American Society for Pain Management Nursing and Hospice and Palliative Nurses Association Position Statement: Pain Management at the End of Life

Utilizing Dexmedetomidine for Opioid-Resistant Pain and Anxiety in the Palliative Care Unit: A Case Report on Efficacy, Withdrawal Challenges, and Protocol Adaptations

Dexmedetomidine (Precedex™) has proved useful in palliating anxiety and intractable pain in patients at the end of life. However, abrupt cessation can precipitate withdrawal, which is highly unpleasant and potentially dangerous. Here, we present the case of a patient whose intractable pain was successfully palliated with a dexmedetomidine infusion but who then developed severe withdrawal when the infusion was stopped with a change in her plan of care. We present a review of the literature around transitioning patients off dexmedetomidine and highlight the need for more guidance on nonintensive care unit management of its side effects and alternatives.

A Clinical Consult to Explain the Biofeedback Process

CLINICAL ISSUE

Psychophysiological assessments and biofeedback-based interventions for chronic for chronic pain can be highly effective. The purpose of this clinical consultation was to provide an overview of the psychophysiological assessment process and present a primer on biofeedback for chronic pain. The biofeedback process was presented by a biofeedback content expert, with photos and diagrams.

PRACTICE RECOMMENDATIONS

Nurses advocate for non-pharmacological pain interventions. However, biofeedback is a practice that has been overlooked and underutilized in nursing. This clinical consultation is meant to educate clinical nurses on psychophysiological assessment and biofeedback for chronic pain.

Using 'Situation-Background-Assessment-Recommendation' Method in Palliative Care to Enhance Handover Quality and Nursing Practice: A Mix Method Study

AIM

To evaluate the impact of using 'Situation-Background-Assessment-Recommendation' method ('SBAR') in a palliative care setting.

BACKGROUND

Effective handover communication is crucial for patient safety. Standardised communication tools, such as the SBAR method, are recommended to reduce errors and improve care coordination, but their use in palliative care is not investigated.

DESIGN

Mixed method study design, adhering to the GRAMMS guideline.

METHODS

From January to October 2021, a SBAR guide tailored for palliative care was developed using the Delphi method and implemented in a Hospice setting. Data on 150 nurse handovers were collected before and after implementation to assess changes in nursing outcomes, including medication errors, adverse events and the identification of psychological and spiritual needs. Nurses' perceptions on the handover process were gathered through a qualitative survey.

RESULTS

The SBAR guide significantly improved the handovers quality, reducing medication errors and eliminating adverse events postimplementation. The identification of psychological and spiritual needs increased during postimplementation period. Nurses also reported improved clarity, accuracy and completeness of information during handover.

CONCLUSION

This is the first study to evaluate the impact of SBAR for handover in palliative nursing care. Findings show the added value of using communication tools.

Postoperative pain management practice and associated factors among nurses working at public hospitals, in Oromia region, Ethiopia, 2021: an institution-based cross-sectional study

BACKGROUND

Management of postoperative pain leads to positive patient progress and shortens the duration of hospital stay. There is a lack of information on nurse's postoperative pain management practice and its associated factors.

OBJECTIVE

To assess postoperative pain management practice and associated factors among nurses working in public hospitals of West Shoa Zone, Oromia, Ethiopia, 2021.

DESIGN

An institutional-based cross-sectional study was employed.

SETTING

Study was conducted among eight public hospitals (two tertiary hospitals and six secondary hospitals), which were located in West Shoa Zone in Oromia, Ethiopia.

PARTICIPANTS

Totally 377 participants were selected by using simple random sampling. From this, 277 were men and 100 participants were women. All nurses who were worked in surgical ward, medical wards, minor operation room and major operation room, recovery rooms, emergency, obstetrics and gynaecology wards were included.

METHODS

Data were collected by distributing structured self-administered questionnaires that adapted from different literatures and were entered into Epi data V.3.1 and exported to SPSS V.22 for analysis. Variables with significant association in the bivariate analyses were entered into a multivariable regression analysis to identify the independent factors associated with nurses' postoperative pain management practice. Significant factors were declared at p<0.05.

