Barriers to cancer pain management: home-health and hospice nurses and patients

Goals Undertreatment of cancer pain remains a major health-care problem. We utilized focus groups of hospice and home-health nurses and patients to elucidate factors contributing to inadequate pain management and to generate solutions for closing the gap between the current reality and optimal pain management.Patients and methods Focus groups were conducted among hospice and home-health-care nurses (two groups; n=22) and patients (six groups; n=54) using a standardized question guide. Audiotapes were transcribed and analyzed using NUD*IST software. Themes discovered among patients and nurses were analyzed for similarities and differences.Main results Of 22 participants in the two home-health and hospice nurses focus groups, all were white women, the average age was 43 (range 29–64) years, and the average number of years in nursing was 21 (range 8–47) years. Of 54 participants in the six cancer patient focus groups, 80% were women, the average age was 54 (range 25–76) years, and 76% were white. Fifty-four percent of patients reported a history of pain associated with their cancer, and almost 30% had pain that they rated as 8 or higher on the pain scale. Barriers to adequate pain management fell into four categories: fears; attitudes, beliefs, and values; patient and provider behaviors; and structural barriers. Patients and nurses reported similar barriers to pain management; however, patients identified more barriers related to provider behavior and structure of the health care system.Conclusions This study identified several barriers to cancer pain control not previously identified in the literature. Strategies to improve cancer pain control are suggested.     

Treating cancer-related pain in the emergency department: the emergency nurse's role.

Ask for and believe the patient's report of pain, use a preventive approach, combine opioids and nonopioids when possible, and consider adjuvant drugs for neuropathic pain not relieved by an adequate trial of opioids and NSAID. Remain a patient advocate through careful assessment and reassessment of the patient and informative collaboration with the physician and other colleagues. Anticipate and treat side effects, and identify and address pain myths held by patients and families that interfere with sound pain management practices. Establish mutually set goals and direct the patient to necessary follow up. Emergency nurses can do much to alleviate unnecessary suffering and improve quality of life for patients with cancer who come to the emergency department for help.     

Cancer pain education: a structured clinical instruction module for hospice nurses.

The learning experience with the Cancer Pain Structured Clinical Instruction Module (SCIM), a highly structured skills training course for medical students, has been reported favorably. The purpose of this study was to present the Cancer Pain SCIM to registered nurses employed in a hospice setting. The goal of the study was to pilot test a structured cancer pain educational program for hospice nurses and to determine the perceived effectiveness of this course on the participants' cancer pain assessment and management skills. A multidisciplinary Cancer Pain SCIM was presented to 25 hospice nurses to improve their understanding of the management of cancer pain. The development group identified essential aspects of cancer pain management and then developed checklists defining specific station content. During the 2-hour Cancer Pain SCIM, nurses rotated through 8 stations in groups of 3, spending 15 minutes at each station. Eight instructors and 6 standardized patients, 5 of whom were survivors of cancer, participated in the course. All participants (students, instructors, and patients) evaluated the course, using a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree). Nurses provided self-assessments of their perceived competence on important aspects of cancer pain management both before and after the SCIM. The self-assessment items used a 5-point scale ranging from 1 (not competent) to 5 (very competent). Twenty-five hospice nurses, averaging 4.1 years (range 1-30 years) postgraduation, participated in the Cancer Pain SCIM. Overall, nurses agreed that they improved on each of the 8 teaching items (P < 0.001). The average (SD) pretest score of 2.8 (0.72) improved to 3.8 (0.58) on the post-test (P < 0.001). Nurses believed that their mastery of specific clinical skills, taught in all 8 stations, improved as a result of participation in the course. Nurses strongly agreed (mean +/- SD) that it was beneficial to use patients with cancer in the course (4.6 +/- 0.82). Faculty members enjoyed participating in the course (4.9 +/- 0.35) and indicated a willingness to participate in future courses (4.7 +/- 0.49). Significant perceived learning among hospice nurses took place in all aspects of the Cancer Pain SCIM. Participating nurses, instructors, and patients with cancer appreciated the SCIM format. Nurses and faculty considered the participation of actual patients with cancer highly beneficial. The SCIM format has great potential to improve the quality of cancer pain education.     

