Can A Complex Online Intervention Improve Cancer Nurses’ Pain Screening and Assessment Practices? Results from a Multicenter, Pre-post Test Pilot Study

Effectiveness of implementing a Best Practice Guideline recommendations to manage pain in oncological hospitalized patients

OBJECTIVE

To evaluate the effectiveness of implementing the Clinical Best Practice Guideline (BPG) "Assessment and Management of Pain" recommendations for pain control in oncological/oncohaematological hospitalized patients.

METHODS

Ambispective cohort study.

SAMPLE AND SETTING

Adults admitted to oncological unit in Hospital of Albacete.

INTERVENTION

Implementation of GBP recommendations.

VARIABLES

1) Demographic data. 2)On implementation of GBP recommendations. 3) Outcome in patients: pain intensity in the first 24 h after admission and maximum intensity during admission Tools: Numeric and Visual Scales.

DATA COLLECTION

indicators exported from clinical history for evaluation of the BPSO® program. Ethical aspects: anonymous data. Data analysis (SPSS®): Descriptive during periods: baseline (T0 = December 2015); initial (T1 = 2017); consolidation (T2 = 2018-2019); sustainability (T3 = 2021-2022). Measurements of central tendency and dispersion, absolute and relative frequencies. Comparison of proportions (Chi-Square) and averages (Student t-test, ANOVA). Statistical significance: p < 0.05.

RESULTS

Included 572 patients, 61.5% (352) men. Daily intervention of pain detection was performed in 94.6% (538) of patients (20%-T0; 98.3%-T1; 98.4%-T2; 91.2%-T3; p < 0.001), pain assessment using an appropriate scale in 97.6% (558) (0%-T0; 98.3%-T1; 99.2%-T2; 100%-T3; p < 0.001); 93.7% (535) had a care plan for assessment and management of pain (0%-T0; 98.3%-T1; 96.3%-T2; 92.3%-T3; p < 0.001). The percentage of patients who had severe pain (6-10) during the first 24 hours was reduced from T1 to T3 (5.1%-T1; 6.6%-T2; 2.1%-T3; p = 0.145), but throughout hospitalization increased from T1 to T3 (19.2%-T1; 17%-T2; 22.5%-T3; p = 0.21).

CONCLUSIONS

Implementation of recommendations has led to a statistically significant improvement over the periods in the study; however, no effectiveness has been shown to reduce pain intensity.

Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System

Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.

Effect of Pain Education Interventions on Registered Nurses' Pain Management: A Systematic Review and Meta-Analysis

OBJECTIVES

This review and meta-analysis aims to reveal how pain education interventions affect registered nurses' pain management.

DESIGN

A systematic review and meta-analysis DATA SOURCES: PubMed, Scopus, CINAHL (EBSCOhost), and ERIC REVIEW METHODS: A systematic search of four electronic databases was conducted to identify relevant peer-reviewed English or Finnish-language articles published between 2008 and 2021. The review included a quality appraisal and a meta-analysis of articles providing group-level data before and after the intervention (n = 12). The methods followed the PRISMA guidelines.

RESULTS

Overall, 23 articles met the inclusion criteria for the review, of which 15 were evaluated as good quality. Based on the articles on document audits (n = 10), pain education interventions reduced the risk of not receiving the best pain management by 40%, whereas based on the articles on patients' experiences (n = 4), they reduced the risk by 25%. The study quality and design of these articles were considerably heterogenous.

CONCLUSIONS

Pain education study strategies varied widely among the included articles. These articles used multivariate interventions without systematization or sufficient opportunity to transfer the study protocols. It can be concluded that versatile pain nursing education interventions, as well as auditing of pain nursing and its documentation combined with feedback, can be effective to nurses in adapting pain management and assessment practices and increasing patient satisfaction. However, further research is required in this regard. In addition, well-designed, implemented, and reproducible evidence-based pain education intervention is required in the future.

The effectiveness of clinical guideline implementation strategies in oncology-a systematic review

IMPORTANCE

Guideline recommendations do not necessarily translate into changes in clinical practice behaviour or better patient outcomes.

OBJECTIVE

This systematic review aims to identify recent clinical guideline implementation strategies in oncology and to determine their effect primarily on patient-relevant outcomes and secondarily on healthcare professionals' adherence.

