Patients' and nurses' assessment of cancer pain

The Abbey Pain Scale: not sufficiently valid or reliable for assessing pain in patients with advanced cancer

BACKGROUND

Patients with advanced cancer can be unable to verbalize their pain. The Abbey Pain Scale (APS), an observational tool, is used to assess pain in this setting, but has never been psychometrically tested for people with cancer. The aim of this study was to assess the validity, reliability, and the responsiveness of the APS to opioids for patients with advanced cancer in a palliative oncology care setting.

MATERIAL AND METHODS

Patients with advanced cancer and poor performance status, drowsiness, unconsciousness, or delirium, were assessed for pain using a Swedish translation of the APS (APS-SE) and, if possible, the Numeric Rating Scale (NRS). The assessments using APS were conducted simultaneously, but independently, by the same raters on two separate occasions, approximately one hour apart. Criterion validity was assessed by comparing the APS and NRS values using Cohen's kappa (κ). Inter-rater reliability was determined using the intraclass correlation coefficient (ICC), internal consistency using Cronbach's α, and responsiveness to opioids using the Wilcoxon signed-rank test.

RESULTS

Seventy-two patients were included, of whom n = 45 could rate their pain using the NRS. The APS did not detect any of the n = 22 cases of moderate or severe pain self-reported using the NRS. The APS at first assessment had a κ of 0.08 (CI: -0.06 to 0.22) for criterion validity, an ICC of 0.64 (CI: 0.43-0.78) for inter-rater reliability, and a Cronbach's α of 0.01 for internal consistency. The responsiveness to opioids was z = -2.53 (p = 0.01).

CONCLUSION

The APS was responsive to opioids but displayed insufficient validity and reliability and did not detect moderate or severe pain as indicated by the NRS. The study showed a very limited clinical use of the APS in patients with advanced cancer.

[Improving the quality of cancer pain management in palliative care unit: Targeted clinical audit]

Goal This study aims to assess the quality of the cancer pain management in Palliative care unit.

METHOD

The method used was the targeted clinical audit. The audit grid was built according to the recommendations of the pilot Committee, and tested until the final version with 19 items was obtained. In this retrospective study, 60 consecutive patients were studied on 2 periods of time. The first one (T1) shows the gap between the patient's chart and the expected standard, and proposes corrective measures. The second one (T2) re-assesses, using the same items list, the efficacy of these measures.

RESULTS

After the corrective measures, the patients' medical record documentation was significantly improved at T2 for: neuropathic pain assessment improved, from 3% (T1) to 67% (T2) (P<0.001), so did pain assessment during the titration, from 6.7% (T1) to 90% (T2) (P<0.001). The overdoses symptoms assessment improved from 17% at T1 to 93% at T2, (P=0.002) and breakthrough pain evaluation improved from 3% at T1 to 73% at T2, (P<0.001). The pain reassessment after the rescue doses improved from 10% at T1 to 73% at T2 (P<0.001). The other points improved but not significantly.

CONCLUSION

The quality of the pain cancer management was improved during the audit, but some points (patient education and in patient medical record documentation) can be improved. We need to continue to implement the improvement measures in our unit.

Nursing staff, patient, and environmental factors associated with accurate pain assessment

CONTEXT

Although pain ranks highly among reasons for seeking care, routine pain assessment is often inaccurate.

OBJECTIVES

This study evaluated factors associated with nurses (e.g., registered) and other nursing support staff (e.g., licensed vocational nurses and health technicians) discordance with patients in estimates of pain in a health system where routine pain screening using a 0-10 numeric rating scale (NRS) is mandated.

METHODS

This was a cross-sectional, visit-based, cohort study that included surveys of clinic outpatients (n=465) and nursing staff (n=94) who screened for pain as part of routine vital sign measurement during intake. These data were supplemented by chart review. We compared patient pain levels documented by the nursing staff (N-NRS) with those reported by the patient during the study survey (S-NRS).

RESULTS

Pain underestimation (N-NRS<S-NRS) occurred in 25% and overestimation (N-NRS>S-NRS) in 7% of the cases. Nursing staff used informal pain-screening techniques that did not follow established NRS protocols in half of the encounters. Pain underestimation was positively associated with more years of nursing staff work experience and patient anxiety or post-traumatic stress disorder and negatively associated with better patient-reported health status. Pain overestimation was positively associated with nursing staff's use of the full NRS protocol and with a distracting environment in which patient vitals were taken.

