Bakgrund: Smärta är för intensivvårdspatienten en unik, subjektiv, obehaglig och flerdimensionell upplevelse. Intensivvårdssjuksköterskan har ett moraliskt ansvar att lindra patienternas smärta. Verbalt icke-kommunicerandepatienter kan inte skatta sin smärta med hjälp av Numeric Rating Scale (NRS). På en neurointensivvårdsavdelning (NIVA) i Stockholm har det beteendebaserade smärtskattningsverktyget- the Critical-Care Pain Observation Tool (CPOT), implementerats. Intensivvårdssjuksköterskorna på NIVA använder CPOT dagligen i sitt arbete. Som en del i implementeringsprocessen har denna enkätundersökning genomförts, med fokus på CPOT och dess användbarhet. Standarden ISO 9241-11 definierar begreppet användbarhet. Ledande komponenter i definitionen är – ändamålsenlighet och måluppfyllelse, effektivitet och tillfredsställelse. Syfte: Syftet med denna studie var att undersöka intensivvårdssjuksköterskors uppfattningar om användbarheten av the Critical-Care Pain Observation Tool – CPOT, hos verbalt icke kommunicerande patienter, på en neurointensivvårdsavdelning. Metod: Detta är en kvantitativ icke-experimentell tvärsnittsstudie. 32 intensivvårdssjuksköterskor har besvarat en enkät. Resultat och slutsats: Resultatet är en momentan mätning. Begreppet användbarhet har flera aspekter och resultatet kan tolkas på olika sätt. Intensivvårdssjuksköterskorna på NIVA har olika uppfattningar om CPOT och dess användbarhet. 84 % känner någon grad av tillfredsställelse med att använda CPOT på NIVA. De flesta uppfattar CPOT som effektiv. Respondenter har uttryckt svårigheter i att utföra smärtskattningar med hjälp av CPOT och delar av populationen ser brister i verktygets måluppfyllelse och ändamålsenlighet på NIVA. Klinisk betydelse: Implementeringsprocessen av CPOT på NIVA har en utvecklingspotential. Undersökningens resultat bör kunna användas vid fortsatt utvecklingsarbete i verksamheten. / Background: Pain for the intensive care patient is a unique, subjective, unpleasant and multidimensional experience. The critical care nurse has a moral duty to relieve the patient’s pain. Non-verbal communicative intensive care patients can´t self-report and score their pain using the Numerical Rating Scale (NRS). At a neurological intensive care unit (neuro-ICU) in Stockholm, one behavior based pain scale, the Critical-Care PainObservational Tool (CPOT), has been implemented. The critical care nurses at the neuro-ICU use CPOT daily in their work. As a part of to the implementation process one self-administered questionnaire has been conducted with focus on the concept usability. The European Standard ISO 9241-11 defines the concept usability. Main components in the definition are the attainment of goals, suitability, effectiveness and satisfaction. Purpose: The aim of this research was to investigate critical care nurses’ perceptions of the usability of the Critical-Care Pain Observation Tool – CPOT, for non-verbal communicative patients, at a neurological intensive care unit. Method: The investigation is a quantitative questionnaire-based cross-sectional survey. 32 critical care nurses answered a questionnaire. Results and conclusion: The result is a momentary measurement. The concept usability has various aspects and the result can be interpreted in different ways. The critical care nurses at the neuro-ICU express varying opinions about CPOT and its usability. 84 % experience some degree of satisfaction using CPOTat the neuro-ICU. The majority perceive CPOT as effective. The respondents have expressed difficulties in carrying out pain assessments with the CPOT at the neuro-ICU, and part of the population see deficiencies in the tools goal attainment and suitability at the neuro-ICU. Clinical Significance: The implementation process of CPOT at the neuro-ICU shows potential for further development of CPOT within the organization. The results of the investigation should be able to be used for further development.

