Pain is one of the most feared and upsetting symptoms experienced among patients with a cancer diagnosis. Cancer-related pain is not a single entity, but rather is a subjective, unique, and multidimensional experience that affects individuals physically, psychologically, socially, and spiritually. Pain can occur throughout the disease progression and can significantly and negatively impact patient quality of life, cause or exacerbate other symptoms (ie, fatigue, anxiety), and interfere with functional capability. It is therefore vital that adequate assessment of cancer-related pain be performed so that effective pain management interventions can be implemented, enabling patients to achieve effective control of pain and live their lives as fully as possible.1
Registered nurses (RNs), as part of an interdisciplinary team (IDT), play a significant role in caring for patients who experience cancer-related pain. Because hospice and palliative care nurses often act as mediators between the physician, patient, and caregiver in the management of the patient's care, it is essential that nurses be knowledgeable about pain management.2 Administering nursing care to patients with cancer pain is a challenging task that requires up-to-date knowledge, evidence-based interventions, and appropriate attitudes, all of which can act as a barrier to effective treatment of pain.3-5
Nurses' knowledge of pain assessment and evidence-based management of cancer-related pain is an essential factor in promoting positive patient outcomes. Competence in these skills is essential to the role of palliative care nurses. In a systematic review of the literature, Gunnarsdottir and Gretarsdottir6 reinforced the importance of educational interventions aimed at improving pain management. The authors included 11 interventional studies, 9 randomized controlled trials, and 2 quasi-experimental designs, published during the years 1997 to 2010. Three educational interventions were found to affect patient outcomes positively despite variation in the delivery of the content. The first intervention was a 1-hour education course on pain and pain assessment, followed by individualized feedback on documented pain assessments. The second intervention consisted of 5 hours of curriculum, provision of support material, use of a designated role model who worked to educate their peers, and an evidence-based pain algorithm developed by the authors. The third intervention provided 30 hours of education including eight 3-hour sessions plus a follow-up meeting with the nursing staff. The content reviewed the physiology of pain, pain assessment, and both pharmacological and nonpharmacological interventions to manage pain. Harden et al7 also established that a pain management educational program improved the knowledge, attitudes, and behaviors of nursing staff caring for patients on an inpatient oncology unit.
Phillips et al4 investigated the impact an online pain assessment learning module had on nurses' pain assessment competencies (knowledge, tool awareness, and confidence) and reported patient pain ratings. The online learning platform included education encounters via 11 case-based pain assessment scenarios that were spaced over a 28-day period. The authors concluded that the educational interventions improved nurses' pain assessment practices and reduced patient-rated pain intensity scores.
Organizations such as the National Comprehensive Cancer Network (NCCN) have developed guidelines to address pain assessment and management. Evidence-based practice guidelines establish a knowledge base for clinical competence and provide a framework to support clinical practice decision making. The NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain8 provides a high level of evidence with easy-to-follow algorithms. The guidelines provide principles of cancer-related pain management with an emphasis on pain reassessment and comprehensive pain assessments. Enhanced pain assessment and evidence-based management practices can benefit all patients with cancer. Nurses can be champions for effective cancer-related pain management by practicing in accordance with the most recent guidelines and providing patient-centered care.
The Edmonton Symptom Assessment System9 was utilized by the clinical site before the project began. The Edmonton Symptom Assessment System tool was designed to assist in the assessment of 9 symptoms common in patients with cancer including pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, and shortness of breath. The severity of each symptom at the time of assessment is rated from 0 to 10 on a numerical scale, with a score of zero meaning that the symptom is absent and 10 that it is the worst possible. Four additional questions may be asked during a hospice visit including the following: “Are you uncomfortable because of pain?” “What is the pain location?” “What is current pain intensity using a numeric (NRS) and verbal pain rating scale?” “What is an acceptable level of pain using an NRS and verbal pain rating scale?” According to hospice policy, comprehensive pain assessment was to be conducted within 1 day of a patient screening positive for pain during the initial home assessment. Examination of 3 months of benchmarking data from the Centers for Medicare & Medicaid Services Hospice Quality Reporting Program revealed that only 26% (n = 23) of patients at the clinical site who screened positive for pain received a comprehensive pain assessment within 1 day of screening compared with 86% in the national database.
