Inadequate treatment of pain is a serious clinical problem in hospitalized patients and has been well documented for more than 25 years.1–4 Pain can be associated not only with the disease process itself but also with the treatment of disease. Many diseases such as cancer, sickle cell anemia, and chronic arthritis may cause pain.5 It was shown that 90% of the patients terminally ill with cancer had been suffering from pain.6,7
Uncontrolled pain impairs the physical, social, and psychological functions of the patients.5,7,8 Pain, if left untreated, can significantly affect the patient's quality of life, will to live, or willingness to cooperate during treatment.8–13 Inadequate treatment of pain may result in slowed healing, a higher rate of complications, anxiety, sleep disturbance, and lowered quality of life.3,14–17
Several types of barriers to pain assessment and management in variety clinical settings have been reported and these barriers can be grouped into 4 themes: patient-related barriers, nurses-related barriers, physician-related, and systems-related barriers.17–23
It is known that the professional-related barriers are very important to manage the pain.1 A number of studies indicate that knowledge deficits, inadequate pain assessment, and reluctance to administer opiates are the most important barriers for health care professionals in implementing pain management.16,21–25
The teamwork is essential for optimal pain management. Particularly, doctors and nurses should work in close collaboration.17,26 Nurses play a critical role in this team work because they deliver direct patient care on a 24-hour basis.26 The nurse should evaluate and monitor the patients and their relatives attitude, knowledge, and experiences. The nurses' perception effects her approach to the patients in pain.1,20,25–28 Despite the fact that nurses are the front-line caregivers in inpatient settings, there is limited data on the nurses' perceived barriers to optimal pain management in our country. In this study, we aimed to define the nurses' perceived barriers to pain management in clinics where patients with cancer are hospitalized for diagnosis and treatment.
This is a descriptive study searching for the hospital nurses' perception of barriers to good cancer pain control. A self-report questionnaire was given to the hospital nurses working at the oncology, internal medicine, and surgery clinics, where mostly patients with cancer had been hospitalized. As a result of the limited bed capacity in the oncology hospital, many patients with cancer are hospitalized in internal medicine and surgical wards both for diagnostic interventions and cancer treatment.
There were 178, 140, and 29 nurses working in the surgery, internal medicine, and oncology clinics, respectively. One hundred fourteen of the nurses answered the questionnaire voluntarily.
Data and Instruments
A standardized questionnaire was tailored for this study based on the questionnaires used by the earlier studies.17,18,20 The questionnaire consisted of two parts. The first part was designed to identify nurses' personal and demographic features, which included age, education, working place, and years of professional experience.
The second part aimed to evaluate nurses' perceived barriers related to patients, nurses, physicians, and the system. The questionnaire was pretested on 30 nurses for relevance and comprehensibility. It took about 15 to 20 minutes to complete a questionnaire. The questionnaire was distributed to be completed by them and was then collected.
It was emphasized that this study was anonymous and the data would be used only for scientific research. Participation was voluntary, and oral approvals were taken from each study participant. Institutional approvals from the Nursing Department were also obtained.
Data were entered and analyzed using the Statistical Package for the Social Sciences version 11.5. Before entry, all data were examined for accuracy. Descriptive statistics were used to describe nurses' background characteristics. Kruskal-Wallis tests (nonparametric comparisons) were used to compare the differences of nurses' perceived barriers according to various demographic groups including age, nursing education, and working place. To compare the differences of years of experience χ2 test was used. A significance level of P=0.05 was used.
Demographic Characteristics of Participants
The demographic characteristics of the participating nurses are shown in Table 1. Majority (71%) of the nurses was 20 to 30 years old, 99% were female, and 77% had a baccalaureate degree. Years of experience were more than five years in 54 % of nurses. Fifty-six percent of the participants were working in the surgical wards.
Perceived Barriers to Assessment and Management of Pain
In this study, nurses' perceived barriers to assessment and management of pain was evaluated in four different parts; nurse-related barriers, physician-related barriers, patient-related barriers, and system-related barriers.
Table 2 shows the mean of the barriers that nurses perceived to assessment and management of cancer pain.
The most commonly perceived barriers to assessment and management of pain were system-related barriers. When compared with the other barriers, nurse-related barriers were less perceived as an obstacle.
The patient-related barriers can be seen in Table 3. Patients' difficulty with completing pain scales (56%) and consumers not demanding results (53%) were the most commonly reported barriers. A significant percentage of the participating nurses (45% to 79%) indicated that they have no idea with regard to 7 of 9 patient-related barrier items.
The nurse-related barriers can be seen in Table 4. Inadequate time for health teaching with patients was reported by the 65% the nurses. Most of the nurses (64% to 82%) did not agree with 6 of 7 nurse-related barriers. Asmall percentage of the nurses agreed that nurses' inadequate knowledge of pain management (10%) and nurses' indifference (8%) were barriers to pain management.
Physician-related barriers perceived by the nurses are shown in Table 5. Inadequate assessment of pain and pain relief (63%) and doctor's indifference (47%) were the most reported barriers by nurses. More than half of the nurses disagreed on inadequate knowledge, reluctance to prescribe adequate painkillers for fear of overmedicating, and lack of trust in nurses' assessment of pain. At least one fifth of the nurses indicated that they had no idea about the physician-related barriers addressed.
Table 6 shows the system-related barriers. Lack of psychological support services (77%), patient-to-nurse ratio (74%), and lack of social workers (70%) were the most commonly perceived system-related barriers by the nurses.
