Management of Cancer Pain. When pain is chronic and poorly controlled it produces anxiety and emotional distress, interferes with functional capacity, and can affect a patients social, family and professional life. I have chosen this aspect of nursing

University Degree Subjects allied to Medicine

07974594

MANAGEMENT OF CANCER PAIN

The experience of pain can have a negative effect on nearly every aspect of life, including mood and capacity to function in daily activities. According to the World Health Organization, individuals who live with persistent pain are four times more likely than those without pain to suffer from depression or anxiety, and more than twice as likely to have difficulty working. Also the costs associated with pain are extremely high, due both to the healthcare system and to society at large (Katz, 2002). Most people with pain have a greater rate of utilization of the healthcare system and also their productivity is substantially reduced. However one of the most important characteristics of pain is it’s effect on quality of life. The impact of malignant pain on quality of life is severe. When pain is chronic and poorly controlled it produces anxiety and emotional distress, interferes with functional capacity, and can affect a patient’s social, family and professional life. I have chosen this aspect of nursing practice because I have a personal interest in the subject. Also many people suffer from cancer and I believe it’s an important aspect of nursing care to treat and effectively relieve patient’s pain and therefore improve a patient’s quality of life.

According to the code of professional conduct of the Nursing and Midwifery Council (NMC), professional nurses, midwives and heath visitors have a responsibility to deliver care based on current evidence, best practice, and - where applicable - validated research when available (NMC, 2004). In recent years, interest in research related to nursing care has grown and nurses have been encouraged to ensure that their practice is based on research evidence rather than tradition (Clifford, 1997). The nurse has a personal responsibility to remain updated on ‘current best practice’, which includes the ability to critically evaluate new research effectively (Hek, 1996). Nursing research is essential for the development of scientific knowledge that enables nurses to provide evidence-based health care. Evidence based nursing predisposes research. Without it evidence will remain elusive and no credence will be given to clinicians who base their work on routine and tradition alone. According to LoBiondo-Wood (2006) we can think of evidence-based practice (EBP) as the collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, and hierarchy of grades for robustness and validity. The Levels of Evidence according to Melnyk (2005) are: first strong evidence from at least one systematic review of multiple well designed randomised controlled trials; second strong evidence from at least one properly designed, randomised controlled trial of appropriate size; third evidence from well designed trials without randomisation, single group pre-post, cohort, time series or matches case-control studies; fourth evidence from well designed non-experimental studies from more than one control or research group; fifth opinions of respected authorities, based on clinical evidence descriptive studies or reports of expert committees. Also to ensure best practice, valuing feedback from patients and professionals opinions is research derived evidence. This means that the best available evidence, moderate by patient circumstances and preferences, is applied to improve the quality of clinical judgments and facilitate cost-effective health care (Sackett, 2000). LoBiondo-Wood (2006) states that when using EBP strategies, the first steps are to decide which level of evidence a research articles provide.

The aspect of practice I have chosen to investigate in this essay is the management of pain in cancer. To find the evidence to support my essay I did my literature review through a main nursing database called the Cumulative Index to Nursing & Allied Health Literature. I have chosen this debase because it provides nurses with the best available and most recent clinical evidence from thousands of full-text documents. It’s a database with a nursing and medical focus (Ebesco Publishing, 2010). The main concepts in my search were first cancer, second pain and third management. These three words were automatically combined and I received two thousand three hundred and twenty search results. After that I wanted to limit my search to ensure that I retrieved only the most relevant references. First I used the key words “cancer”, “pain management” and “research” getting three hundred and eighty five search results. I limited my search after that to full text, recent articles from 2000 and 2009 and the age groups “all adults” getting twenty search results. From these search two studies, a primary and a secondary source of evidence were found to be suitable for the purpose of this evidence-base care appraisal. The primary source of evidence is a qualitative study called “Cancer-related pain in palliative care: patients’ perceptions of pain management (Bostrom, 2004).