The Neuman Systems Model of Nursing10 was selected as the framework for this project because it focuses on the constant interactions between the client and the environment to maintain a sense of balance and wellness from the individual's perspective served as the framework for this study. The Neuman Systems Model of Nursing also focuses on the human needs of protection or relief from stress and consists of 5 interacting variables that retain the desired state of stability including physiological, psychological, sociocultural, developmental, and spiritual. The variables can be stressors, or they can be restorative. Stressors can have a direct impact on pain management.
The nurse's role within the model is to recognize the client as a unique individual with goals, beliefs, values, and coping abilities that are crucial in hospice and palliative care. While implementing primary, secondary, and tertiary interventions, the nurse works within a holistic view of the client and in tandem with their protective barriers to help promote a return to health as defined by the patient.
The Johns Hopkins Nursing Evidence-Based Practice11 model was used to guide the project implementation. The Johns Hopkins Nursing Evidence-Based Practice model occurs in 3 phases described as practice question, evidence, and translation. The practice question is derived from the identification of a practice problem or issue and is placed in the patient, intervention, comparison, and outcome or PICO format. This phase of the process includes the formation of an IDT. The evidence phase begins with a thorough review of the literature and concludes with the IDT developing recommendations for practice change based on the compiled evidence appraisal and synthesis. The translation phase consists of the team creating and implementing an action plan for the recommended practice change and concludes with the dissemination of findings within and outside the organization.
The purpose of this project was to enhance assessment and management of cancer-related pain practices in the hospice setting. The goals of the project were to determine and improve nurses' knowledge regarding pain assessment and management, evaluate the effectiveness of a pain education program in decreasing hospice patient's pain, and assess the adherence to recommended pain practices in the documentation.
The design of this project was evidence-based quality improvement and was implemented from February 2017 through June 2017.
Setting and Participants
The project implementation occurred at a rural home health and hospice in Southwestern Pennsylvania that is part of a larger health system. The clinical site had an average daily patient census of 317 patients with an average of 20 patients in adult hospice care. The hospice unit utilized an interdisciplinary approach to provide high-quality end-of-life care in the home. The hospice IDT at the clinical site consisted of a medical director, hospice director, hospice manager, social worker, spiritual counselor, hospice secretary, home health aides, home health aide manager, 1 part-time RN, and 7 full-time RNs. The hospice IDT conducted weekly meetings to discuss the patients' plans of care.
A convenience sample from all hospice nursing staff (n = 8) were invited to participate in the project. The participants requested that no demographic information be collected.
The institutional review board approved this project as a quality improvement.
After the practice issue/problem was identified, the project leader developed the practice question in PICO format: Among palliative care nurses, how does an evidence-based pain education program affect reported patient pain comfort levels? A project team was formed to review the literature and make recommendations for practice changes. The team consisted of 8 people, including the nurse project leader, hospice medical director, hospice director, hospice manager, clinical pharmacist, 2 hospice/palliative care RNs, and a spiritual counselor. Following the literature review, the team completed a gap analysis to compare evidence-based best practices to current practice and plan the practice change (Table).
Education about the physiology of pain and pain management was provided to the hospice nursing staff (n = 8) in 2 workshops. One way to standardize pain assessment is through the use of a reliable and valid tool, such as the Nurse's Knowledge and Attitudes Survey Regarding Pain (KAS).12 The KAS was administered at the beginning of the first workshop as learning needs assessment and results were used to guide the content of the second educational program. Nurses completed the KAS again 6 weeks after the second workshop to determine their knowledge and attitudes regarding pain assessment and management. The surveys were anonymous with no identifying information on the tool. The project leader exited the room during completion of the survey. Following completion, nurses placed the survey in a manila envelope and returned it to the project leader.
The pain education program for hospice and palliative care nurses was delivered in a workshop format to promote interactive learning. Following a formal didactic presentation, open discussion about the application of the content to patient care occurred. The curriculum for the workshops was based on the NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain8 and consisted of 3 foci: pain assessment, management, and documentation. Two 60-minute workshops were delivered in a Lunch and Learn format at the clinical agency before a regularly scheduled hospice IDT meeting. The first workshop was composed of information on types of pain, comprehensive pain assessment, pain assessment tools, misconceptions about analgesics (ie, addiction, tolerance, and dependence), and documentation requirements. The second workshop reviewed pharmacological and nonpharmacological interventions for cancer-related pain and management of opioid adverse effects.