Bakgrund: Smärta hos intensivvårdspatienter är vanligt förekommande och kan medföra förlängd vårdtid och leda till flera negativa konsekvenser för patienten samt bidra till ökad mortalitet. Smärtskattning med ett validerat smärtskattningsinstrument som Critical-Care Pain Observation Tool (CPOT) kan underlätta smärtskattningen och förbättra smärtbehandlingen samt minska översedering. Syfte: Syftet med denna studie är att beskriva om införandet av smärtskattningsverktyget CPOT, anpassat för patienter i ventilatorbehandling, påverkar dygnsdoserna av smärtlindrande- och sederande läkemedel samt om sederingsbehandlingen förändras. Syftet är även att undersöka hur ofta sjuksköterskorna smärtskattar patienterna med CPOT och om antalet smärtskattningar överensstämmer med gällande rekommendationer. Metod: Kvantitativ journalgranskningsstudie med retrospektiv design. Vuxna patienter som ventilatorbehandlades under minst ett dygn på en intensivvårdsavdelning i Sverige inkluderades (n=55). Resultat: Totalt 55 patienter inkluderades i två grupper, före och efter införandet av CPOT. Doserna av smärtlindrande läkemedel ökade i gruppen som undersöktes efter att CPOT infördes. Patienterna erhöll i genomsnitt 1,4 mg morfin/kg/dygn jämfört med 1,1 mg morfin/kg/dygn innan införandet. Dosen av det sederande läkemedlet Propofol® minskade efter införandet av CPOT från 48,3 mg/kg/dygn till 47,5 mg/kg/dygn. Alla patienter i studiegruppen förutom två (92 %) smärtskattades vid minst ett tillfälle under mätdygnet efter införandet av CPOT. Slutsats: Doserna av smärtlindrande läkemedel var högre och doserna av det sederande läkemedlet Propofol® var lägre efter införandet av CPOT. Skillnaderna var dock inte statistiskt signifikanta. Patienterna i studiegruppen hade en något ytligare sederingsnivå enligt RASS-skalan. Patienterna smärtskattades med CPOT i genomsnitt 1,6 gånger under mätdygnet. Studien kan bidra till en ökad medvetenhet om vikten av att skatta smärta med ett validerat bedömningsinstrument hos intensivvårdspatienter. / Background: Critically ill intensive care patients frequently experience pain and pain may lead to consequences such as prolonged length of hospital stay and increased mortality. The Critical-care Pain Observation Tool (CPOT) is a validated tool for pain assessment in mechanical ventilated patients and is used to enable pain assessment, improve pain management and reduce over-sedation.  Aim: The aim is to examine if the implementation of CPOT affects the doses of analgetics, sedatives administered to the Intensive Care Unit (ICU) patients and/or the sedation levels using RASS-scores. The aim was also to study how often pain-assessments were performed by nurses. Method: A quantitative study with retrospective design, data was collected from patients’ medical records. Included were adult patients treated under mechanical ventilation >24h at an intensive care unit in Sweden (n=55). Results: For this study 55 patients were included and divided into two groups, before and after the introduction of CPOT at the intensive care unit. The amount of analgetics increased among the patients after CPOT was implemented, they were given 1,4 mg of morphine/kg/24h compared to 1,1 mg of morphine/kg/24h before the implementation. The amount of sedatives, Propofol®, given to the patients decreased from 48,3 mg/kg/24h to 47,5 mg/kg/24h after CPOT was implemented. CPOT was used to assess pain levels in all patients except for two (98%) after the implementation of CPOT. Conclusion: The doses of analgetics were higher and the doses of sedatives (Propofol®) were lower after the implementation of CPOT. However, the differences between groups were not statistically significant. Patients were less sedated, according to RASS-scores, after the implementation of CPOT. Nurses used CPOT on an average 1, 6 times/ 24 h. This study can be used to increase the awareness for the need of using a validated tool for assessing pain in ICU-patients.