CONCLUSION

Despite a long-standing mandate, pain-screening implementation falls short, and informal screening is common.

Use of the Greek McGill Pain Questionnaire in cancer patients

Cancer directly causes pain and raises a significant clinical problem. Pain is the most dominant cause of suffering in cancer patients. The accurate assessment of pain is a prerequisite for its effective relief, and therefore, a universal methodology for the assessment of the pain status of a patient is required. There are many different methods and various instruments for the measurement of pain. The McGill Pain Questionnaire is a multidimensional instrument for the assessment of pain intensity and the multiple dimensions of the pain experience. Several translations and version of the McGill Pain Questionnaire exist. The Greek version was developed in Athens and has been tested for its use in cancer patients receiving palliative care. The Greek McGill Pain Questionnaire validation study provided preliminary evidence of the validity and reliability of the questionnaire. Future studies are needed to confirm the validity of the instrument in order to render it fully utilizable for the assessment of pain caused by the diverse conditions experienced by Greek patients.

Exploring understanding of the term nursing assessment: a mixed method review of the literature

BACKGROUND

Much skilled nursing practice is described by words that at face value appear low-tech and self-explanatory. Despite being intrinsic to practice, the term "nursing assessment" has few operational definitions. Evidence-based practice and the quality agenda makes it imperative that this term is well understood.

OBJECTIVES

To contribute to the evidence base and facilitate a greater understanding of assessment of patients as carried out by nurses through exploring the research question: How is the term "nursing assessment" used in the current health care literature?

DESIGN

The review process, synthesised from the work of Greenhalgh et al. (2005), Clancy (2002), Egger et al. (2001), identified and assessed the quality of articles, text books, the grey literature, policy documents and databases. Glaser's Grounded Theory (GT) method was utilised to analyse the concept of "assessment" as exemplified within the included studies.

METHODS

The focus for this mixed-method review is the health care literature between 1990 and 2005. Studies were identified, screened and assessed for methodological quality and data were extracted and recorded. Analysis of the included studies was facilitated using a GT approach. Possible tensions when using a mixed-method research design are acknowledged and briefly discussed.

RESULTS

Of the 32,602 instances initially identified, 329 articles, policy documents and book extracts were closely read and after further screening, 120 articles and 12 policy documents and book extracts were analysed. Seven overlapping categories were identified, with "judicial" or "judgement making" identified as the core category.

CONCLUSIONS

Hierarchies of nursing practice, government policies and inter-professional agendas cause barriers to meaningful assessment. Informal and formal assessments and screening processes are often conflated, resulting in confusion regarding the scope and nature of the process. Differences between the rhetoric of placing the patient at the heart of the assessment process and practice have been identified.

Percepção de profissionais da saúde sobre aspectos relacionados à dor e utilização de opióides: um estudo qualitativo

A dor é um problema de saúde pública cujo manejo tem apresentado diversas deficiências. Esta pesquisa avalia a percepção e conhecimento de profissionais de saúde a respeito do tema dor e aspectos relacionados à utilização de medicamentos opióides, como legislação, efeitos colaterais, crenças, medo e preconceito. A pesquisa realizada foi exploratória qualitativa, aplicada na forma de entrevistas focais. A amostra estudada foi estratificada, aleatória, composta por trinta profissionais farmacêuticos, médicos e enfermeiros. Observou-se nesse trabalho a necessidade de os profissionais da saúde se familiarizarem mais com o tema, independente de terem demonstrado conhecimento em alguns aspectos. Foi observado conhecimento mais evidente com relação aos efeitos colaterais nas classes farmacêutica e médica, enquanto que na enfermagem o conhecimento maior foi relacionado com as escalas analgésicas. Foram detectados alguns aspectos subjetivos relacionados ao uso de medicamentos opióides, como indícios de medo e preconceito, que podem estar contribuindo para subutilização destes fármacos. Há a necessidade indiscutível da atuação de uma equipe multidisciplinar de saúde bem consolidada para o manejo da dor e melhora da qualidade de vida do paciente.

