How nursing knowledge and attitudes affect the management of pain within cancer patients

Written by Nika van Eeden

  Introducton

Pain is one of the most frequent consequences among patients diagnosed with cancer, but is unfortunately still ineffectively managed by health professionals (Borglin, Gustafsson, & Krona, 2011). This literature review focuses specifically on the pain management of cancer patients because with everything they experience physically and emotionally, pain is something that they deserve to have well managed and not be something they fear. Therefore this review critically considers the nurse’s role in pain management and what factors are important in providing effective relief for patients. By using the PICOT model I have brought my question from the broad idea of ‘how well do nurses manage patient’s pain,’ to a refined question of ‘how do nursing knowledge and attitudes affect the management of pain within cancer patients?’ 

  Literature review

Pain is one of the most feared consequences of cancer experienced by patients (Shahnazi, Saryazdi, Sharifirad, Hassanzadeh, Charkazi, & Moodi, 2012). It is generally a side effect of cancer treatment or the cancer itself and will have an impact on a person’s quality of life whether it is short term or chronic (Cancer Society, 2010). It should be effectively treated either way. With all the other physical and mental consequences of cancer, pain is something that can and should be managed to ease the experience for patients. Nurses should be regularly assessing cancer patient’s pain and being active in implementing the most effective pain management strategies. In 2010, there were 21,235 registered cancer patients in New Zealand alone (Ministry of Health, 2013). Each of those individuals will be experiencing their own suffering and turning to health professionals for support and pain management. As nursing students in New Zealand we get taught some basic pharmacology related to pain medication and learn how to take a thorough pain assessment, but there is very little focus on how to manage patient’s pain. Of course a lot of this learning would develop in a ward setting, specific to the needs of that area. However in an area such as oncology, patients are extremely vulnerable and need the best nursing care available to ensure they are as comfortable as possible and not dealing with unnecessary suffering. To enable this, nurses should take every opportunity to increase their knowledge of pain management and consider how their own attitudes towards patient’s pain experience are affecting their practice. With oncology being an area I am interested in for a future nursing career, this encouraged me to complete a literature review on how nursing knowledge and attitudes affect the management of pain within cancer patients. Using the PICOT framework model from Schneider and Whitehead (2013) I was able to critique my question and consider what I wanted to include in the review which is defined below.

PICOT Category

Information

Explanation

Population

Oncology/cancer patients experiencing mild to severe pain due to   cancer treatment or the cancer itself.

The majority of cancer sufferers will experience some pain due to   their illness and/or treatment, so it is an important side effect to have   well managed.

Intervention

First we will investigate how nursing knowledge and attitudes   affect cancer pain management, and then consider interventions to improve   this through education seminars to enhance nursing knowledge of cancer pain   management and pain assessment tools and holistic health models that improve   nurse’s attitudes towards cancer patients.

I will be looking for articles that recognise how a lack of   nursing knowledge and negative attitudes affect the management of cancer   patient’s pain and experiments people conducted to see if more education and   ways to avoid making bias nursing judgements improved their nursing care in   pain management for cancer patients.

Comparison/Control

Nurses who do not receive interventions to improve their pain   management skills.

We are interested in what happens compared to what oncology nurses   might normally do. 

Outcome

Interventions should be suggested which would enhance nursing   knowledge and attitudes and therefore create more effective nursing   management of cancer patients pain.

We need to find out how nursing attitudes and knowledge influence   cancer pain management and then discuss the outcomes of interventions and   suggest those most effective for future nursing practice.

Time

There is no time frame in this PICOT question.

The amount of pain management required can be extremely varied   among cancer patients because of such varying diagnosis and treatments.