RESULT

The result showed that 66% of nurses had good pain management practice. Nurses favourable attitude towards postoperative pain management (adjusted OR (AOR): 4.698, 95% CI (2.725 to 8.100)), having access to read pain management guideline (AOR: 3.112, 95% CI (1.652 to 5.862)), adequate knowledge of postoperative pain management (AOR: 2.939, 95% CI (1.652 to 5.227)), working at operation room (AOR: 2.934, 95% CI (1.27 to 6.795)) and received training on pain management (AOR: 3.289, 95% CI (1.461 to 7.403)) were significantly associated with the practices of postoperative pain management.

CONCLUSION AND RECOMMENDATION

65% of participants (nurses) have a good level of practice of postoperative pain management. Training, access to pain management guidelines, knowledge and attitude are significant factors in postoperative pain management practice. Governmental and other bodies concerned to postoperative care quality needs to show commitment on availing needed training and infrastructures.

Relationship Between Primary Caregiving Type and a Peaceful End-Of-Life Experience Among Older Adults in China

Few studies have compared pain management provided by informal and formal caregivers of older adults in China at the end of life. This study aims to address this gap by investigating the association between formal and informal care and painfulness at the end of life among older adults in China. Specifically, the study focuses on the influence of various types of informal care. Data were obtained from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) conducted from 2002 to 2018, which is the largest nationally representative study of older adults in China, with a sample size of 21,849 deceased participants. Results from multiple logistic regressions suggest that informal care is associated with a more painful end-of-life experience compared to formal care, with care provided by adult children being a more favorable option within informal care. These findings underscore the urgent need to prioritize education on death and dying, improve the formal care system, and enhance professionalism within informal care.

Continuous Ambulatory Delivery Device Use for Patients Managed by an Inpatient Palliative Care Team

BACKGROUND

The use of Patient Controlled Analgesia (PCA) via a Continuous Ambulatory Delivery Device (CADD) is a common and effective means of pain and symptom management for hospitalized patients with a malignancy. Studies exploring the indications for starting such a device for hospitalized inpatients referred to inpatient palliative care teams are limited.

AIM

This retrospective chart review aims to explore indications, timing of initiation, and barriers to the use of a CADD.

METHODS

Over a six month period, during daily inpatient palliative care consult team rounds, patients who required a CADD were enrolled in this study. Sixty-one adult patients were identified who required a pump for symptom control. The team's database sheets were used to capture patient demographics.

RESULTS

The main reasons for initiating a Continuous Ambulatory Delivery Device in the above setting included: lack of efficacy of oral opioids and to increase patient autonomy of their pain management. Approximately 20% of patients required transfer to another unit that could accommodate the CADD. The median length of stay for these patients was 13 days, with a median length of half a day for a pump to be started.

CONCLUSIONS

This initial study provides the Palliative Care Consult Team with information on the indications for the use of a CADD. The lack of universal access to a CADD in various areas of our hospital due to differences in departmental protocols may compromise good symptom management and patient safety. These results strengthen the argument that the existing hospital policy requires revamping to improve CADD access. A CADD has been shown to provide hospitalized patients, with a malignancy, with timely access to effective symptom management, and in turn, reducing their length of stay in hospital. These findings will help inform this organization's CADD policy and support the need to broaden access to this device.

Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients

BACKGROUND

Central to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering.

AIMS

The purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients.

DESIGN

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks.

SETTINGS

On a six-bed adult inpatient Palliative Care Unit (PCU).

PARTICIPANTS/SUBJECTS

Nonverbal palliative care patients.

METHODS

Evidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption.

RESULTS

Nurses' attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores.

CONCLUSIONS

MOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

Attending to the Moral Meaning of Pain

In addition to a physical and emotional experience, pain is also a morally infused experience with deep, often subconscious, meaning for many sufferers. Whether justified or not, for many people, pain may represent loss, judgement, unworthiness, abandonment, punishment, and even existential suffering and thoughts of death. The moral meaning of pain is what influences the associated experiences of stigma, loneliness, and guilt that contribute to suffering. It is why nurses and other healthcare practitioners have long adhered to a moral obligation to treat those with pain, implying a duty to attempt to make right the wrong of undeserved suffering. Yet the moral meaning of pain is rarely discussed and is often overlooked when establishing a relationship with and a treatment plan for a person with pain. It is the unattended moral meaning of pain that may contribute to unnecessary suffering, futile treatment, and even moral dilemmas in establishing care. In this paper, I explore the definition of morality itself, the moral meaning of pain, and its implications for care. I discuss how moral pluralism in contemporary society contributes to various moral perceptions that influence a person's pain experience and how their pain is treated. Finally, I make the case that using a narrative approach to intentionally look for moral meaning in an individual's pain story may reveal opportunities for more effective pain management options.

