Background: Pain recognition and assessment in individuals with profound intellectual disabilities are challenging. Exploring effective methods of addressing this is essential. This study aims to discover current nursing practice in this area of care as the first of a four-phased appreciative inquiry study, to inform further research and practice. Methods: Data from individual and focus group interviews with co-researching nurses were collated and developed into themes. Results: Six themes were identified: unconditional positive regard, honouring of relationship, creative best practice, pain through a competing lens, accurate assessment--an impossible task? Medicating pain-oversimplified and undervalued? Conclusion: Relationship is essential, in recognising pain and distress. There is an understanding of the multifaceted nature of pain in the care of this population; however, physical pain recognition and assessment are prioritised, to prevent serious ill health and death. Formal methods of assessment and communication between professionals are needed.