A Voice for the Nonverbal Patient

Mar 03, 2020

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When I started as a bedside ICU nurse in the ‘90s, we had no tool to assess pain. I felt that something had to be done.

Céline Gélinas

In the ICU, recognizing and managing a patient’s pain is especially difficult when they’re unconscious, sedated or have delirium. In 1996, when Céline Gélinas became an ICU nurse, she says, “There was no tool to assess pain in nonverbal patients, and I felt powerless.” So she did some¬thing about it. As Gélinas earned her PhD in nursing she also developed the Critical-Care Pain Observation Tool (CPOT), a behavioral scale to assess pain in critically ill adults unable to self-report, which is used by nurses around the world. Gélinas — now an associate professor at McGill University Ingram School of Nursing and researcher at Centre for Nursing Research and Lady Davis Institute of the Jewish General Hospital in Montreal — received the AACN 2019 Pioneering Spirit Award.

What led you to this research and creation of the CPOT?

Pain management in the ICU is highly challenging. My bedside practice was my inspiration to pursue graduate studies in nursing research. In the ICU, a high proportion of patients cannot self-report their pain due to their critical care condition, which may cause altered levels of consciousness and require the use of sedative agents. Also, many patients cannot provide a reliable self-report of pain due to delirium. Therefore, often the nurse doesn’t have access to the patient’s self-report — the gold standard measure of pain. When I started as a bedside ICU nurse in the ‘90s, we had no tool to assess pain. I had to advocate for nonverbal patients who I thought were in pain but did not receive adequate treatment for pain relief. I felt that something had to be done.

I completed my PhD in nursing and measurement. The CPOT was initially created in French — my mother tongue — and back-translated into English for further validation during my postdoctoral fellowship in nursing. Since then, the CPOT has been translated into more than 15 languages and used in ICUs in over 20 countries. Several guidelines and position statements also recommend the CPOT, and my team and I are working on a project to implement best pain management guidelines into ICU practice in Canada.

Describe how nurses use the CPOT and how it has evolved.

The CPOT includes four items — facial expression, body movements, muscle rigidity, and compliance with the ventilator or vocalization according to the patient’s condition — each rated from 0 to 2, for a total score from 0 to 8. The patient should be assessed for pain regularly at rest over one minute observation, during procedures or activity, as well as before and at the peak effect of an analgesic, to evaluate its effec¬tiveness. The highest score observed is attributed to each item. Muscle rigidity should be evaluated last, especially at rest because it requires the passive flexion and extension of the patient’s arm to feel any resistance to movements, which may lead to behavioral reactions. A total score greater than 2 usually indicates pain. It’s important to emphasize that the scoring reflects the intensity of pain-related behaviors and not the self-report of pain intensity.

Throughout its validation process with different ICU patient clienteles, many nurses pointed out that certain behaviors are specific to patients with a brain injury or cerebral stroke. Brain-injured ICU patients with an altered level of consciousness are less likely to grimace, and other reactions are observed, including tearing and face flushing. In accordance with expert opinions and clinical observations, we’ve made some changes to the original version of the tool for this clientele and named it the CPOT-Neuro, which is available in English and French. Its use has been validated in some ICU settings in Canada and the United States. We are finalizing a paper for publication.

When you received your Pioneering Spirit Award, the audience had a rousing reaction to you and your fellow recipients.

I couldn’t believe I was there receiving this prestigious award. Being onstage with highly accomplished leaders with distinguished careers in critical care nursing and medicine was unbelievable. During the presentation of awardees, Sharon Inouye took my hand, and I could feel the vibrant emotions we were both sharing. I was shaking and trying not to burst into tears.

Having Kathleen Puntillo [professor of nursing emeritus, University of California, San Francisco] introduce me meant a lot. She and I have a long history together. She is a close colleague and a mentor who has inspired me so much and supported me since I was a PhD student. When I walked toward her, I could not contain my emotions and tears were shed. It was a unique and profound moment for me. My daughter was in the audience, and I could feel her presence next to me. I could not have achieved these goals without the support of a wonderful team of mentors, colleagues and students, and my family’s love.

The true heroes of effective ICU pain management are the nurses at the patient’s bedside, the educators who disseminate evidence-based nursing practice to their colleagues and to students, and the nurse managers who support changes in practice for the best care. It’s only together that we make a huge difference.

What was your daughter’s reaction to watching you being honored?

I asked my daughter to answer this question. Here’s her response: “I was very surprised. I didn’t know my mom’s work had such a big impact in critical care nursing. I didn’t know that her project was so well-known in the world. I’m proud of her because she really works hard, and congratulating her for the CPOT was significant as it’s an accomplishment that means a lot to her. It proves that hard work pays off.”

What’s your advice for nurses who want to enact change, improve care and embark on research?

When I look back on my own path, I have three key ingredients to share:

  • Believe in yourself. You can achieve any goals if you believe.
  • Let your passion guide you. It’s your driving energy to move forward.
  • Build a team. You can achieve more together. Stay open to people who will inspire, guide and support you, but also those who challenge you constructively.

What do you and your family like to do for fun?

We [her husband and three children] went to Disney World this past year. We had a lot of fun and walked more than 100 kilometers in a week! Avatar Flight of Passage was our favorite attraction — flying on a dragon was a unique and pleasant feeling. My husband and son enjoyed the new Star Wars attractions. My daughters preferred the Aerosmith Rock ’n’ Roller Coaster.

I am an animal and nature lover. I share a passion with my daughters as a horseback rider. This sport allows me to develop a relationship with a horse and to fully focus my mind on the here and now. Horses are very sensitive and easily feel a human’s stress. They rely on their rider to guide them during training and to keep focus. Having a passion unrelated to my job allows me to achieve work-life balance and remain healthy.

What else would you like our readers to know about you?

I am so proud to be a nurse! Nursing is about caring, is based on strong science and on human qualities. As nurses, we can play different roles, and we have the power to make a real difference in patient and family care.