Improvement in Nurses' Knowledge of Subcutaneous Catheter Use for Pain Management

BACKGROUND

Nurses often have insufficient knowledge of subcutaneous catheter use for pain management. This quality improvement project evaluated implementation of an evidence-based subcutaneous catheter nursing policy with education to improve pain management for hospitalized patients.

METHOD

A convenience sample of nurses (N = 515) completed a posttest after online training on effective subcutaneous pain management. Patient pain ratings were assessed to evaluate whether they changed after nurses' training.

RESULTS

Posttest scores showed the online learning module effectively contributed to nurses' knowledge of subcutaneous catheter pain management. A statistically significant reduction occurred in patient pain ratings (p < .001) postintervention. The number of patients experiencing moderate or severe pain decreased by 58%, for a significant reduction in pain.

CONCLUSION

An online learning module was successful in educating nurses on pain medication administration through an indwelling subcutaneous catheter. [J Contin Educ Nurs. 2024;55(1):13-20.].

Attitude toward care of the dying and practice of peaceful end-of-life care in community hospitals in China

AIM

To evaluate nurses' attitude toward caring for dying patients, their practice of peaceful end-of-life care in community hospitals, and the association between these two variables.

BACKGROUND

Community hospitals play an important role in the peaceful end-of-life care. For nurses, one of the key points of offering high-level care is to improve attitude. However, there are very few studies exploring how the attitude of nurses toward caring for dying patients relates to the practice of peaceful end-of-life care in community hospitals across China.

METHODS

A total of 363 questionnaires were included in this study. Simple random sampling was used to recruit participants from six community hospitals in China. A new instrument, Nurses' Practice of Peaceful End-of-Life Care Instrument (NP-PECI), was developed according to the Theory of Peaceful End of Life to assess the practice of nurses. Besides, Frommelt Attitudes toward Care of the Dying (FATCOD) was adopted to assess nurses for their attitude toward caring for dying patients.

RESULTS

The nurses' attitude toward caring for dying patients showed a significant positive correlation with their practice of peaceful end-of-life care statistically (r = 0.175, p < 0.01).

CONCLUSION

For community nurses, it is necessary to improve the attitude of nurses toward the practice of caring for dying patients, thus enhancing the outcome of peaceful end-of-life care.

IMPLICATIONS FOR NURSING PRACTICE

The Theory of Peaceful End of Life provides a theoretical framework and guideline on the practice of clinical nursing for quality control of peaceful end-of-life care, which is significant for improving the palliative care system. In the future, it is worth developing programs based on the Theory of Peaceful End of Life.

IMPLICATIONS FOR NURSING POLICY

For healthcare policy makers, this study can be helpful to refine the existing palliative care support policies and strategies targeted at community hospitals and their nurses.

Family Caregiver Challenges in Pain Management for Patients with Advanced Illnesses: A Systematic Review

Although pain management is integral to the caregiving role, there is a paucity of evidence synthesizing specific challenges family caregivers (FCs) face when managing pain for their care partners. This review comprehensively identified and summarized such challenges in the setting of advanced illnesses. Electronic databases (PubMed, CINAHL, PsycINFO, Scopus, and Health and Psychosocial Instruments) were searched using index and keyword methods for all articles published before April 2021. Fifty-five studies were included in this review. Most articles were published within the last 10 years (54%) in community settings, with home hospice care comprising the majority (50%). Most studies included patients with an advanced cancer diagnosis (84%), and 16% of the studies included patients with a noncancer diagnosis. Four major categories of challenges were identified: (1) caregiver-related issues (e.g., fears, beliefs, function), (2) caregivers' limited knowledge and skills in pain management (e.g., verbal and nonverbal pain assessment skills, pharmacological knowledge, documentation, safe management of medication), (3) communication challenges with health care providers, and (4) patient-related issues (e.g., inability to report pain). Many of these challenges have not been fully addressed in prior literature. Thus, this review provides a framework for needed future research to develop interventions that target FCs' specific challenges in providing pain management. The results also highlight a significant lack of research surrounding challenges faced by caregivers of care partners having a noncancer, dementia, or multimorbidity diagnosis.