A Descriptive Study of the Management of Pain and Pain-Related Side Effects in a Cancer Center and a Hospice

The purpose of this study was to describe the pain and pain-related symptoms experienced by persons receiving treatment in a cancer center or a hospice and to describe the nurses’ responses to these problems. The sample consisted of 25 hospice and 19 cancer center patients who were being treated for pain. Pain was assessed three times in a 24-hour period using a visual analogue scale (VAS). Constipation was assessed using the Constipation Assessment Scale. Sedation was assessed on a 0 (fully alert) to 4 (comatose) scale. The nurses’ documentation was assessed using the Chart Audit for Pain. Results showed that patients in the cancer center and hospice continued to experience pain (VAS M?=?38.6 and 29.7 respectively) in spite of their pain management regimens. The cancer center patients were given an average of 38% of the maximum ordered dose of analgesic while the hospice patients self-administered 93% of the ordered dose. The cancer center nurses documented the efficacy of the analgesics in only 26% of cases while hospice nurses recorded this information in 96% of the charts. Sedation was not found to be a problem. Constipation was reported by 100% of cancer center patients and 84% of hospice patients but was rarely documented by nurses in either setting. It appears that nurses need to do more thorough assessment of patient symptoms and more consistent follow-up evaluation and documentation.     

Pediatric nurses' knowledge and attitudes survey regarding pain

PURPOSE: The purpose of this study is to determine pediatric nurses' current attitudes and knowledge regarding pain. METHOD: The Pediatric Nurses' Knowledge and Attitudes Regarding Pain Survey was completed by a convenience sample of 274 nurses at a large children's medical center. RESULTS: Sixty-six percent of the questions were answered correctly. Nurses with their master's degree scored significantly higher (75%). Hematology/oncology nurses (76%), nurses from the intensive care unit (71%), and emergency room nurses (70%) scored significantly higher than nurses from other patient care units. CONCLUSIONS: Pain management knowledge deficiencies were identified, including assessment; pharmacologic management with opioids, nonopioids, and adjuvant medications; risks of addiction; risks of respiratory depression; nonpharmacologic pain interventions; and the treatment of procedural pain, surgical pain, and cancer pain.     

Nurses' attitudes and practices in sickle cell pain management

Professional objectivity should be the primary focus of patient care. Health care professionals are at times reluctant to give opioids out of fear that patients may become addicted, which would result in the undertreatment of pain. The influence of nurses' attitudes on the management of sickle cell pain was studied. The variables of age, education, area of practice, and years of active experience were considered. Of the respondents, 63% believed addiction was prevalent, and 30% were hesitant to administer high-dose opioids. Study findings suggest that nurses would benefit from additional education on sickle cell disease, pain assessment and management, and addiction. Educational recommendations are discussed.     

Barriers to effective symptom management in hospice

The barriers to effective symptom management in hospice are not well described. We surveyed nurses of hospices affiliated with the Population-based Palliative Care Research Network (PoPCRN) to identify barriers to the effective management of common symptoms in terminally ill patients. 867/1710 (51%) nurses from 67 hospices in 25 U.S. States returned surveys. Of 32 symptoms, nurses reported agitation (45%), pain (40%), and dyspnea (34%) as the 'most difficult to manage.' The most common perceived barriers to effective symptom management were inability of family care providers to implement or maintain recommended treatments (38%), patients or families not wanting recommended treatments (38%), and competing demands from other distressing symptoms (37%). Patterns of barriers varied by symptom. These nurses endorsed multiple barriers contributing to unrelieved symptom distress in patients receiving hospice care. Interventions to improve symptom management in hospice may need to account for these differing barrier patterns.     

Acute musculoskeletal pain in the emergency department: a review of the literature and implications for the advanced practice nurse

Acute pain assessment and management and their accurate documentation have been identified by The Joint Commission on the Accreditation of Healthcare Organization as significant components of the emergency department experience. Research studies have historically focused on the subjective perception of the physician or nurse for evidence of acute musculoskeletal pain assessment for the patient; however, the lack of interrater reliability between caregivers and patients has illustrated the need to evaluate the patient's perception of pain. A review of the literature for acute musculoskeletal pain in the emergency department shows that a patient's pain experience is often underestimated, and severity of pain often does not predict pain management. Relying on patient satisfaction surveys as a surrogate marker for effectiveness of pain management is inadequate, and factors, such as age, gender, or ethnicity, may contribute to a disparity in pain management. The purpose of this article is to review pain management practices for patients with acute musculoskeletal pain who present to the emergency department and to provide recommendations for advanced practice nurses working with this emergency department patient population. Promising areas for future research include targeting mechanisms of pain with specific medications, identifying vulnerable populations at risk for inadequate pain management, and universal use of a standardized pain rating scale.     

Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting

This study examined differences in the assessment of symptoms and quality of life (QoL) between patients with advanced cancer living at home and their specialist palliative care nurses. Nurses introduced a recently validated outcome measure, the Palliative Care Outcome Scale (POS), to patients referred to their hospice at their first or second home visit. The POS has two components: a patient questionnaire mirrored almost exactly by a staff questionnaire, which are both completed independently. The POS contains 10 core questions examining aspects of symptom control and QoL. Of the 338 patients referred during the study period, 174 (51%) were eligible for inclusion in the study. Of these, 55 (32%) pairs of patient and nurse questionnaires were returned and suitable for assessment. Not all questionnaires were returned by nurse and patient to form a matched pair. There was good agreement and correlation between patients and nurses in the assessment of pain and symptom control. However, important differences were found in other areas explored including anxiety levels of patients and their families, personal thoughts, practical matters and information received. The study confirms the importance of evaluating the needs, feelings and concerns of patients with advanced cancer cared for at home and highlights both the significance and necessity of the patient's contribution to any such assessment.     