From the literature I have found that the prevalence of pain in patients with cancer is still too high and one of the reasons for this is ineffective pain treatment from health professionals, such as nurses (van der Peet et al., 2009). Inadequate pain relief is well documented and can involve up to 40% of patients (Shahnazi et al., 2012). Despite the availability of effective pharmacology treatments and the fact that up to 90% of cancer patients can gain pain relief with the correct pain management, this group often receives less than optimal treatment (Borglin, Gustafsson, & Krona, 2011). The literature states there is too much focus on “curing” cancer patients and a lack of attention on “caring” for them (van der Peet et al., 2009). Health professionals can become so focused on treating the cancer that they subconsciously ignore other side effects, particularly pain, and they are left unmanaged. Nurses have a key role in effective pain management and communicating their knowledge is of critical importance in the care of patients with cancer pain (Shahnazi et al., 2012). There is clear evidence from the literature that nurses lack of knowledge and individual attitudes towards pain can interfere with their ability to sufficiently manage pain (Shahnazi et al., 2012). The most frequent explanation is that nurses are receiving too little pain management education in their curriculum (Shahnazi et al., 2012). Nurses can agree that seminars and workshops play an important role in increasing knowledge towards cancer pain management and would have been valuable right from the start of nursing training (Shahnazi et al., 2012).(van der Peet et al. ( 2009) study provided pain education programmes for nurses, who then provided specialised support to patients and results showed that over time there were significant improvements in patient’s pain management and oncology patients were far more satisfied with their treatment. There is also concern that nurses pain assessment focuses too much on patient’s non-verbal behaviours rather than pain intensity and other descriptive characteristics of pain (Shahnazi et al., 2012). As a result, nurses have negative attitudes towards patients, overestimating the percentage of patients who over-report their pain or appear drug-seeking (Shahnazi et al., 2012). This creates barriers to effective pain relief and upsets the therapeutic relationship between the nurse and patient. It appears to the patient as if the nurse distrusts what they are experiencing and believes their own subjective judgements are more accurate (Borglin, Gustafsson, & Krona, 2011). Oncology ward nurse’s lack of knowledge and negative attitudes towards cancer patient’s pain management impacts on the patient’s quality of life (Shahnazi et al., 2012). To improve patient’s pain management, oncology nurses should take opportunities to advance their pain management education and have a holistic attitude when discussing pain relief with patients.

  Recommendations

A literature review was carried out to establish how nursing practice effects how pain relief among cancer patients is managed. The findings suggest that nursing knowledge and attitudes are significant factors in the management of cancer patient’s pain. Nurses need to enhance their knowledge through further education seminars and understanding of the most effective analgesic routines for pain management (Borglin, Gustafsson & Krona, 2011). The World Health Organisation has a three step method to managing cancer pain, therapy begins with using NSAIDs and/or adjuvants and progress to weak, then strong, opioids if pain persists (Pisani, Partridge, Taylor, & Porter, 2009). However, in order to successfully follow this method, nurses need ongoing education around cancer pain pharmaceuticals, their different uses, effects, interactions, and side effects (van der Peet et al., 2009). Educational interventions will improve knowledge of pain and its treatment and also contribute to eliminating the nursing barriers to pain management (Borglin, Gustafsson, & Krona, 2011). I recommend educational workshops, based on New Zealand guidelines for the treatment of cancer pain, which involve interaction within small groups and draw on personal experience (Borglin, Gustafsson, & Krona, 2011). That way nurses can discuss scenarios with each other and share their own knowledge and experiences to identify what appears to work best for them and why. It will help nurses to critically think about their practice and what they identify as barriers to how effective their cancer pain management is. Nurses on an oncology ward should be active in expanding their own knowledge through up to date education programmes as well as having a broad awareness of specialist services for cancer patients to use in the community for support and pain management at home, such as the New Zealand Cancer Society and non-pharmaceutical pain reliefs. Nurses also need to consider how their own subjective attitudes to patient’s pain is impeding the management of their pain (Borglin, Gustafsson, & Krona, 2011).