Nurses' knowledge and skills in colonoscopy patients' pain management

AIM

This study aimed to describe the knowledge and skills of nurses in managing pain during colonoscopy procedures.

BACKGROUND

Colonoscopy is a procedure to diagnose diseases of the intestine, and patients consider it even painful. However, few studies have described patients' pain management during the colonoscopy procedure.

DESIGN

A quantitative survey design was used. The data were collected from colonoscopy nurses with a self-completed semi-structured questionnaire developed for the study.

METHODS

The hospitals performing colonoscopies in Finland, with the exception of the ones where the questionnaire was pilot-tested, were included in the study (n = 12). The optional sample was drawn by mailing questionnaires (n = 147) to endoscopy units to be filled in by three colonoscopy nurses during 2002. The response rate was 79% (n = 116).

RESULTS

The majority of nurses used versatile non-pharmacological methods of managing pain and had practice-based knowledge of pain management during the colonoscopy procedure, but pain education and the acquisition of new professional knowledge were rarely reported. Pain scales were not in use and ethical conversation was lacking among the endoscopy staff in most (95%) hospitals.

CONCLUSION

The study showed that colonoscopy nurses used numerous non-pharmacological methods, but only rarely acquired professional knowledge. There was a lack of pain scales and ethical conversation in the participating endoscopy units.

RELEVANCE TO CLINICAL PRACTICE

The results can be used to improve the treatment of pain during colonoscopy procedures and endoscopy nurses' education. Nurses should be motivated by education and ethical conversation. Future studies should aim to analyse patients' own evaluation of pain during the colonoscopy procedure. The applicability of the existing pain scales and non-pharmacological methods should be tested in practice.

How do patients with colorectal cancer perceive treatment and care compared with the treating health care professionals?

BACKGROUND

Patient evaluations are widely used in quality assessment of health services. It is widely recognized that patients and professionals provide a different perspective on quality. However, the extent to which they differ and the conceptual areas in which they differ is not well understood.

OBJECTIVES

We sought to examine how well professional and patient assessments of hospital health care correspond.

METHODS

We undertook a prospective study in which information from a national clinical register was combined with questionnaires to patients, surgeons, and nurses. The study included 527 patients after surgery for colorectal cancer. The patients and their professionals assessed the same questions. For 336 patients, all questionnaires and register information were available. The response rate was 64%. The main measures were assessments of technical, interpersonal, and organizational aspects of care. Agreement was analyzed by kappa statistic, kappa, and McNemar's test.

RESULTS

Comparing assessments of technical surgical care kappa statistic demonstrated moderate-to-almost perfect agreement (0.35 <or= kappa <or= 0.95). Assessments of technical nursing care demonstrated slight agreement (0.19 <or= kappa <or= 0.26). Comparing answers to questions on interpersonal or organizational care, kappa statistic revealed only slight or no more agreement than expected by chance (-0.06 <or= kappa <or= 0.30). For several items, McNemar's test revealed a significant difference in the distribution of answers.

CONCLUSIONS

Within a Danish population undergoing treatment of colorectal cancer, there were significant differences in perceptions of care between patients and health professionals. In particular, health professionals and readers of reports on patient evaluations ought to remember that patients' perspective is just one source of information in assessment of hospital health care.

Knowledge and Attitudes About Cancer Pain Management

To obtain information about the knowledge and attitudes of Italian hospice nurses concerning cancer pain management and to determine the predictor of nurses' pain management knowledge. Nationwide descriptive study. Hospice nurses in Italy from 9 hospice units distributed in the north, center, and south of Italy. Sixty-six nurses completed the questionnaire, indicating a 66.6% response rate. The Nurses' Knowledge and Attitudes Survey (Italian version) and a background information form were used to collect the data. Knowledge and attitudes regarding cancer pain. Among the 39 pain knowledge questions assessed, the mean number of correctly answered question was 24.4 (SD = 4.2), with a range of 15 to 35 items correctly answered. The correct answer rate for the entire scale, on average, was 62.7% (SD = 28%). Further analysis of items showed that more than 30% of hospice nurses underestimated the patients' pain and they did not treat the pain in the correct way; they had an incorrect self-evaluation about their pain management knowledge. Results from stepwise regression showed that nurses with higher mean correct answer scores had attended more courses on pain education. From these results, we conclude that there are still significant knowledge deficits and erroneous beliefs that may hamper treatment of hospice patients in pain. The results of this study could be useful to institutions involved in the education and application of patient pain management.