Managing symptoms at the end of life: a guide for non-palliative care nurses

Nurses, regardless of their area of practice, may have to care for a person in their last days and hours of life. However, many nurses outside of specialist palliative and end of life care settings do not feel adequately prepared for this. Nurses can usually obtain advice from specialists working in local hospices or palliative care centres, but they may still find it challenging to act on that advice if it is not underpinned by their own knowledge base. This article provides a guide to assist non-palliative care nurses in recognising dying and managing common symptoms at the end of life.

Exploring Hospice Nurses' Viewpoints on End-of-Life Practices and Assisted Dying: A Thematic Analysis

This qualitative study explores the viewpoints of hospice nurses about end-of-life issues and proposed legislation that would allow assisted dying/euthanasia to be performed in New Zealand. The study uses data that were obtained from in-depth interviews with 15 experienced Palliative Care Nurses who were all working at various hospices around New Zealand. A thematic analysis process was used to develop a thematic framework, and the results indicated that there were at least 3 main themes supported by a number of related subthemes. These main themes were as follows: (a) personal values converge with professional ones when hospice nurses are asked to offer their viewpoints, (b) common end-of-life practices are not regarded by hospice nurses as acts of euthanasia, and (c) hospice nurses are greatly concerned about the effects of a euthanasia law on their profession and its relationships with the public. Our findings reveal that the hospice nurses in New Zealand largely hold negative viewpoints about the introduction of legalized assisted dying practices, arguing that such changes will present major challenges to their perceived role within their profession and within society. These findings suggest that this research should have a considerable primary impact among hospice and palliative care nurses in other nations.

When Management of Cancer-Related Pain Is Complicated by Coexisting Opioid Use Disorder: A Case Review

Patients with cancer are living longer, and many experience pain secondary to tumor invasion or as a consequence of cancer-directed therapies. Opioid use disorders and associated morbidity and mortality have increased with dramatic rise during the SARS-CoV-2 pandemic. National and international stakeholders have developed clinical practice guidelines in an effort to curb opioid misuse and overdose-related death. However, to ensure that patients with cancer do not experience barriers to adequate pain management, most of these guidelines are not intended for patients with cancer-related pain or for those receiving palliative or hospice care. Oncology, palliative, and hospice care providers are increasingly tasked with the management of severe disease-related pain in the setting of coexisting opioid use disorder without research on the most effective risk and harm reduction strategies to guide care. Clinicians should be familiar with addiction medicine and chronic pain literature and be able to incorporate some of these best practices. This case study reviews the management of severe cancer-related pain in a patient with co-occurring opioid use disorder, utilizing many of the best practices in available clinical practice guidelines for the management of chronic non-cancer-related pain.

Chronic Obstructive Pulmonary Disease Symptom Cluster Composition, Associated Factors, and Methodologies: A Systematic Review

This systematic review details symptom clusters, their compositions, and associated factors and appraises the methodologies of studies that reported symptom clusters in patients with chronic obstructive pulmonary disease (COPD). Ten studies were eligible for inclusion in this study. Four common symptom clusters were identified. Two theoretical frameworks, four statistical methods, and various symptom assessment tools were used to identify symptom clusters. Factors associated with symptom clusters included demographic, clinical, and biological factors. No studies examined the subjective experiences of symptom clusters. Overall, inconsistencies were identified in the composition of symptom clusters across studies. This may be due to variations in study design, assessment tools, and statistical methods. Future studies should attempt to arrive at a common definition, especially that is theoretically derived, for symptom clusters, standardize the criteria for symptoms for inclusion in the clusters, and focus on patients' subjective experience to inform which clusters are clinically relevant.

A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse

BACKGROUND

Nursing brings a unique lens to care of patients with pain and opioid misuse.

AIMS

This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care.

DESIGN

The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.

DATA SOURCES

Using combined key terms ("opioid misuse," "pain," "nursing") in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites.

ANALYSIS METHOD

Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature.

RESULTS

Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108).

CONCLUSION

Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse.

IMPLICATIONS FOR NURSING

This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.

