Pain management strategies used by patients with breast and gynecologic cancer with postoperative pain

Many people with cancer will experience pain when they are outside of structured care settings. Patients must provide their own self-care, drawing on instructions from healthcare providers and on independently developed plans for pain management. With growing interest in complementary therapies, the scope of nonpharmacologic interventions used by patients with cancer to manage pain may be very different than 10-15 years ago. The purpose of this study was to describe steps taken by patients with breast and gynecologic cancer to manage pain after discharge from a surgical hospitalization. A secondary analysis was completed using data from 34 women who participated in a randomized trial of guided imagery. Techniques used included positioning, distraction, relaxation, heat, and eating/drinking. Compared to results of previous studies, increased use of relaxation strategies (breathing, imagery, music, meditation) was noted in the current study. The majority of participants used nonpharmacologic strategies in addition to analgesic medications. Pain-related outcomes were similar among persons who used analgesic medications alone and those who used a combination of analgesics and nonpharmacologic strategies. Nurses may benefit from knowing which pain management strategies patients find helpful so that they can encourage their use and teach similar strategies to the patients who find them useful.

Outcome expectancy and success with cognitive-behavioral interventions: the case of guided imagery

PURPOSE/OBJECTIVES

To describe the role of outcome expectancy in the use of cognitive-behavioral interventions and to test three variables (history of imagery use, preferred coping style, and perceived credibility of the imagery provider) as predictors of outcome expectancy regarding guided imagery.

DESIGN

Secondary analysis using a descriptive, correlational design.

SETTING

Surgery clinics at a large, midwestern university hospital.

SAMPLE

75 women undergoing surgery for gynecologic or breast cancers.

METHODS

Data were collected as part of an ongoing trial of guided imagery. Participants completed measures of outcome expectancy and predictor variables at a preoperative clinic visit.

MAIN RESEARCH VARIABLES

Outcome expectancy regarding a guided imagery intervention, previous history with imagery, preferred coping style, and perceived credibility of the imagery provider.

FINDINGS

Significant relationships were demonstrated between previous history of imagery use and outcome expectancy (r = 0.47, p < 0.01) and between perceived credibility of the imagery provider and outcome expectancy (r = 0.45, p < 0.05). Preferred coping style was not related to outcome expectancy in this sample. Psychometric properties of new instruments were satisfactory.

CONCLUSIONS

Previous history of imagery use and perceived credibility of the imagery provider were supported as predictors of outcome expectancy. Future research will be necessary to reexamine the predictive role of preferred coping style.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should be aware of the potential role of outcome expectancy in effectiveness of nursing interventions. Patients' previous use of cognitive-behavioral interventions and perceptions of credibility may be helpful in selecting appropriate strategies.

Assessment of pain in the critically ill

Accurate assessment of pain in the critically ill is undoubtedly a challenge. In this setting, however, the nurse can rise to the challenge and have a significant impact on pain management. Some careful thought and planning may allow the nurse to adapt usual assessment tools for use by patients who have difficulty in communicating. When patients cannot communicate, having accurate knowledge about pain and about the patient's condition can help nurses to make appropriate use of behavioral and physiologic signs. More research is necessary to test specific pain assessment tools in ICU settings. In addition, more studies are needed to document the reliability and validity of scales based on behavioral and physiologic indicators of pain in critical care settings. In the meantime, nurses can take several steps to ensure adequate pain assessment: (1) use all means possible to document the patient's self-report of the pain experience, (2) supplement these ratings with behavioral and physiologic indicators of pain status, and (3) document findings to comunicate the patient's pain to others caring for the patient. A careful thorough attempt to assess pain can ensure better pain, outcomes as well as a quicker and more positive return to health.

Measuring imaging ability in children

INTRODUCTION

Guided imagery has been suggested as an intervention to help children cope with noxious symptoms associated with medical care. A measure of imaging ability, that is, the ability to generate vivid mental images and to experience those images as if they were real, could be helpful in identifying children most likely to succeed in relieving symptoms with guided imagery. The purpose of this study was to test psychometric properties of a new instrument, the Kids Imaging Ability Questionnaire (KIAQ).

METHOD

Three expert clinicians and researchers were asked to review the KIAQ to assess content validity. A convenience sample of 58 children were invited to complete the questionnaire twice to obtain data for tests of reliability and criterion-related validity.

RESULTS

Content validity, internal consistency (alpha =.75-.76), and test-retest reliability (r =.73) were acceptable. Criterion-related validity using the Singer Fantasy Proneness Interview as a standard was poor (rho =.31-.46).

