Abstract
This study compared how nurses perceived their assessment of infant pain and how the pain was actually assessed in an intensive care unit. A descriptive design was used to collect data about nurses' beliefs and documentation practices related to pain assessment in infants. An anonymous subset of the unit nurses (n = 24) responded to a questionnaire regarding infant pain assessment. Pain assessment documentation of the unit nurses was examined in a retrospective chart review (n = 107). Results showed an inconsistency between what nurses believe about infant pain assessment and the documentation practice in the unit. According to the questionnaire, the nurses believed that pain assessment was important to providing effective pain relief and that nurses are capable of assessing infant pain. However, it was not evident in the documentation that nurses used pain tools or other means to document their evaluations of infant pain or the infant's response to pain medication interventions. Conclusion: Greater consistency of nurses in documenting pain assessment, thereby improving care provider communication of an infant's pain experience, is needed to improve the standard of care in managing infant pain.