Knowledge and attitudes about cancer pain management: a national survey of Italian oncology nurses

The purpose of this study was to obtain information about the knowledge and attitudes of Italian oncology nurses concerning cancer pain management and to determine the predictors of nurses' pain management knowledge. The study was a nationwide descriptive survey and included 287 nurses in Italy from 21 oncology wards in the north, center and south of Italy. The Nurses' Knowledge and Attitudes Survey (Italian version) and a background information form were used to collect the data. Knowledge and attitudes regarding cancer pain were the main research variables. Among the 39 pain knowledge questions assessed, the mean number of correctly answered question was 21.4 (SD=5.5), with a range of 6-35. The correct answer rate for the entire scale, on average, was 55% (SD=25.9). Further analysis of items showed that more than 50% of oncology nurses underestimated the patients' pain and they did not treat it in the correct way; they also had an incorrect self-evaluation about their pain management knowledge. Results from stepwise regression showed that nurses with higher mean correct answer scores had attended more courses about pain education. There are still significant knowledge deficits and erroneous beliefs that may hamper treatment of oncology patients in pain. The results of this study could be useful to institutions involved in patient care and teaching of pain management.

Cancer pain in palliative care: why is management so difficult?

Pain is the major source of anxiety and distress at the end of life, particularly in cases of end-stage cancer. However, pain management is not always effective or effectively implemented. This article identifies several barriers to effective pain relief in terminal cancer--the complexity of pain; difficulties in physical, emotional and spiritual assessment; difficulties in the delivery of medication--that challenge the skills of all professionals involved in palliative care. There are no simple answers, but awareness of the breadth of the issues may help focus nurses' minds on the patient in every encounter.

Patients' and nurses' perceptions of nursing problems in an acute care setting

AIM

This paper reports a study to determine the degree of agreement or disagreement between nurses and patients in their perceptions of the presence, severity, and importance of nursing problems.

BACKGROUND

Patient experiences, values and preferences are increasingly acknowledged as important factors underpinning healthcare decision-making. The ability to identify patient problems accurately is an important prerequisite for planning and implementing individualized high quality care.

METHODS

A convenience sample of patients (n = 80) and Registered Nurses (n = 30) in an acute care setting responded to a 43-item questionnaire. Findings. Nurses identified patients' problems with a sensitivity of 0.53 and a positive predictive value of 0.50. Patients identified several severe problems that were not identified by nurses, particularly problems with nutrition, sleep, pain, and emotions/spirituality. Nurses underestimated the severity in 47% of mutually-identified problems. An overall level of agreement of 44% was found on the importance of patient problems. Low levels of agreement on severity and importance were related more to individual differences than to systematic differences.

CONCLUSIONS

Nurses need to be more aware that patients and nurses often hold disparate views of the priorities in nursing care. To plan individualized nursing care effectively, nurses need to elicit and use individual patients' preferences more systematically in care planning.

Influences of Patient Behavior on Clinical Nurses' Pain Assessment: Implications for Continuing Education

Pain management is an important consideration in the promotion of patients' comfort. However, research continues to indicate patients' pain management is poor. The nursing literature cites nurses' lack of knowledge as a significant determinant of poor pain management practices. The impetus for this study arose from poor attendance by nurses at inservice sessions discussing pain assessment and management. Knowledge of existing nursing practice and accompanying beliefs and attitudes in relation to pain management is paramount in the development of relevant continuing education for registered nurses. The aim of this investigation was to study nurses' intention to treat pain in different patients. A 10-page questionnaire with eight different patient scenarios was distributed to 886 nurses across all clinical divisions of an acute tertiary facility. Results indicate knowledge deficits regarding optimum pain relief for patients. This article highlights the need for innovative teaching strategies and approaches in the clinical context to heighten nurses' awareness of their lack of knowledge of pain assessment and management.