According to Parahoo (2006) original publications are known as primary sources. The framework I will use to critique my primary piece of research evidence is the LoBiondo-Wood (2006). According to this author the title of an article is the first part of the study to be encountered. The title should drawn the reader’s attention to the precise area of the study and make reference to the population from whom the data is collected. The title of the article I have selected to critique is consistent with both recommendations as it informs the reader that it is a qualitative study about patient’s perceptions of pain management in palliative care. According to Denzin and Lincoln (2000) qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research is generally conducted in natural settings and uses words or text as data rather than numeric data in order to describe the experiences being studied. Data are collected from a small number of subjects, allowing an in-depth study of the phenomena. LoBiondo-Wood states that an abstract is a short comprehensive summary at the beginning of an article. It provides a succinct overview of the study. The abstract of the Bostrom (2004) article clearly states the aim of the study: to describe how patients with cancer-related pain in palliative care perceive the management of their pain, sample and the main findings. Also it mentions the methods used in the study and a brief conclusion. The aim of a literature review is to prepare the ground for new research (Parahoo, 2006). Brostrom (2004) is able to explain about previous researches done on the topic. The researcher effectively managed to reference the related studies, most of which were qualitative studies. Although most of the studies were related to managing pain in cancer patients, according to Brostrom (2004) no research with the phenomenolographic approach to investigate patients’ perceptions of pain management has been found. The choice of method depends on the question being asked (Streubert, 1999). To fully understand the perceptions of cancer related pain management of patients who participated in the study the researcher used a phenomenological approach. Phenomenology is a qualitative research method which focuses on, and aims to describe and understand, the “lived experience” of the individual with regards to their emotions and perceptions (Young, 2001) which is then appropriated for the aim of this study. The sample in this study is thirty patients strategically selected with regard to the following criteria: gender age, marital status, and diagnosis, duration of the care from palliative care team and place of care. It’s clear in the study that the selected sample is living the phenomenon of interest. Unlike quantitative research, there is no need to randomly select individuals, because manipulation, control, and generalization of findings are not the intent of the inquiry. Open and semi-structured interviews were the basis for gathering data in this study which provides the opportunity for the participants to fully explain their experiences (Streubert, 1999). Unfortunately there is no mention in the article of the length of time spent interviewing participants, which makes it difficult to evaluate this aspect of the data collection. Even if the sample data was adequate, a study must continue long enough to gain adequate results, being long enough to produce enough data for analysis. The study was approved by the relevant research committee. The article states that participants gave informed consent prior to interviews. Patients were informed that participation in the study was voluntary; that their answers would be treated in confidence and that they could withdraw from the study at any time without giving a reason. The researcher outlined the results clearly and systematically. The results of the study were organized into three themes: communication, planning and trust. All related to the study aim by illuminating cancer patient’s perceptions of pain management. The conclusion of the report summarises the main study findings and made explicit the significance the findings may have for nursing practice. The opportunity for patients to discuss pain and its treatment seems to have occurred late in the course of the disease, mostly not until coming into contact with a palliative care team. A trusting relationship with nurses and physicians was perceived as fundamental for optimal pain control (Bostrom, 2004).

According to LoBiondo-Wood (2004) qualitative studies has historically ranked lower in a hierarchy of evidence, along with descriptive, evaluative, expert opinions, and case studies, as weaker forms of research designs. Yet the answers to questions provided by qualitative data reflect important evidence that may offer the first systematic insights about a phenomenon and the settings in which it occurs. Broadening evidence models beyond a narrow hierarchical perspective is work that has already begun as there are more professionals that consider how qualitative evidence can be evaluated and included more in systematic reviews (Pearson, 2002).

A systematic review can ...

