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).