Previous research has established that observing another in pain activates both affective and sensorimotor cortical activity that is also present during the first-hand experience of pain. Some researchers have taken this “mirroring” response as indicative of empathic processing. However, very little work has explored the downstream behavioral effects of empathic pain observation. The aim of this dissertation is to begin to fill this gap in the literature by exploring the relationship between empathic pain observation, overt motor behaviours, and sensorimotor activity. In chapters 2-4, I provide robust evidence that observing pain inflicted on another person leads to faster reaction time responses. This effect is shown to be temporally extended (by at least 500ms after pain observation), effector-general (affecting both finger and foot responses), influenced by top-down (i.e., instructions to explicitly empathize) but not bottom-up (i.e., the perceived level of pain) factors, and is not influenced by adaptive (approach/withdraw) behaviours. In chapter 5, I show that sensorimotor activity, measured via TMS-induced Motor Evoked Potentials, increases while observing another in pain regardless whether the observer is preparing to make an action vs. passively observing the stimuli. These results run counter to the literature, and I provide several explanations for why these results were found. Lastly, in chapter 6, I show that sensorimotor activity, measured via Mu and Beta suppression, also increases while observing another in pain regardless whether the observer is preparing to make an action vs. passively observing the stimuli. Interestingly, I do not find significant correlations between sensorimotor activity during pain observation and faster reaction times after pain observation. I embed these findings in relation to the wider social neuroscience of empathy literature and discuss several limitations and challenges in empirically measuring “empathy” as a psychological construct. Overall, this dissertation furthers our understanding of empathy for pain by highlighting the behavioural consequences of pain observation and its connection (or rather, lack thereof) to sensorimotor activity during pain observation. / Thesis / Doctor of Philosophy (PhD) / Past research suggests that overlapping brain activity during the first-hand experience of pain and pain observation may be indicative of empathy. However, very little work has been done to explore how pain observation influences overt behaviours. This thesis investigates this issue by having participants complete a reaction time task while watching videos of needles stabbing a person’s hand. The findings reported in this thesis suggests that observing another in pain facilitates motor behaviours (i.e., faster reaction times); this facilitation extends 500ms after pain observation, affects both the hand and feet, is accentuated by instructing participants to explicitly empathize, and is not influenced by approach vs. withdraw movements. Brain activity in the motor system was also found to increase during pain observation. Overall, this thesis begins the discussion of how empathic pain observation influences explicit motor behaviours, and how such behaviours may be related to brain activity.

Bakgrund: Smärta är ett flerdimensionellt fenomen och ett vanligt problem inom äldrevården. Smärtbehandling finns att tillgå, trots detta är smärta underbehandlat hos äldre patienter. Syftet: Syftet med studien är att belysa hur sjuksköterskor bedömer fysisk smärta i omvårdnad av äldre patienter. Metod: Litteraturöversikt med kvalitativ ansats har använts. Datamaterialet bestod av fem kvantitativa och fyra kvalitativa vetenskapliga artiklar. Resultat: Det framkom tre huvudkategorier: smärtbedömningsprocesser, smärtbedömningsmetoder och smärtbedömningsredskap. Ur huvudkategorierna urskildes sex underkategorier: smärtidentifiering, smärtbedömningssvårigheter, kommunikation med patienterna för att bedöma smärta, smärtobservation, smärtbedömningsinstrument och dokumentation. Slutsatser: För att göra en smärtbedömning behövs en god relation till patienten, närstående och övrig personal där kommunikation har central roll. Sjuksköterskan måste tro på patientens egen skattning och smärtupplevelse. / Background: Pain is a multidimensional phenomena and a common problem in care of elderly patients. There are several pain treatment methods available however pain is often not fully treated. Aim: The aim of this study is to illustrate how nurses assess physical pain in care of elderly patients. Method:  A literature review based on a qualitative approach has been used. The study consists of an analysis of five quantitative and four qualitative research articles.  Results: Three main categories were found: the process of pain assessment, the methods of pain assessment and the tools of pain assessment. Those categories were further divided into six subcategories: pain identification, pain assessment difficulties, patient communication to assess pain, pain observations, pain assessment instruments and documentation. Conclusions: Pain assessment requires a good relation to the patient as well as relatives and other staff. Communication takes a central part of the pain assessment. A nurse must believe in the patient's own estimation and pain perception.