All hospice and palliative care nurses continued to use a 0- to 10-point NRS to assess pain during every patient contact. As part of the practice change, a comprehensive pain assessment was completed when a patient reported current pain intensity as a numeric rating greater than 3. The comprehensive pain assessment consisted of 14 pain characteristics: intensity, best NRS score in the last 24 hours, worst NRS score in the last 24 hours, description, location, pattern/frequency, duration, effects/function, manner expressed by patient, current pain medications, utilization of as-needed pain medications, control measures, effectiveness of relief interventions, and spiritual/cultural beliefs. Using the NRS, nurses also identified the patient's pain management goal at each hospice visit. Discussion about pain management was added as a standing agenda item at the weekly hospice IDT meeting to enhance symptom management and reinforce education on evidence-based interventions. Each patient's NRS score was reviewed along with current and recommended pain interventions during the discussions. Several months into the project, it became apparent that the nurses, patients, and families needed a common language to assess and rate pain. The nurse project leader in collaboration with the hospice IDT developed a pain algorithm tool for mild, moderate, and severe pain (Figure 1) that included patient and visiting nurse actions. The nurses used the algorithm to discuss pain management options with the patients and caregivers to guide care and documented a plan in the medical record.
Before beginning the project, baseline data were collected on the last 30 patients admitted to hospice with cancer as the primary diagnosis. Baseline data consisted of a 0- to 10-point pain NRS, patient pain goal, and completion of a comprehensive pain assessment. A complete comprehensive pain assessment was defined as having documented findings for the 14 pain characteristics. An incomplete comprehensive pain assessment was defined as having an omission for 1 or more of the 14 pain characteristics.
The KAS12 tool measures nurses' knowledge and attitudes about pain management and can be used as a pretest and posttest evaluation measure for educational programs. This 39-item tool has been used extensively from 1987 to present. Its reliability and validity have been reported elsewhere.2,5 Because 2 of the items related to care of the pediatric patients, the questions were eliminated for the adult population in this project.
The project leaders completed monthly chart audits on all cancer patients who received hospice visits during the implementation period. The chart audit consisted of 7 areas of information, including visit date, visiting RN, previous pain NRS score, current pain NRS score, patient pain goal, whether the patient pain management goal was met, and if the pain NRS score had improved since the last visit. Patient charts were also checked for completion of a comprehensive pain assessment when a patient reported current pain intensity as a pain NRS score greater than 3.
Statistical analysis was carried out using SPSS software version 20 (IBM Corporation, New York, New York). A paired 2-sample t test was conducted to compare KAS survey scores before and 6 weeks after the pain education program. Descriptive statistics were used for patient pain assessment data (ie, NRS score and patient goal) at baseline and by month over the 4-month data collection period and the comprehensive pain assessment completion rates. Differences in patient pain assessment data at baseline and overall were performed using a χ2 analysis. An α value of less than 0.05 was accepted as statistically significant.
All hospice and palliative care nurses at the agency (n = 8) completed the educational program. Knowledge of cancer-related pain assessment and management practices improved significantly (t39 = 3.95, P < .001) on KAS completed 6 weeks after the second educational session compared with the survey administered before the education. The mean score on the KAS survey increased from 28/37 on the pretest to 32/37 on the posttest (14.28% increase).
Pain data (ie, NRS score and patient goal) were extracted from patient charts (n = 26) and entailed 240 patient encounters. Patient-reported pain levels were lower than the mean pain NRS score at baseline of 3.23 to a mean of 2.54 (21% decrease) overall average during the project. The mean pain NRS score during each month of the intervention was less than that at baseline. Attainment of patient-identified pain goals occurred significantly more often (χ2 = 25.3904, P < .05) after the practice change, with 37.0% (n = 11) of patients meeting goals at baseline and 55.0% (n = 14) during the project period (Figure 2).
Comprehensive pain assessment completion rates increased from 42% (n = 13) at baseline to 52% (n = 14) during the intervention.