METHODS

A systematic search of five electronic databases (PubMed, Web of Science, GIN, CENTRAL, CINAHL) was conducted on 16 december 2022. Randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) assessing the effectiveness of guideline implementation strategies on patient-relevant outcomes (overall survival, quality of life, adverse events) and healthcare professionals' adherence outcomes (screening, referral, prescribing, attitudes, knowledge) in the oncological setting were targeted. The Cochrane risk-of-bias tool and the ROBINS-I tool were used for assessing the risk of bias. Certainty in the evidence was evaluated according to GRADE recommendations. This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number CRD42021268593.

FINDINGS

Of 1326 records identified, nine studies, five cluster RCTs and four controlled before-and after studies, were included in the narrative synthesis. All nine studies assess the effect of multi-component interventions in 3577 cancer patients and more than 450 oncologists, nurses and medical staff.

PATIENT-LEVEL

Educational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain.

PROVIDER-LEVEL

Multi-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.

CONCLUSIONS AND RELEVANCE

Knowledge and skill accumulation through team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched guideline implementation strategies in oncology recently. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.

Psychometric Evaluation of the Nurses' Cancer Pain Management Competency Scale

BACKGROUND

There is lack of instruments for assessing nurses' comprehensive pain management competency.

AIM

This study aimed to assess the psychometric properties of the Nurses' Cancer Pain Management Competency Scale and to conduct a cursory survey of the pain management educational needs/resources of nurses caring for patients with cancer pain.

METHOD

A convenience sample of 230 Korean nurses who met the eligibility criteria completed the researcher developed the Nurses' Cancer Pain Management Competency Scale and a pain management educational needs/resources survey. The Nurses' Cancer Pain Management Competency Scale was based on the pain management core competencies identified by Fishman et al (2013). Internal consistency was assessed using Cronbach's alpha, and construct validity was examined using exploratory factor analysis with varimax rotation.

RESULTS

Cronbach's alpha of the scale was 0.89. Nurse cancer pain management competency includes four factors, which accounted for 68.44% of the variance: the context of pain management, pain assessment and measurement, management of pain, and multidimensional nature of pain. Approximately 42% of nurses had no available protocols related to cancer pain management. Nurses preferred multi-component educational modalities, including simulation-based learning.

CONCLUSIONS

Findings support internal consistency reliability and content and construct validity of the Nurses' Cancer Pain Management Competency Scale that can help examine pain management competency of nurses. Adopting an evidence-based clinical cancer pain management-related protocol and multi-component training programs are needed to achieve optimal cancer pain management competency in nurses.

Pilot study to explore the use of mobile spaced learning as a digital learning platform when teaching symptom management to undergraduate nursing students: SPLENdidS study

Background

The management of patients’ holistic symptom needs are often complex and challenging. The education needs of undergraduate nursing students must be optimally addressed to have a significant positive impact on patient care. Mobile spaced learning has been recognised as a form of online education which can provide a novel approach to delivering effective evidence based healthcare education to undergraduate students.

Objective

The objective of this pilot study was to explore the experiences of undergraduate nursing students in a university setting, of using mobile spaced learning as a digital platform for symptom management education.

Method

This pilot study used a mixed methods approach. Online spaced learning material, which utilised both case based scenarios and multiple choice questions, was delivered to first year undergraduate nursing students over a period of 2 weeks. Participants were then invited to participate in an online survey related to the usability of mobile spaced learning. A focus group was conducted to further explore the participants’ views.

Result

Findings conveyed that students viewed mobile spaced learning as an acceptable platform that enhanced both their learning and their ability to transfer knowledge into clinical practice.

Conclusion

Implementation of a digital spaced learning intervention would be acceptable to undergraduate nursing students learning about holistic symptom management. Further research is needed to explore the feasibility of implementing this intervention within the undergraduate nursing curriculum, and also to explore the impact on long-term knowledge retention.

Complementary and Alternative Medicine Online Learning Intervention for Oncology Healthcare Providers: A Mixed-Methods Study

Introduction:

With the increased usage of complementary approaches in oncology comes the need for its integration into healthcare professional (HCP) education. The purpose of this single-arm, mixed-methods study was to examine the feasibility and benefits of a brief complementary and alternative medicine (CAM) learning intervention for improving HCP knowledge, attitudes, and practices regarding CAM use in cancer care, and explore the experiences of participating HCPs.