Nurses?? Repeat Measurement of Chemotherapy Symptoms

The aim of this study was to investigate the feasibility and acceptability of a repeated measurement of 5 major side effects (pain, nausea, vomiting, anxiety, and fatigue) experienced by patients during an entire course of chemotherapy. Forty-nine inpatients receiving intravenous chemotherapy in the Medical Oncology Department of the Institut Paoli-Calmettes (Marseilles, France) were included in the study. At the study entry and every 12 hours from beginning of chemotherapy course, nurses assessed symptoms using Visual Analogic Scales (except for vomiting measured in number of episodes). Patients' pretreatment characteristics and their degree of satisfaction with nursing assessment were also recorded. The mean number of symptom measures was 2.9 in courses of less than 3 days, 5.4 in courses of 3 days, and 7.5 in courses of more than 3 days. Symptom patterns varied according to length of course. Furthermore, patients' pretreatment characteristics (age, sex, marital status, education level, type of cancer) had an impact on symptom scores at baseline and during treatment. About 80% of patients judged the nursing assessment as not constraining and 55% considered that its impact on their care was positive. This study demonstrates that repeated measurement of chemotherapy side effects was feasible and provide useful information for symptom management that might increase patient treatment satisfaction.

Comparing patient and nurse perceptions of perioperative care quality

This study compared surgical patients' (n = 874) and perioperative nurses' (n = 143) perceptions of the quality of perioperative nursing care. The data were collected with a structured questionnaire in five hospital operating departments in Finland. The questionnaire items were divided into five main categories (staff characteristics, nursing activities, preconditions, progress of nursing process and environment); some of these categories were further divided into subcategories. Overall, patients tended to give significantly higher (P <.001) ratings than nurses, but for some items the patients had more critical perceptions. The results provide important clues for improving the quality of patient care so that staff activities better serve the needs of patients.

Learning disability nurses' experiences of being with clients who may be in pain

AIMS

This study aims to describe the experiences of Learning Disability Nurses (RNLDs) when they are with clients who may be in pain but who cannot communicate their feelings verbally.

BACKGROUND

Research indicates that general nurses often find it difficult to perceive their patients' pain accurately, but no studies refer to the experiences of RNLDs. For people with severe learning disabilities this could lead not only to unnecessary suffering, but also to long-term tissue damage and may even prove fatal.

METHOD

A phenomenological approach was adopted, as unrecognized pain is a subject about which little is known and the lived experiences of nurses and the meanings that they attach to them were being explored. Data were collected by unstructured interviews with a snowball sample of eight RNLDs. The participants were asked to describe a situation in which they thought a client was in pain. Analysis was based on Hycner's guidelines for the phenomenological analysis of interviews.

FINDINGS

Five central themes emerged: the importance of a caring relationship with the client, recognizing changes in verbal and nonverbal behaviour, searching for a meaning in the client's behaviour, negotiating with other health professionals and sharing in the client's feelings.

CONCLUSIONS

Nurses valued highly their relationship with a client, which can, in itself, be therapeutic. Clients apparently used a wide range of both conventional and nonconventional forms of nonverbal communication, including aggressive and self-harming behaviours, as the primary way of expressing pain. Functional speech cannot be taken as an indicator that the clients can self-care with regard to pain. RNLDs play an important role in negotiating between their clients and other health professionals, but must be careful not to make assumptions about the causes of pain and pass these assumptions on to the General Practitioner as a professional opinion. The use of diagnostic tests should be supported. RNLDs appeared to be sympathetic, rather than empathetic, towards their client's painful experiences.

Defending against patients' pain: a qualitative analysis of nurses' responses to children's postoperative pain

OBJECTIVE

Cognitive approaches to clinical communication attribute deficits in communication to lack of skill. We examined, instead, emotional influences on communication by finding out how nurses construed patients who were in pain, and how these constructions were related to the emotional challenge of patients' pain and to deficits in clinical communication.

METHODS

Data, analyzed qualitatively, included: (i) direct observations of verbal interactions of 13 nurses with 16 children after orthopedic surgery; (ii) standardized open-ended interviews with the nurses, patients and parents.

RESULTS

Nurses tried to prevent children from displaying pain behavior. When pain behavior did occur, they construed pain as unreal, unwarranted or not deserving help. These findings were apparent in observations of, and interviews with, nurses and also in parents' and children's accounts of nurses' behavior.

CONCLUSION

We identified behavioral and cognitive strategies whereby clinicians defend themselves emotionally against patients' pain, and which compromise communication with patients in pain.