DISCUSSION

Some psychometric properties were acceptable; however, continued research will be necessary to test validity of the questionnaire and demonstrate a relationship between KIAQ score and success with imagery. With continued research, pediatric nurses may use the KIAQ in practice to identify children most likely to benefit from guided imagery.

Measuring imaging ability: psychometric testing of the imaging ability questionnaire

Imaging ability, defined as the ability to create vivid mental images and to experience those images as if they were almost real, has been suggested as a moderator in effective use of guided imagery for symptom relief. Persons with good imaging ability are thought to be more likely to succeed in relieving a symptom with guided imagery than persons with poor imaging ability. The purpose of this paper is to describe the development of an instrument designed to measure imaging ability, the Imaging Ability Questionnaire (IAQ). A descriptive correlational design was used to conduct item analyses and explore psychometric properties of the IAQ. A total of 200 persons from the Midwest completed a 54-item version of the IAQ. Twenty-two items that failed to discriminate among levels of imaging ability were eliminated from the questionnaire. The final version of the IAQ contained 32 items and demonstrated good internal consistency (alpha =.93) and test-retest reliability (r =.92). Support for construct validity of the questionnaire was provided by demonstrating expected differences in IAQ score between persons for whom imagery worked and persons for whom imagery did not work. Future testing and use of the questionnaire in research and practice are discussed.

A model for cognitive-behavioral interventions in cancer pain management

PURPOSE

To propose a model for predicting success with cognitive-behavioral interventions in cancer pain management. Practice guidelines are useful, however nurses currently have little theoretic or empiric basis for choosing one particular strategy over another. Moreover, nurses have no way of knowing if a particular intervention is likely to work.

ORGANIZING CONSTRUCT

The model indicates characteristics of a person in relation to interventions including skill and ability, outcome expectancies, perceived credibility, history of use, preferred coping style, and pain outcomes.

SOURCES

The model was developed using sources identified through a literature search of relevant topics in MEDLINE, CINAHL, and Psychlit (1996-1997), as well as through clinical experience.

CONCLUSIONS

Continued empiric testing of the model is necessary to confirm proposed relationships and to assess accuracy of the model's predictions with various cognitive-behavioral interventions. With this testing, the model can help nurses select appropriate interventions for individual patients.

The impact on quality of life of patient-related barriers to pain management

A stress-coping model of relationships between patients' beliefs about pain, coping (analgesic use), pain severity, analgesic side-effects, and three quality of life (QOL) outcomes was tested. Participants were 182 men and women with cancer who completed valid and reliable self-report measures of relevant variables. Antecedent variables (age and education) showed expected relationships with beliefs. As predicted, beliefs were significantly related to analgesic use. Analgesic use was inversely related to pain severity, but was not related to side-effect severity. Analgesic use was inversely related to impairments in QOL before controlling for pain and side-effect severity, but not after these two variables were controlled. Both analgesic side-effects and pain severity were related to impaired QOL outcomes, including difficulty performing life activities, depressed mood, and poor perceived health status.

The impact on quality of life of patient-related barriers to pain management

A stress-coping model of relationships between patients' beliefs about pain, coping (analgesic use), pain severity, analgesic side-effects, and three quality of life (QOL) outcomes was tested. Participants were 182 men and women with cancer who completed valid and reliable self-report measures of relevant variables. Antecedent variables (age and education) showed expected relationships with beliefs. As predicted, beliefs were significantly related to analgesic use. Analgesic use was inversely related to pain severity, but was not related to side-effect severity. Analgesic use was inversely related to impairments in QOL before controlling for pain and side-effect severity, but not after these two variables were controlled. Both analgesic side-effects and pain severity were related to impaired QOL outcomes, including difficulty performing life activities, depressed mood, and poor perceived health status.

The placebo effect in symptom management

PURPOSE/OBJECTIVES

To explore current knowledge of placebo effects, including proposed explanatory mechanisms, influencing factors, characteristics, and implications for practice and research.

DATA SOURCES

Published and unpublished articles, books, and monographs.

DATA SYNTHESIS

Placebo effects occur in up to 90% of nursing interventions. They may be explained by several mechanisms and are influenced by nurse/physician demeanor, patient factors, the patient-provider relationship, treatment factors, and context of the healthcare encounter.

CONCLUSIONS

Nurses need to control for placebo effects when testing whether an intervention has desired effects, but once such effects have been demonstrated, nurses can make use of placebo effects to enhance the impact of their interventions.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can take measures to improve the patient's response to treatment, including providing a comfortable environment, using therapeutic communication techniques, helping patients to understand specific mechanisms of their treatment, and encouraging positive expectations and motivation for effectiveness.