Methods:

HCPs from the Tom Baker Cancer Centre in Alberta, Canada, were invited to participate in 3 online interactive learning modules that reviewed: (1) basic CAM information, (2) HCP-patient CAM communication, and (3) evidence-based CAM decision support. The study survey consisted of attitude (n = 14), knowledge (n = 31), and practice (n = 31) items, administered at baseline and two-months post-intervention. Semi-structured interviews were conducted with a subset of participants.

Results:

Approximately 300 HCPs were invited to participate, of which 105 expressed interest in the study (35%), and 83 of them consented to participate (79%). The intervention completion rate was 73% (61/83 HCPs). There was a significant pre-post change in HCPs’ attitudes and, to a lesser extent, knowledge and practices related to CAM (8/14 attitude items changed pre-post compared to 13/31 knowledge items and 5/31 practice items), in which more HCPs reported patients should be assisted in making complementary therapy (CT) decisions, exhibited greater knowledge about CAM, and more often engaged in a CAM-related clinical practice. Qualitative findings supported the beneficial effects of the modules, with HCPs describing themselves as being more likely to ask patients about their CAM use and referring them to credible CAM resources. Nonetheless, the majority did not feel adequately prepared to make recommendations about specific CTs, even after the intervention.

Conclusion:

The current study suggests that online CAM learning offers a feasible and potentially promising intervention for improving oncology HCP knowledge, attitudes, and practices regarding CAM, warranting further investigation. This study highlights a need for institutional resources to help HCPs fully integrate CT decision support into cancer patient care. A coordinated evidence-based CAM program at cancer centers may help ensure that all patients’ CAM-related needs are properly attended to.

Scoping Review of Distributed Practice in Nursing Education

AIM

The aim of this study was to describe the status of distributed practice in research of nursing education.

BACKGROUND

The science of learning has compiled evidence-based strategies that should be integral to nursing education. One long-standing strategy, distributed practice, involves spacing, placing cognitive breaks between study or practice sessions with priority information.

METHOD

Reviewing literature published over 20 years at every level of nursing education, the authors conducted a scoping review to determine the extent to which research of nursing education includes attention to distributed practice.

RESULTS

In the 13 articles meeting criteria, distributed practice was most common in continuing professional development, with an emphasis in learning psychomotor skills. Study authors used a variety of terms and descriptions in referring to the strategy.

CONCLUSION

By way of research, distributed practice appears underutilized in nursing education, especially at prelicensure and graduate levels, and could benefit from clear and consistent use of terminology.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

BACKGROUND

Health care professionals (HCPs) use clinical practice guidelines (CPGs) to make evidence-informed decisions regarding patient care. Although a large number of cancer-related CPGs exist, it is unknown which CPG dissemination and implementation strategies are effective for improving HCP behaviour and patient outcomes in a cancer care context. This review aimed to determine the effectiveness of CPG dissemination and/or implementation strategies among HCPs in a cancer care context.

METHODS

A comprehensive search of five electronic databases was conducted. Studies were limited to the dissemination and/or implementation of a CPG targeting both medical and/or allied HCPs in cancer care. Two reviewers independently coded strategies using the Mazza taxonomy, extracted study findings, and assessed study quality.

RESULTS

The search strategy identified 33 studies targeting medical and/or allied HCPs. Across the 33 studies, 23 of a possible 49 strategies in the Mazza taxonomy were used, with a mean number of 3.25 (SD = 1.45) strategies per intervention. The number of strategies used per intervention was not associated with positive outcomes. Educational strategies (n = 24), feedback on guideline compliance (n = 11), and providing reminders (n = 10) were the most utilized strategies. When used independently, providing reminders and feedback on CPG compliance corresponded with positive significant changes in outcomes. Further, when used as part of multi-strategy interventions, group education and organizational strategies (e.g. creation of an implementation team) corresponded with positive significant changes in outcomes.