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A systematic review can be defined as the rigorous search, selection, appraisal, synthesis and summary of the findings of primary research in order to answer a specific question (Parahoo, 2006). I will use Parahoo (2006) and Gerrish (2006) framework to critique my secondary source of evidence. It’s called “A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: A critical appraisal” Oldenmenger (2009). According to Parahoo (2006) no systematic review can take place without a question and aim or a hypothesis. Pearson (2004) states a sound, systematic review rests on a well defined review question. Oldenmenger (2009) study has two aims which are clear and unambiguous: to identify the mayor barriers hindering adequate pain management and critically review interventions aiming to overcome them. Parahoo (2006) states the aim of a systematic review is to answer the review in question and to obtain a credible answer. Every effort to locate all relevant studies must be made. Therefore databases, the grey literature (studies that are published in-house or not published), reference list and manual searches are all important sources of literature which should be accessed in the process of a systematic review. The search of relevant literature in Oldenmenger (2009) study seems to be limited. The study included relevant literature published in English and the senior author’s personal library was checked to retrieve relevant publications. The researchers didn’t included a searcher for unpublished studies or non-English language studies. Bowling (2009) states that the first step on a topic of study is to search and review the published and also the unpublished literature. Sometimes authors may ignore non-significant findings and only publish those which attain statistical significance resulting in “publication bias.” Also it is possible that the English language publications are more likely to publish significant findings, and therefore non-significant findings are more likely to be in other language journals. Moher (2003) states language-inclusive systematic reviews are better quality reviews. According to Parahoo (2006) knowing what sources of information to access and how to access them are key requisites for locating the evidence. As we have seen, Oldenmenger (2009) used two search procedures, one online database (PubMed) and relevant articles from the author’s personal library. The key words used in the search were “pain management” and “barriers” or “concern”. The researchers restricted the search to patients and health care providers and found that seventy studies met the inclusion criteria. Herbert (2005) indicates that a systematic review that specifies clear inclusion and exclusion criteria provides stronger evidence for their field of search than those which do not. For the study of interventions aiming to overcome barriers hindering adequate pain management the authors selected randomised clinical trials (RTCs). The methodological quality of the RCTs was assessed using the criteria of van Tulder (2003). The main outcome measurements used were patient’s pain intensity, patient’s or professional’s barriers, adherence to analgesics and adequacy of pain treatment, measured with the pain management index (PMI). To give an indication of the effect of the intervention studies in the RCTs on pain, the author calculated the difference in the decrease of pain intensity, with respect to a baseline, between the intervention and the control group. A clinically relevant effect was defined as a difference in the reduction of pain intensity with 30% or >2 points on a 0-10 (Oldenmenger, 2009). The types of data extracted from the reports include: study details, methods, participants, interventions, outcome measured, characteristics of participants, and results. If data were missing from the reports the authors tried to contact the first author in order to gain access to the source of data. All data on the statistical significances, reported in the review, were retrieved from the original papers (Oldenmenger, 2009). The authors presented the data by providing a narrative commentary and summary tables with the numerical data. It seems that in Oldenmenger (2009) study there is significant differences in the participants, interventions, and settings of the reports that could have an effect on the outcomes. The findings of the study are presented in three categories. First, patient-related barriers with the result that patients often impede their own treatment due to misconception about analgesics, non-adherence to treatment regimens, and poor communication of their pain to healthcare providers. Second, interventions that reduce patient-related barriers: patient education. The authors found 11 RCTs evaluating patient education. A statistically significant improvement was found on patient’s adherence to analgesics in the intervention group compared to the control group. In the third category, professional-related barriers, physicians and nurses reported the following barriers most frequently: a) inadequate assessment of pain and pain management, b) patient’ reluctant to report their pain and c) inadequate knowledge of pain management of professionals. Finally Oldenmenger (2009) concluded that according to the American Pain Society adequacy of cancer pain management will only improve when a multidisciplinary and multilevel approach will be chosen and, although, internationally this approach is considered the only way to effectively improve cancer pain management, it is not supported in the studies reported. Oldenmenger (2009) indicates that the authors were incapable of identifing interventions that unequivocally demonstrated clinically relevant improvement in patient’s pain using the outcome measurement and criteria selected for this systematic review. In Oldenmerger (2009) systematic review there is a detailed explanation of how the search was carried out, how the selected studies were appraised and how the conclusions were reached but the transparency and rigorous of the whole process seemed confusing and difficult to follow.