In this project, evidence-based educational interventions and the use of a pain algorithm resulted in positive outcomes. The pain education program significantly improved nurses' knowledge and attitudes about pain and is consistent with the results of other studies.4,6,11 The increased awareness of evidence-based assessment and management practices that followed the NCCN Clinical Practice Guidelines empowered the RNs to make evidence-based decisions about cancer-related pain interventions and improved symptom management. Also, adding patient pain as a standing agenda item during hospice IDT meetings encouraged open discussions about individualized treatment options and reinforced learning that occurred during the workshops. Similar results were noted by Gunnarsdottir and Gretarsdottir,7 who reported that individualized feedback on pain documentation and mentoring was associated with improved pain management.
As expected, patients experienced decreased overall pain levels with the addition of comprehensive pain assessments and following the management algorithm. In addition, patients experienced a significant increase in meeting their individualized pain management goals. Individual patient pain management goals are crucial in pain assessment and management practices because it ensures that patients and those in their support system are engaged as partners in their care.
The comprehensive pain assessment completion rates improved; however, the RNs did not follow the recommendation to complete the pain assessment in its entirety with each NRS rating greater than 3. During an IDT meeting midway through the project, the lack of compliance with documentation as noted in chart audits was explored with the nursing staff. The nurses informed the project leader that a comprehensive pain assessment was time consuming. Duplication of work, especially with medication documentation, was noted. The nurses felt that they could adequately assess for pain using only 6 measures in the comprehensive tool including pain intensity, character, frequency, duration, alleviating factors, and function.
The project leader encouraged the staff to continue with the completion of the comprehensive assessment for the remainder of the project, resulting in a 10% improvement from baseline data.
Completion of pain screening tools has been noted as a barrier to best practice in other settings. Phillips et al13 reported having a similar difficulty with nurses' adherence to pain screening and assessment guidelines. The authors tested the impact of an online, spaced education cancer-related pain assessment learning module had on nurses' adherence to the Australian cancer pain screening and assessment guideline recommendations. A quality score was calculated using an 8-point assessment tool on documented items noted in the patient's chart. One point was assigned to each item documented when a patient screened positive for pain. Scores ranged from 0 to 8. The authors concluded that although there was evidence of improvement in pain assessment practices, the actual number of patients with a documented comprehensive pain assessment was less than ideal.
This project had several potential limitations. The project was implemented at 1 site with a small number of palliative and hospice nurses. Second, administration of the pain workshops and the KAS tool before a weekly hospice IDT meeting may have limited the amount of time allotted for these activities, such as rushing to complete survey or nonparticipation in open workshop discussions. Third, the findings are based only on a positive change measured after 6 weeks and do not reveal if there would be a permanent positive change in attitude or knowledge among the participating RNs; however, the practice change has been maintained during the 6 months following project implementation except for completing all 14 pain characteristics in the comprehensive pain assessment. Fourth, because different populations were used for the baseline and intervention comparison, the decrease in pain levels could have been attributed to other variables not considered in the project.
The use of an evidence-based guideline and pain management algorithm to care for patients with cancer within the hospice setting resulted in improved care for patients. Currently, the practice site has determined to continue with the practice changes with plans to spread the practice to other hospice units within the health system. Several of the practice change recommendations will also be applied in the clinical site home health unit as many of these patients experience chronic types of pain. For example, pain will be assessed at each patient encounter, and if the NRS score is greater than 3, a comprehensive pain assessment will be completed. Nurses in the home health unit will use the pain algorithm tool in the patient's plan of care when applicable.
Pain assessment and management are an essential part of hospice and palliative care. The findings of this project suggest that evidence-based pain education and interventions can change clinical practice and improve oncology health care. Patients with cancer depend on nurses recognizing, assessing, quantifying, and communicating findings to members of the hospice IDT. Administering effective care to patients with cancer-related pain requires current knowledge and attitudes of evidence-based interventions.
Comprehensive pain assessments can be more effective at addressing patients' cancer-related pain, especially when combined with timely evidence-based interventions. The challenge is that nurses report that the tools in current practice are cumbersome and time consuming to use. Future work to streamline the assessment of pain to achieve similar results as the comprehensive assessment is needed. Until better tools are developed, education and role modeling are 2 strategies mentioned in the literature as helpful in improving pain assessment and management.
Sustainable, evidence-based education and communication for enhancing knowledge and attitudes of cancer-related pain assessment and management in hospice care are a critical component of effective pain management and improving quality of care in patients with cancer now and into the future.
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