CONCLUSIONS

Future CPG dissemination and implementation interventions for cancer care HCPs may benefit from utilizing the identified strategies. Research in this area should aim for better alignment between study objectives, intervention design, and evaluation measures, and should seek to incorporate theory in intervention design, so that behavioural antecedents are considered and measured; doing so would enhance the field's understanding of the causal mechanisms by which interventions lead, or do not lead, to changes in outcomes at all levels.

Conceptualising spaced learning in health professions education: A scoping review

OBJECTIVES

To investigate the definitions and applications of 'spaced learning' and to propose future directions for advancing its study and practice in health professions education.

METHOD

The authors searched five online databases for articles published on spaced learning in health professions education prior to February 2018. Two researchers independently screened articles for eligibility with set inclusion criteria. They extracted and analysed key data using both quantitative and qualitative methods.

RESULTS

Of the 2972 records retrieved, 120 articles were included in the review. More than 90% of these articles were published in the last 10 years. The definition of spaced learning varied widely and was often not theoretically grounded. Spaced learning was applied in distinct contexts, including online learning, simulation training and classroom settings. There was a large variety of spacing formats, ranging from dispersion of information or practice on a single day, to intervals lasting several months. Generally, spaced learning was implemented in practice or testing phases and rarely during teaching.

CONCLUSIONS

Spaced learning is infrequently and poorly defined in the health professions education literature. We propose a comprehensive definition of spaced learning and emphasise that detailed descriptions of spacing formats are needed in future research to facilitate the operationalisation of spaced learning research and practice in health professions education.

Effectiveness of the spaced education pedagogy for clinicians' continuing professional development: a systematic review

CONTEXT

Ensuring clinical practice reflects current evidence is challenging given the rapid proliferation of new knowledge. Changing entrenched clinical behaviours and facilitating the adoption of best practice evidence requires a range of strategies, including affordable, scalable and effective continuing professional development (CPD). Yet, identifying the CPD delivery method most likely to effectively change and improve patient outcomes is difficult given the variability in the evidence for different learning approaches. Although there is moderate level evidence for outreach education, audit and feedback, and face-to-face or online learning, little is known about the capacity of spaced education to change ineffective clinical practice(s). Spaced education harnesses the power of spacing, repetition and testing learning content to increase topic-specific knowledge. Although spaced education is widely used in undergraduate and postgraduate medical programmes, its effectiveness as a CPD delivery method that improves patient outcomes is less certain.

AIM

To determine the effectiveness of the spaced education CPD programmes to change targeted clinical knowledge and practice(s) to improve patient outcomes.

METHOD

A systematic review, appraising the spaced education CPD evidence generated from searching six specialist medical and psychosocial databases. Studies published in English peer-reviewed journals from 1 January, 2000 to 31 August, 2018 were eligible for inclusion. A modified Kirkpatrick four levels of evaluation framework assisted with appraising the effect of spaced education CPD interventions on clinicians and patients.

RESULTS

Of the 2396 studies identified, 17 met the inclusion criteria, involving 2701 practising clinicians from multiple disciplines and specialties. Five randomised controlled trials generated level II evidence, with the remaining 12 studies generating lower levels of evidence. The majority of studies (n = 14) involved the delivery of online spaced education. All studies were evaluated using the modified Kirkpatrick four levels of evaluation framework with: 10 studies demonstrating significant increases in participants' knowledge; seven studies reporting significant changes in clinician behaviour; four studies showing significant increases in clinician confidence; and three studies identifying significant and sustained increases in participants' clinical skills. Only two studies reported positive improvements in patient outcomes.

CONCLUSION

Spaced education via an online platform offers a scalable CPD format that can increase clinical knowledge and change practice. However, further adequately powered randomised controlled trials are required to confirm that spaced education CPD can impact positively on patients' reported outcomes.

Impact of a Training Intervention on the Pain Assessment in Advanced Dementia (PAINAD) Scale in Noncommunicative Inpatients

BACKGROUND

Public hospitals in Catalonia (Spain) recommend using the Spanish version of the Pain Assessment in Advanced Dementia (PAINAD-Sp) scale for assessing pain in adult patients unable to self-report. However, since its inclusion in Catalonian nursing care plans in 2010, there have been no training programs for nurses, contributing to its current underuse.

AIMS

The aim of this study was to assess the impact of a nurse training intervention on the PAINAD-Sp scale in noncommunicative inpatients unable to self-report.