Pain assessment in critical care: what have we learnt from research.

Despite an ongoing acknowledgement in the literature that pain is a significant problem within the critical care environment, this issue has not been adequately addressed by critical care nurses. This paper examines strategies for changing pain management practices in critical care, including reviewing documentation practices, the utilisation of guidelines and algorithms to augment clinical decision making, and increasing educational opportunities available to critical care nurses. It is recommended that pain assessment be given a higher priority within the clinical context, particularly as inadequate pain assessment and management has been linked to increased morbidity and mortality within critical care. Importantly, critical care nurses need to not only be aware of research-based pain management practices, but also lead the way in implementation and continuous evaluation as a measure of decreasing patient pain in the future.     

Elderly pain assessment and pain management knowledge of long-term care nurses.

The purpose of this study was to determine the knowledge base of long-term care nurses regarding pain assessment and management in the elderly. Three specific themes related to long-term care nurses were investigated: personal beliefs regarding patients' self-reports of pain, documentation of patients' self-reports of pain, and choice of pain medication and dose. Eighty-nine long-term care nurses, from 6 rural counties in California, responded to a questionnaire that consisted of 2 patient scenarios. The scenarios portrayed 1 patient as smiling and showing no objective signs of pain and the other patient as grimacing. Three questions followed up the scenarios related to elder pain assessment and management. Nurses were asked to indicate their pain assessment on a 0 to 10 scale and to choose the correct pain medication and dose. Frequencies and means were used to analyze demographic data; frequencies, t tests, and chi 2 testing compared nurse responses with the different questions. Results indicated that nurses were more likely to believe and document the grimacing patient's self-report of pain than the smiling patient. Older nurses with more experience were less likely to believe or document their patient's self-report of pain than younger nurses with fewer years of experience. Less than half of the nurses would increase the analgesic dose for either patient scenario. Nursing implications include the importance of ongoing pain assessment and management education tailored to the geriatric population and long-term care.     

Impact of a half-day multidisciplinary symptom control and palliative care outpatient clinic in a comprehensive cancer center on recommendations, symptom intensity, and patient satisfaction: a retrospective descriptive study

To characterize a new, one-stop multidisciplinary palliative care (MD) clinic which offers standardized multidisciplinary assessment, specific care recommendations, patient and family education, and on-site counseling, we retrospectively compared the assessments of 138 consecutive patients with advanced cancer referred to the MD clinic and 77 patients referred to a traditional pain and symptom management (PSM) clinic. The two groups were similar in tumor type, demographics, and symptom distress. The MD clinic team (physicians; nurses; pharmacists; physical, speech, and occupational therapists; social workers; chaplains; nutritionists; psychiatric nurse practitioner) delivered 1,066 non-physician recommendations (median 4 per patient, range 0–37). The PSM clinic team made no non-physician recommendations, but referred 14 patients to other medical specialists. In 80 (58%) MD-clinic patients with follow-up 9 days (median) after assessment, significant improvement was observed in pain, nausea, depression, anxiety, sleep, dyspnea, and well-being, but not in fatigue, anorexia, or drowsiness. In 83 patients interviewed after the MD clinic, satisfaction was rated as excellent (5 out of 5) in 86–97% of seven areas. Assessment at an MD clinic results in a high number of patient care recommendations, improved symptoms, and high levels of patient satisfaction.     

Attitudes and knowledge about cancer pain in Flanders. The educational effect of workshops regarding pain and symptom control.

Despite international agreements and recommendations regarding cancer pain therapy, the effectiveness of pain treatment is still a major problem even in Western countries. Part of the problem is that physicians and nurses often lack knowledge of methods for the assessment and treatment of cancer pain and may have many rigid beliefs and attitudes. This study investigated the misconceptions of physicians and nurses that play a role in the undertreatment of pain in Flanders (Belgium). We approached 197 health care workers who participated in the pain and symptom control education sessions organized by the Federation Palliative Care Flanders, and asked them to complete a questionnaire both before and after the sessions. The impact of the education sessions on their knowledge and beliefs regarding the management of cancer pain was substantial. Methods of reaching the target groups that do not feel the need for further education are discussed.     

The impact of the nurse-physician professional relationship on nurses' experience of ethical dilemmas in effective pain management.