The introduction of new guidelines related to pain assessment recommend that cancer pain should be assessed routinely and systematically (Borglin, Gustafsson, & Krona, 2011). Pain assessment frameworks, alongside vital sign taking, help provide detailed accounts of the types of pain each patient is experiencing and should be used daily. A common tool which should be used on New Zealand oncology wards is the PQRST pain assessment framework. It helps identify all the specific information required to consider the type and strength of medication that may be helpful, created from the patient’s subjective information rather than the judgement of the nurse (Foster, Grimes, & Hornyak, 2014). In this way nurses can consider the patients behaviour in relation to the pain assessment and then decide if their non-verbal behaviour correlates, rather than passing a bias judgement without proper assessment. Every diagnosis made from a pain assessment should also be followed by an intervention and evaluation. Nurse’s timely, appropriate, and thorough assessment and treatment of cancer patients experiencing pain should reduce their suffering and improve their quality of life (Turk, Monarch, & Williams, 2002). This will also help provide consistent routine information among nursing staff and actively involves the patient in the assessment process (Turk, Monarch, & Williams, 2002). Nurses should encourage patients to become involved in their pain management. One way to do this is to encourage patients to keep a pain diary where they can record their pain intensity throughout the day (van der Peet et al., 2009). The diary can be a useful tool for nurses and physicians to assess and review how patient’s pain is being managed at home and if adjustments need to be made (van der Peet et al., 2009). If any physical or emotional problems arise patients can contact their health care provider (van der Peet et al., 2009). Nurses are responsible for serving as advocates for empowering patients to engage in self-management of their pain, and offer education and support to patients and families at their most vulnerable times (Vallerand, Musto, & Polomano, 2011).

  Conclusion

The deficits in nursing knowledge and attitudes identified throughout the literature are significant barriers to effective pain management among cancer patients. Oncology nurses need to become more proactive, involving themselves in pain management education seminars and sharing their knowledge with patients to help empower them identify their pain management needs and the options available for them. They also need effective, consistent assessment tools that remove the incidence of negative nursing attitudes towards addictive behavioural cues of patients and instead focuses on the subjective view of the patient’s experience. Patients with a diagnosis of cancer should not have to fear pain, it should be well managed with the guidance of skilled health professionals. With nurse’s enhanced knowledge and attitudes, they can help patients successfully manage their pain and improve their quality of life.

  References

Borglin, G., Gustafsson, M., & Krona, H. (2011). A theory-based educational intervention targeting nurses’ attitudes and knowledge concerning cancer-related pain management: A study protocol of a quasi-experimental design. BMC Health Services Research, 11(233), 1-7.

Cancer Society. (2010). Managing cancer pain. Retrieved from The Cancer Society website:http://www.cancernz.org.nz/assets/files/info/Information%20Sheets/IS_ManagingCaPain_oct2010.pdf

Foster, S., Grimes, M. M., & Hornyak, J. (2014). Best practices: PQRST method facilitates accurate pain assessment. Retrieved from Crozer Keystone Health System website: http://www.crozerkeystone.org/

Ministry of Health. (2013). Cancer: New registrations and deaths 2010. Wellington, NZ: Ministry of Health.

Pisani, H., Partridge, F., Taylor, C., & Porter, T. (Eds.). (2009). Potter & Perry’s fundamentals of nursing (3rd ed.). Chatswood, Australia: Mosby Elsevier.

Schneider, Z., & Whitehead, D. (Eds.). (2013). Nursing and midwifery research: Methods and appraisal for evidence-based practice (4th ed.). Sydney, Australia: Mosby Elsevier.

Shahnazi, H., Saryazdi, H., Sharifirad, G., Hassanzadeh, A., Charkazi, A., & Moodi, M. (2012). The survey of nurse’s knowledge and attitude toward cancer pain management: Application of Health Belief Model. Journal of Education and Health Promotion, 1(15), 1-4. 

Turk, D. C., Monarch, E. S., & Williams, A. D. (2002). Cancer patients in pain: Considerations for assessing the whole person [Abstract]. Hematology/Oncology Clinics of North America, 16(3), 511-525. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12170565#

Vallerand, A. H., Musto, S., & Polomano, R. C. (2011). Nursing’s role in cancer pain management [Abstract]. Current pain and headache reports, 15(4), 250-262. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21538044

van der Peet, E. H., van den Beuken-van Everdingen, M. H. J., Patijn, J., Schouten, H. C., van Kleef, M., & Courtens, A. M. (2009). Randomised clinical trial of an intensive nursing-based pain education program for cancer outpatients suffering from pain. Support Cancer Care, 17, 1089-1099.