Optimising pain management in intensive care setting: Insights from a realist evaluation.

Background: Inconsistent pain management in intensive care settings contributes to poor patient outcomes and prolonged hospital stays. Implementing evidence-based pain management strategies is critical to mitigating complications, such as oversedation and excessive analgesia. The process is inherently complex, requiring an exploration of contextual factors that enable implementation, the mechanisms triggered within these contexts, and strategies to enhance stakeholder engagement. Objective: In this discussion paper, we examined sociocultural, organisational, professional, and individual factors influencing the implementation of pain management interventions in intensive care settings. We considered their implications for diverse stakeholders and have offered evidence-informed recommendations to strengthen implementation. Information Source: In this discussion we synthesise findings from a theory-driven, three-phase realist evaluation that examined and refined program theories related to successful implementation of pain management interventions. Phase one involved a scoping review of the literature and a survey with open-ended questions to elicit initial program theories. Phases two and three comprised a rapid realist review followed by stakeholder interviews to iteratively refine these theories. Results: Interventions succeed or fail not solely based on design but within complex contexts where knowledge, power, and professional identity intersect. Across micro, meso, and macro levels of care, mechanisms such as empowerment, moral distress, and institutional trust influenced intensive care nurses' willingness and capacity to adopt interventions. Biomedical hierarchies may marginalise nursing knowledge, while interprofessional hierarchies and organisational cultures can either constrain or enable meaningful change. Conclusion: We have advanced critical nursing scholarship by conceptualising pain management not merely as a clinical intervention but as a socially embedded practice. We have offered implications for educators, policymakers, nurse leaders, and practitioners to promote equitable, context-sensitive strategies for implementing pain management interventions, thereby possibly enhancing clinical practice and improving patient outcomes.