedecor, G.W., Cochran, W.G., 1989. Statistical Methods. Iowa State University
pupillometry for evaluation of analgesia before noxious procedures in the Press, Ames, IA.
intensive care unit. Anesth. Analg. 20, 1297–1300. https://doi.org/10.1213/ Streiner, D.L., Norman, G.R., 2008. Health Measurement Scales. A practical guide to
ANE.0000000000000609. their development and use. Oxford University Press, Oxford.
Maneesriwongul, W., Dixon, J.K., 2004. Instrument translation process: a methods Timmers, T.K., Verhofstad, M.H., Moons, K.G., van Beeck, E.F., Leenen, L.P., 2011.
review. J. Adv. Nurs. 48, 175–186. https://doi.org/10.1111/j.1365- Long-term quality of life after surgical intensive care admission. Arch. Surg. 146,
2648.2004.03185.x. 412–418. https://doi.org/10.1001/archsurg.2010.279.
Middleton, C., 2003. Understanding the physiological effects of unrelieved pain. Uesato, M., Nabeya, Y., Akai, T., Inoue, M., Watanabe, Y., Kawahira, H., Mamiya, T.,
Nurs. Times 99, 28–31. Ohta, Y., Motojima, R., Kagaya, A., Muto, Y., Hayashi, H., Matsubara, H., 2010.
Myhren, H., Ekeberg, O., Toien, K., Karlsson, S., Stokland, O., 2010. Posttraumatic Salivary amylase activity is useful for assessing perioperative stress in response
stress, anxiety and depression symptoms in patients during the first year post to pain in patients undergoing endoscopic submucosal dissection of gastric
intensive care unit discharge. Crit. Care 14, R14. https://doi.org/10.1186/cc8870. tumors under deep sedation. Gastric Cancer 13, 84–89. https://doi.org/10.1007/
Odhner, M., Wegman, D., Freeland, N., Steinmetz, A., Ingersoll, G., 2003. Assessing s10120-009-0541-8.
pain control in nonverbal critically ill adults. Dimens. Crit. Care Nurs. 22, 260– Varndell, W., Fry, M., Elliott, D., 2016. A systematic review of observational pain
267. https://doi.org/10.1097/00003465-200311000-00010. assessment instruments for use with nonverbal intubated critically ill adult
Paulus, J., Roqilly, A., Boloeil, H., Theraud, J., Asehnoune, K., Lejus, C., 2012. Pupillary patients in the emergency department: an assessment of their suitability and
reflex measurement predicts insufficient analgesia before endotracheal psychometric properties. J. Clin. Nurs. 26, 7–32. https://doi.org/10.1111/
suctioning in critically ill patients. Crit. Care 17, R161. https://doi.org/ jocn.13594.
10.1186/cc12840. Vázquez, M., Pardavila, M.I., Lucia, M., Aguado, Y., Margall, M.A., Asiain, M.C., 2011.
Payen, J.F., Bru, O., Bosson, J., Lagrasta, A., Novel, E., Deschaux, I., Lavagne, P., Jacquot, Pain assessment in turning procedures for patients with invasive mechanical
C., 2001. Assessing pain in critically ill sedated patients by using a behavioural ventilation. Nurs. Crit. Care 16, 178–185. https://doi.org/10.1111/j.1478-
pain scale. Crit. Care Med. 29, 2258–2263. https://doi.org/10.1097/00003246- 5153.2011.00436.x.
200112000-00004. Mikkelsen, M. E., Netzer, G., Iwashyna, T., 2019. Post-intensive care syndrome
Pittman, J., Bakas, T., 2010. Measurement and instrument design. J. Wound, Ostomy (PICS). https://www.uptodate.com/contents/post-intensive-care-syndrome-
Continence Nurs. 37, 603–607. https://doi.org/10.1097/ pics (accessed 19.08.30)
WON.0b013e3181f90a60. International Conference on Harmonization of Technical Requirements for
Pudas-Tähkä, S.M., Axelin, A., Aantaa, R., Lund, V., Salanterä, S., 2009. Pain Registration of Pharmaceuticals in Human Use, 1996. ICH harmonized
assessment tools for unconscious or sedated intensive care patients: a tripartite guideline. Guideline for good clinical practice E& (R1). https://www.
systematic review. J. Adv. Nurs. 65, 946–956. https://doi.org/10.1111/j.1365- ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6/E6_
2648.2008.04947.x. R1_Guideline.pdf (accessed 19.09.16).
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.