Impact of a Nurse-Driven Opioid Titration Protocol on Quality of Orders at End of Life

At our community teaching hospital, orders for end of life often lacked instructions to titrate opioids based on evidence-based principles and failed to address nonpain symptoms. An order set and a nursing-driven opioid titration protocol were implemented in August 2016 after extensive education. The purpose of this retrospective preintervention and postintervention study was to evaluate the impact of this intervention on the quality of end-of-life orders. We evaluated 69 patients with terminal illness receiving morphine infusions. After implementation, more morphine infusion orders included an as-needed bolus dose with an objective indication and appropriate instructions on when and how to titrate the infusion compared with before the intervention (94.6% vs 18.8%, P < .0001). Morphine infusion orders were also significantly more likely to include a maximum dose (P = .041) and an initial bolus dose (P < .0001). In addition, prescribers were more likely to order additional medications to manage nausea/vomiting, constipation, anxiety, or pain using a nonopioid (P < .05 for all). In this study, implementation of a standardized opioid titration protocol and symptom management order set led to an improvement in the quality of morphine infusion orders for pain management at the end of life and increased the use of medications to manage nonpain symptoms in dying patients.

Afrontamiento de docentes de enfermería ante la muerte del paciente en unidades de cuidado crítico

Introducción. La muerte es un fenómeno que preocupa a la humanidad, por tanto, es objeto de cuidado por enfermería como parte de las competencias inherentes a la disciplina. Objetivo. Describir el nivel de afrontamiento de las enfermeras frente a la muerte de pacientes en unidades de cuidado crítico. Método. Estudio piloto observacional, de tipo descriptivo transversal, con método de muestreo probabilístico, teniendo en cuenta el número de enfermeras que se desempañaban como docentes de enfermería en el área de cuidado crítico de cuatro universidades de Pereira y Manizales (n = 30). Se aplicó encuesta autoadministrada, elaborada por las investigadoras, con datos sociodemográficos, curriculares y del perfil docente. Para evaluar el nivel de afrontamiento, se utilizó la escala de Bugen de afrontamiento de la muerte, validada al castellano. Resultados. El 100% de docentes de enfermería tuvo una experiencia cercana a la muerte con algún ser querido, y el 73.3% no había tenido ninguna preparación como enfermera acerca de la muerte, lo que se puso de manifiesto según la escala de Bugen, donde el 36.8% (n = 11) de la población puntuó por debajo del percentil 33, el 33.4% (n = 10) de la población por encima del percentil 66, y el 29.9% (n = 9) puntuó en la zona intermedia. Conclusión. Las enfermeras necesitan mejorar su nivel de afrontamiento ante la muerte, mediante una formación sólida en cuidados integrales al final de la vida y el buen morir, para lograr competencias específicas que puedan ser enseñadas en los actos docentes de manera consciente.

Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers

BACKGROUND

Transitioning from the hospital to community is a vulnerable point in patients' care trajectory, yet little is known about this experience within the context of palliative care. While some studies have examined the patient and caregiver experience, no study to date has synthesized the literature on the healthcare provider's perspective on their role and experience facilitating these transitions.

AIM

The purpose of this systematic review was to understand the experience and perspective of healthcare providers who support the transition of patients receiving palliative care as they move from acute care to community settings.

DESIGN

A qualitative systematic review of studies using thematic analysis as outlined by Thomas and Harden. PROSPERO: ID # CRD42018109662.

DATA SOURCES

We searched four databases: MEDLINE, Embase, ProQuest and CINAHL for studies published in English from 1995 until May 22, 2020. Four reviewers screened records using the following selection criteria: (1) peer-reviewed empirical study, (2) adult sample, (3) qualitative study design, (4) perspective of healthcare providers, and (5) included a component of transitions between acute to community-based palliative care. Study findings were analyzed using thematic analysis which entailed: (1) grouping the findings into recurring themes; (2) iteratively referring back to the articles to obtain nuances of the theme and quotations; and (3) defining and solidifying the themes.

RESULTS

Overall 1,791 studies were identified and 15 met inclusion criteria. Studies were published recently (>2015, n = 12, 80%) and used a range of qualitative methods including semi-structured interviews, focus groups, and field interviews. Three core themes related to the role and experience of healthcare providers were identified: (1) assessing and preparing for transition; (2) organizing and facilitating the logistics of transition; and (3) coordinating and collaborating transitional care across sectors. The majority of studies focused on the discharge process from acute care; there was a lack of studies exploring the experiences of healthcare providers in the community who receive patients from acute care and provide them with palliative care at home.