The aims of the current investigation were (1) to examine the ethical and professional conflicts experienced by Tasmanian registered nurses in attempting to provide optimal pain management, and (2) to examine nurse satisfaction with their professional relationship with physicians and with their level of involvement in pain management. A total of 1,015 registered nurses completed a 21-item survey examining ethical and professional conflicts encountered during patient pain management. Data also were gathered investigating nurse satisfaction with their involvement in and professional relationship with physicians during pain management. The respondents who felt adequately consulted by physicians were significantly more likely to instigate the consultation process than the respondents who felt that they were not adequately consulted by physicians about their patient's pain status. This was marked in relation to the need for increased pain relief medications. Nurses who did not feel adequately consulted by physicians were significantly more likely to experience ethical conflicts such as concerns about undermedication and patient reluctance to report pain. Nurses' concerns related to ethical conflicts concerning effective pain management are affected by their relationship with physicians. Education, for both nurses and physicians, concerning the role of the nurse in the workplace will help to ensure that these conflicts do not arise. Guidelines concerning the level of patient care at which consultation is necessary will ensure fewer conflicts and greater nurse satisfaction in the workplace.     

Assessment of pain control in cancer patients during the last week of life: comparison of health centre wards and a hospice

The aim of this prospective study was to assess the quality of cancer pain control during the last week of life in two different types of units for terminal cancer patients in Finland: on health centre wards (N=20) and in a hospice (N=30). Pain scores (VAS), defined daily doses (DDD), routes of administration and costs of pain medication were analysed for each patient. On the 7th-last day before death and during the very last day of life (24 h), respectively, the following results were seen: proportions of patients using strong opioids 64% and 84%, mean equivalent parenteral morphine doses of strong opioids 42 mg and 57 mg, mean pain scores (VAS 0-10) 3.11 and 3.05, mean daily cost of pain medication 2.22 and 2.90 euros. Pain control was thus found to be good with low costs. On the 7th day before death strong opioids were used for a greater proportion of patients on the health centre wards. Differences were also seen in the routes of administration used for strong opioids. Weak opioids were used more in the hospice and NSAIDs, more on the health centre wards. However, no differences were found either in the mean doses of strong opioids or in the quality or the costs of pain control between the health centre wards and the hospice.     

Hospice patient and caregiver congruence in reporting patients' symptom intensity

As healthcare increasingly moves out of hospitals, the care of patients with cancer is provided in the community with the help of family caregivers. In many cases, nurses depend on family caregivers to provide assessment data about patients. This makes the accuracy and dependability of the data given by caregivers particularly important. However, it is not clear whether caregivers can accurately and dependably report such subjective data as symptom intensity. The purpose of this project was to evaluate the ability of the primary caregiver to report the symptom intensity of hospice patients with cancer. The sample consisted of 264 newly admitted adult patients with advanced cancer in hospice home care and their primary caregivers. These subjects were part of a large National Institutes of Health (NIH)-funded randomized clinical trial focused on symptom management and quality of life. The patients were alert and oriented. Among the questionnaires completed by both patients and caregivers on admission were numeric rating scales for pain and dyspnea and the Constipation Assessment Scale. All of these scales were designed to describe the patient's symptom intensity. The patient sample was predominantly white (83%) and male (57%), with a mean age of 71.6 years. The caregiver sample was predominantly white (85%) and female (78%), with a mean age of 62 years. The results indicated that caregivers significantly overestimated symptom intensity for all three symptoms (P =.000). Furthermore, the limited variance accounted for by the two sets of scores for each of the symptoms (R2 =.16-.26) indicated much more error in the scores than agreement between patient and caregiver. It appears that family caregivers cannot reliably report patient symptom intensity. Healthcare providers need to train family caregivers in conducting systematic assessments instead of assuming that they understand patient symptoms.     

Factors associated with the accuracy of family caregiver estimates of patient pain.

This study identified factors associated with inaccurate family caregiver assessments of patient pain. Participants were 31 caregiver-patient dyads receiving hospice home care. All patients had a primary diagnosis of end-stage cancer. As expected, caregivers overestimated patient pain. The degree of disparity for each dyad was calculated by subtracting the patient's pain rating from the caregiver's rating of patient pain. Caregiver knowledge of cancer pain management was not related to the degree of disparity in pain ratings, but caregivers' experience of patient pain was significantly related to accuracy of caregivers' pain ratings. Those caregivers who 1) perceived their loved one to be in a great deal of distress secondary to pain, 2) associated greater efforts at pain relief (i.e., more medication) with greater levels of pain, and 3) were themselves distressed by the patient's pain had the most inaccurate estimates of patient pain. There was a trend for greater disparity in pain estimates to be related to poorer existential quality of life for patients. Overall, the findings suggest that health care providers need to take into consideration family members' interpretation of patient pain when providing pain management education services.