According to the hierarchy of evidence, RCTs and systematic reviews are considered the best evidence or the “gold standard” in producing evidence. In this hierarchy other designs or methods that don’t include randomisation are perceived as producing lower forms of evidence (Parahoo, 2006). The overriding message appears to be that quantitative research provides a stronger evidence base than qualitative methods. Yet qualitative methods are the best way to start to answer questions that have not been addressed or when a new perspective is needed in practice. LoBiondo-Wood (2006) suggests that there is a demand to embrace the wholeness of humans, focusing on the human experience in natural settings. The researcher using qualitative methods believes that each unique human being attributes meaning to their experience and pain is really a subjective experience. Also management of pain is considered to be complex and a multidisciplinary approach to it is needed. Pain is one of the most frequent and distressing symptoms of cancer. More research is needed; this should encompass the views of patients with cancer and investigate the methods of pain management that would be preferred by them. In the topic I have chosen to critique efforts which need to be made to uncover the meaning of cancer related pain, as it extends beyond the facts of the number of medications taken or a rating on a reliable and valid scale.

Because nursing is a practice discipline, the most important purpose of nursing research is to put the research findings to use. However, research activities, such as participation, dissemination, and utilization of research evidence, are still not perceived favourably by the majority of nurses (Edwards, 2002). The use of research evidence by nurses in their practice will remain a challenge until changes occur in the ways nurses understand, value and initiate research. According to Edwards (2002) this will required an ideological shift: a re-education from one set of beliefs, perceptions, values and practices to another. As students, nurses are introduced to reading and evaluation or research evidence. However, according to Edwards (2002) the values and attitudes transmitted in the work place tend to have a stronger influence than the official curriculum. Without the capacity to think critically the danger when entering a new culture is that existing practices and beliefs will be seen as unchallengeable. Also nurse clinicians work in environments that are bureaucratic and which promote consistency and conformity to routine with emphasis on completing tasks rather than on considerations of best practice (Robert, 1998). Many of the impediments to using research in practice stem from the organizations that train and employ nurses. Organizations, to an even greater degree than individuals, resist change (Polit, 2006). Strong leadership in health care organizations is essential to making evidence-based practice happen. Another nursing related barrier to the gap between research and practice is that it has been difficult to encourage clinicians and researchers to interact and collaborate. They are generally in different settings and have different professionals concerns (Polit, 2006).

According to Seers (2004) there are four different types of evidence available for use in clinical practice. Firstly, research. Seers (2004) sates that research evidence, although crucial to improved patient care, may not on its own inform practitioner’s decision-making. Second is knowledge from clinical experience. This knowledge is expressed and imbedded in practice and is often tacit and intuitive. Seers (2004) states that in order for a practitioner’s experience and knowledge to be considered credible as a source of evidence, it needs to be explicated, analysed and critiqued. Third is knowledge from patients, clients and carers. Good practice cannot be separated from the unpredictable way in which individuals and their families respond to concepts of heath and illness, and in my chosen topic how patients respond to cancer related pain. Individual’s experiences and preferences should be central components in the practice of evidence-based heath care. In addition to knowledge that’s come from research, clinical and patient’s experience, the context of care contains sources of evidence. Parahoo (2006) state traditional nursing knowledge is learned mainly from books or journals, by word of mouth and by observing the practice of others. Much traditional practice takes the form of rituals. Biley (1997) suggests that rituals are in some way part of healing, that they have some positive action, ritualistic, symbolism, latent function and meaning for the patient and the nurse. However, the danger of rituals is when the rationale for their practice is long forgotten and never questioned (Biley, 1997).

Finally the findings of the studies I have critiqued in this essay provide important insights when managing pain in cancer patients. Evidence from research, patient assessment, healthcare resources, clinical expertise, information about patient preferences and values, and critically appraising, integrating and evaluating leads to best practice and quality patient care and outcomes. Care cannot be generalized and must be individualised to the needs of each unique patient. Barriers to optimal patient care must be overcome in open and transparent ways.

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