CONCLUSION

This review identified studies from a range of relatively high-income countries that included a diverse sample of healthcare providers. The results indicate that healthcare providers experience multiple complex roles during the transition facilitation process, and future research should examine how to better assist clinicians in supporting these transitions within the context of palliative care provision.

Original Research: Understanding Nursing Home Staff Attitudes Toward Death and Dying: A Survey

BACKGROUND

Nearly 70% of nursing home residents are eligible for palliative care, yet few receive formal palliative care outside of hospice. Little is known about nursing home staff attitudes, knowledge, skills, and behaviors related to palliative care.

METHODS

We administered a modified survey measuring attitudes toward death to 146 nursing home staff members, including both clinical and nonclinical staff, from 14 nursing homes.

RESULTS

Nursing home staff generally reported feeling comfortable caring for the dying, but half believed the end of life is a time of great suffering. Pain control (63%), loneliness (52%), and depression (48%) were the most important issues identified with regard to these patients, and there was ambivalence about the use of strong pain medications and the utility of feeding tubes at the end of life. Top priorities identified for improving palliative care included greater family involvement (43%), education and training in pain control (50%) and in management of other symptoms (37%), and use of a palliative care team (35%) at their facility.

CONCLUSIONS

Findings show there is a need for more palliative care training and education, which should be built on current staff knowledge, skills, and attitudes toward palliative care.

Feasibility of e-Pain Reporter: A Digital Pain Management Tool for Informal Caregivers in Home Hospice

Informal hospice caregivers often have difficulty managing patient pain at home. We developed a digital application, e-Pain Reporter, for informal caregivers to record and providers to monitor patient pain and pain management. The purpose of this study was (1) to assess the feasibility of informal caregivers using the e-Pain Reporter for 9 days in home hospice by investigating recruitment and retention and caregiver satisfaction with and frequency of use of the e-Pain Reporter and (2) describe patient pain characteristics and caregiver's barriers to pain management and self-efficacy in providing patient care in the home. One-group pre-post design was used. Patient-caregiver dyads were recruited from 1 hospice agency. Caregivers were asked to report all patient pain and pain management using the e-Pain Reporter. Feasibility of the e-Pain Reporter was assessed by the average number of times caregivers recorded breakthrough and daily pain and caregiver satisfaction with the app. The 27-item Barriers Questionnaire II and 21-item Caregiver Self-efficacy Scale were administered at baseline. Fourteen dyads enrolled, 2 patients died, and 12 dyads completed the study. Mean number of pain reports over 9 days was 10.5. Caregivers reported high overall satisfaction with the e-Pain Reporter. Barriers scores were moderately high, suggesting erroneous beliefs and misconceptions about pain reporting and use of analgesics, but self-efficacy in managing pain was also high (93% confidence). Findings suggest that the e-Pain Reporter is a feasible method to report and monitor caregiver management of pain at home. Caregiver high barriers and high overconfidence suggest the need for an educational component to the e-Pain Reporter to address misconceptions about pain and pain management.

Racial Differences in Pain Management for Patients Receiving Hospice Care

OBJECTIVES

To investigate racial differences in implementation of 11 evidence-based cancer pain management strategies in a matched sample of patients in hospice.

SAMPLE & SETTING

32 African American and 32 Caucasian American older adults (aged 65 years or older) with cancer pain receiving hospice care in the midwestern United States.

METHODS & VARIABLES

Matched cohort secondary data analysis of postintervention data in a cluster randomized controlled trial was used. Main outcomes are the summative and individual Cancer Pain Practice Index scores.

RESULTS

There were few statistically significant or clinically meaningful differences in implementation of individual best practices for pain management by race. Assessment of primary pain characteristics and management of opioid-induced constipation with a bowel regimen was significantly lower in African Americans than in Caucasian Americans.

IMPLICATIONS FOR NURSING

African American older adults receiving hospice care at the end of life received pain management that was, overall, comparable to matched Caucasian American older adults. Hospice and oncology nurses play a critical role in effective pain management and should continue to implement evidence-based guidelines for pain management into daily practice. Diffusing the hospice model and principles of pain and symptom management into other settings and specialty care areas may reduce widespread pain disparities.

Validation of the Critical Care Pain Observational Tool in Palliative Care

PURPOSE

Pain assessment at the end of life remains a problem for patients who are unable to self-report their pain when transitioning across care settings. This study therefore tested the internal consistency and discriminant, concurrent, and convergent validity of the Critical-Care Pain Observational Tool (French version) when used with end-of-life patients in a palliative care setting.