DESIGN

Before-after study.

SETTINGS

Two public hospitals in Catalonia (Spain).

PARTICIPANTS/SUBJECTS

Four hundred and one nurses participated in the training course and 219 patients received PAINAD-Sp assessments.

METHODS

We used a before-after study design, evaluating the use of the PAINAD-Sp scale over two 6-month periods before and after an online training intervention for nurses in February 2017, in two public hospitals. Data were collected from patient records in each center. The primary outcome was the number of patients receiving PAINAD-Sp assessments during admission. Secondary outcomes were the number of assessments undertaken per patient during admission, the total (0-10) and item-specific (0-2) PAINAD-Sp score, and pharmacologic treatment administered.

RESULTS

There were 401 nurses who took part in the training program. Over the study period, 219 patients received PAINAD-Sp assessments: 29 in the preintervention period and 190 in the postintervention period (p < .001). Administration of analgesics and antipyretics decreased (p < .001) after the intervention, whereas use of hypnotic drugs and sedatives increased.

CONCLUSIONS

Theoretical and practical training may be an effective way to improve nurses' approach to identifying, assessing, and managing pain in patients unable to self-report.

A phase III wait-listed randomised controlled trial of novel targeted inter-professional clinical education intervention to improve cancer patients' reported pain outcomes (The Cancer Pain Assessment (CPAS) Trial): study protocol

Background

Variations in care models contribute to cancer pain being under-recognised and under-treated in half of all patients with cancer. International and national cancer pain management guidelines are achievable with minimal investment but require practice changes. While much of the cancer pain research over the preceding decades has focused on management interventions, little attention has been given to achieving better adherence to recommended cancer pain guideline screening and assessment practices. This trial aims to reduce unrelieved cancer pain by improving cancer and palliative doctors’ and nurses’ (‘clinicians’) pain assessment capabilities through a targeted inter-professional clinical education intervention delivered to participants’ mobile devices (‘mHealth’).

Methods

A wait-listed, randomised control trial design. Cancer and/or palliative care physicians and nurses employed at one of the six participating sites across Australia will be eligible to participate in this trial and, on enrolment, will be allocated to the active or wait-listed arm. Participants allocated to the active arm will be invited to complete the mHealth cancer pain assessment intervention. In this trial, mHealth is defined as medical or public health practice supported by mobile devices (i.e. phones, patient monitoring devices, personal digital assistants and other wireless devices). This mHealth intervention integrates three evidence-based elements, namely: the COM-B theoretical framework; spaced learning pedagogy; and audit and feedback. This intervention will be delivered via the QStream online platform to participants’ mobile devices over four weeks. The trial will determine if a tailored mHealth intervention, targeting clinicians’ cancer pain assessment capabilities, is effective in reducing self-reported cancer pain scores, as measured by a Numerical Rating Scale (NRS).

Discussion

If this mHealth intervention is found to be effective, in addition to improving cancer pain assessment practices, it will provide a readily transferable evidence-based framework that could readily be applied to other evidence practice gaps and a scalable intervention that could be administered simultaneously to multiple clinicians across diverse geographical locations. Moreover, if found to be cost-effective, it will help transform clinical continuing professional development. In summary, this mHealth intervention will provide health services with an opportunity to offer an evidence-based, pedagogically robust, cost-effective, scalable training alternative.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12618001103257. Registered on 3 July 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3152-z) contains supplementary material, which is available to authorized users.

Enhancing Cancer Pain Assessment and Management in Hospice

Pain is one of the most common symptoms in individuals with cancer and is directly associated with significantly reduced quality of life. The purpose of this project was to enhance assessment and management of cancer-related pain for patients in the hospice setting. Nurse attitudes and knowledge about pain were evaluated using the Nurses' Knowledge and Attitudes Survey Regarding Pain before and 6 weeks after an educational program. Nurses completed a pain assessment at each home visit and followed an algorithm based on the National Comprehensive Cancer Network Clinical Practice Guidelines to manage pain. Baseline data were collected on the last 30 patients admitted into hospice with cancer as the primary diagnosis before project implementation. Following the practice change, chart audits of the patients' reported pain and adherence to recommended management were manually extracted from 26 patient records. Results revealed statistically significant differences in acquired knowledge (t = 3.95, P < .05) and attainment of patient-identified pain goals (t = 23.904, P < .05). Patient-reported pain levels decreased by 21%, and comprehensive pain assessment completion rates increased by 10% during the project. Current knowledge of evidence-based pain interventions and a management algorithm improved pain control in patients with cancer.