DESIGN

This was a descriptive correlational study that used a repeated-measures within-subjects prospective design.

METHODS

The pain of 13 patients was assessed when at rest and during turning.

RESULTS

The internal consistency reliability coefficient alphas were .64 at rest and .70 during turning. Discriminant validity was shown by a decrease in the total Critical-Care Pain Observation Tool score. Concurrent validity was demonstrated by the association between the patients' self-report of pain and the Critical-Care Pain Observation Tool score at rest (0.65, p < .016) and during turning (0.77, p = .002). Finally, the convergent validity between the Critical-Care Pain Observation Tool score and the Algoplus scale score was demonstrated with a Spearman's correlation coefficient of 0.76 at rest and 0.84 during turning.

CONCLUSIONS

The results suggest that the Critical-Care Pain Observation Tool can be used with end-of-life patients in French-speaking countries.

Steps to Develop a Mobile App for Pain Assessment of Cancer Patients: A Usability Study

Health-related mobile apps have the potential to allow patients and providers to proactively and responsibly manage pain together. However, there is a gap between the science of pain and current mobile apps. To develop a prototype science-based pain assessment mobile app (PainSmart) for Android smartphones, pain assessment tasks were extracted from a clinical guideline. These tasks were then converted to activity diagrams and became the logic of PainSmart. Five participants diagnosed with breast cancer evaluated usability of PainSmart with the System Usability Scale. Patient experience was recorded using Camtasia Studio Version 9 software. The five participants were able to explore the pain app after only 20 minutes of training. Using the System Usability Scale with comments, participant mean usability score was 77.5; above 68 is considered an above average system. A prototype of a pain assessment mobile app for cancer patients demonstrated high usability and will be refined based on participant feedback.

Perceptions of Palliative Care Nurses Related to Death and Palliative Care Practices

This study has been conducted with the purpose of identifying the perceptions of palliative nurses about death and determining palliative care practices. We conducted qualitative interviews with 23 palliative care nurses in Turkey. Content analysis was used in the evaluation of the data. Three themes have been identified about perception of death. Furthermore, three themes have been identified about palliative care practices. It was concluded that the palliative nurses perceive death as a natural and inevitable process and that as long as their working period increases, they become desensitized. It was identified that the participants generally perform the following procedures in palliative care practices.

Methodological challenges in conducting instrumentation research in non-communicative palliative care patients

Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Validation of the Spanish Version of the Pain Assessment in Advanced Dementia Scale (PAINAD-Sp) in Hospitalized Patients with Neurologic Disorders and Oncologic Patients Unable to Self-Report Their Pain

BACKGROUND

Pain has a significant impact on hospitalized patients and is a quality indicator for nursing care. The Pain Assessment in Advanced Dementia (PAINAD) scale measures pain in people with communication disorders and advanced dementia, but it has not been validated in any other population.

AIMS

The aim of this study was to validate the Spanish version (PAINAD-Sp) in hospitalized patients with neurologic disorders and in end-of-life cancer patients with difficulty self-reporting.

DESIGN

The study had two phases: (1) analysis of the content by a committee of experts and (2) a cross-sectional study.

SETTINGS

We collected phase 2 data from January 2017 to December 2017 in four hospitals in Barcelona: Hospital Germans Trias i Pujol, Institut Català d'Oncologia, Hospital Vall d'Hebron, and Hospital de Bellvitge.

PARTICIPANTS/SUBJECTS

We included all adults who had either a neurological disorder affecting language or an oncological disease with an end-of-life prognosis and difficulty self-reporting pain. We excluded patients with a diagnosis of dementia.

METHODS

The cross-sectional study included 325 patients who were simultaneously evaluated by two observers both at rest and in movement. We analyzed psychometric properties in terms of construct validity, reliability, and sensitivity to change.

RESULTS

We obtained Cronbach α > .70 in both situations and an inter-rater reliability of 0.80. Confirmatory factor analysis indicated that the model adjusted adequately to a unidimensional structure. In terms of sensitivity to change, the mean difference was greater in movement than at rest (difference in means was 1.15).

CONCLUSIONS

The PAINAD-Sp_Hosp scale had good psychometric qualities in terms of validity and reliability in neurology and oncology patients unable to self-report pain.