An mHealth intervention to improve nurses’ atrial fibrillation and anticoagulation knowledge and practice: the EVICOAG study

Background:

There is a need to improve cardiovascular nurses’ knowledge and practices related to stroke prevention, atrial fibrillation and anticoagulation therapy.

Aims:

The aim of this study was to evaluate the efficacy of EVICOAG – a novel mHealth, smartphone-based, spaced-learning intervention on nurses’ knowledge of atrial fibrillation and anticoagulation.

Methods:

Nurses employed in four clinical specialties (neuroscience, stroke, rehabilitation, cardiology) across three hospitals were invited to participate. In this quasi-experimental study, 12 case-based atrial fibrillation and anticoagulation learning scenarios (hosted by an mHealth platform) were delivered to participants’ smartphones over a 6-week period (July–December 2016) using a spaced timing algorithm. Electronic surveys to assess awareness and knowledge were administered pre (T1) and post (T2) intervention.

Results:

From 74 participants recruited to T1, 40 completed T2. There was a 54% mean improvement in knowledge levels post-intervention. The largest improvement was achieved in domains related to medication interaction and stroke and bleeding risk assessment. Post-intervention, those who completed T2 were significantly more likely to use CHA2DS2-VASc (2.5% vs. 37.5%) and HAS-BLED (2.5% vs. 35%) tools to assess stroke and bleeding risk, respectively ( P<0.01).

Conclusion:

The EVICOAG intervention improved nurses’ knowledge of atrial fibrillation and anticoagulation, and influenced their uptake and use of stroke and bleeding risk assessment tools in clinical practice. Future research should focus on whether a similar intervention might improve patient-centred outcomes such as patients’ knowledge of their condition and therapies, medication adherence, time in the therapeutic range and quality of life.

Protocol for a phase III pragmatic stepped wedge cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of screening and guidelines with, versus without, implementation strategies for improving pain in adults with cancer attending outpatient oncology and palliative care services: the Stop Cancer PAIN trial

BACKGROUND

Pain is a common and distressing symptom in people with cancer, but is under-recognised and under-treated. Australian guidelines for 'Cancer Pain Management in Adults' are available on the Cancer Council Australia Cancer Guideline Wiki. This study aims to evaluate the effectiveness and cost-effectiveness of a suite of guideline implementation strategies for improving pain outcomes in adults with cancer in oncology and palliative care outpatient settings.

METHODS

The study will use a stepped-wedge cluster randomised controlled design, with oncology and palliative care outpatient services as the clusters. Patients will be eligible if they are adults with cancer and pain presenting to participating services during the study period. During an initial control arm, services will routinely screen patients for average and worst pain over the past 24 h using a 0-10 numerical rating scale (NRS) and have unfettered access to online guidelines. During the intervention arm, staff at each service will be encouraged to use: 1) a patient education booklet and self-management resource; 2) an online spaced learning cancer pain education module for clinicians from different disciplines; and 3) audit and feedback of service performance on key indices of cancer pain screening, assessment and management. Service-based clinical change champions will lead implementation of these strategies. The trial's primary outcome will be the probability that patients initially screened as having moderate-severe (≥5/10 NRS) worst pain experience a clinically important improvement one week later, defined as  ≥ 30% reduction. Secondary outcomes will include patient empowerment and quality of life, carer experience, and cost-effectiveness. For the main analysis, linear mixed models will be used, accounting for clustering and the longitudinal design. Eighty-two patients per service at six services (N = 492) will provide > 90% power. A qualitative sub-study and analyses of structural and process factors will explore opportunities for further refinement and tailoring of the intervention.

DISCUSSION

This pragmatic trial will inform implementation of guidelines across a range of oncology and palliative care outpatient service contexts. If found effective, the implementation strategies will be made freely available on the Wiki alongside the guidelines.

TRIAL REGISTRATION

Registered 23/01/2015 on the Australian New Zealand Clinical Trials Registry ( ACTRN12615000064505 ).