Lack of access to professionals who practice specialized pain treatment methods (66%), lack of guidelines for pain management (66%), and difficulty contacting or communicating with physicians to discuss treatment of pain (61%) were indicated as being the more common system-related barrier by the nurses. A significant percentage of the nurses disagreed on the barriers about inconsistent practices around giving “as needed” medications for patients (45%), lack of pain medicine in the market (41%), and lack of equipment or skill in using equipment (42%).
When the barriers were analyzed according to demographic variables, no significant differences were found among nurses according to age (Kw2, 0.005; P=0.997), education level (Kw2, 4.905; P=0.179,), and the years of experience (Kw2, 3.434; P=0.329). However, significant differences were found among work settings (Kw2, 38.84; P=0.000). The nurses who worked in oncology clinics agreed more on the system-related barriers.
Nurses play a crucial role in pain assessment and management. They often act as mediators between the doctor and the patient, and serve as the main observer of pain and discomfort in the patient. Therefore, it is very important to determine the barriers perceived by nurses to assessment and management of pain.2 The pain barriers experienced by the nurses from different countries have been defined in a number of earlier studies.17,18,23 However, these barriers may show some differences according to some variables including the undergraduate and postgraduate education provided to health care professionals, availability of painkillers in a given setting, and institutional practices. Despite the fact that nurses are the front-line caregivers in inpatient settings, there is limited data on the nurses' perceived barriers to optimal pain management in our country. Our study aimed to define the nurses' perceived barriers to pain management in a university hospital.
The results of this study indicate that nurses perceive a variety of barriers when attempting to provide optimal pain assessment and management in our hospital. The most commonly perceived barriers to assessment and management of pain were system-related barriers. When compared with the other barriers, nurse-related barriers were less perceived as an obstacle.
Among the system-related barriers, lack of psychosocial support services was the most commonly perceived barrier. This finding is similar to the results of studies by Furstenberg et al18 and Sun et al,19 which defined the lack of support systems as being a barrier interfering with optimal pain management. In our hospital, psychosocial services are not part of routine patient care. Although psychological support can be provided to a very limited number of patients with cancer on demand of the attending physician, there is no social work for patients. Institutional and governmental attempts are needed to establish psychosocial support services for all patients.
Another commonly (74%) expressed system-related barrier was the patient-to-nurse ratio. This result was also consistent with some earlier studies.20,22 When the patient-to-nurse ratio is high, nurses experience time constrains which interferes with quality of care. Research from developed countries may show different figures as it was in Johnson et al23 study reporting that only 13% of nurses identified time as a barrier to pain management. However, understaffing remains a barrier to optimal patient care in our country. Each nurse has to take care of 8 to 10 patients in the hospital where this study was done. There are no nurse aids; therefore, nurses are responsible for all the nursing care. Therefore, they have been facing time limitation for symptom assessment and management.
More than half of the participating nurses indicated that the lack of access to professionals who practice specialized pain treatment methods (66%) and the difficulty in contacting or communicating with physicians to discuss treatment of pain (61%) were important barriers to pain management. In our hospital, nurses and physicians have been making separate patient rounds. The negative impact of this disconnection can be clearly seen in these results. The appropriate assessment and treatment of pain is highly dependent upon communication between physicians and nurses. Lack of adequate and accurate communication between nurses and physicians was reported as an important barrier to optimal management of pain.20,23 Van Niekerk and Martin20 showed that nurses who did not feel adequately consulted by physicians were significantly more likely to encounter barriers such as insufficient cooperation by patient's physicians and inadequate prescription of analgesic medications. A collaborative relationship between the two professions would ensure that the barriers experienced by nurses could be resolved in a supportive team approach. Education on pain management emphasizing the importance of teamwork, and the role of each health care professional in the team is essential to overcome this barrier. Although it has been a widespread practice to order analgesics “as needed” instead of “around the clock” usage in our hospital, a significant percentage (45%) of the nurses disagreed with inconsistent practices around giving medications as needed. In contrast, lack of pain medicine in the market was expressed as a barrier only by 26% of the nurses, although we have been experiencing problems about the availability of some strong opioids. There is no immediate release oral morphine available in the market in Turkey. A sustained release oral opioid appeared in the market recently. A significant percentage (74%) of the nurses either disagreed (41%) with this barrier or expressed that they did not know (33%) about this issue. This finding may be explained by lack of knowledge on cancer pain management, as oral opioids are the drug of choice for moderate-to-severe cancer pain. Another reason for this finding may be related with the current pain management practice which involves parenteral use of opioids, particularly for patients with cancer, while they stay in hospital.
In this study, lack of standardized clinical guidelines for pain treatment was indicated as a barrier by 66% of the nurses. It has been reported that pain management guidelines contribute to nurses' pain knowledge and attitudes.4,29 More effective pain management practice can be achieved if clinical practice guidelines are tailored to the specific type of the institution and the available resources within a given setting.
Lack of alternatives for nonpharmacologic pain management was agreed on by the 47% of the nurses. Nonpharmacologic pain management modalities remain a neglected treatment option in our hospital because of time limitations and lack of expert staff.
Among the patient-related barriers, more than half of the nurses agreed with the patients' difficulty with completing pain scales (56%) and consumers not demanding results (53%). This result can be related that the pain assessment scales were taking place in a very busy nursing chart, representing an obstacle to concentrate on the scales. Therefore, a pocket pain assessment scale was developed and distributed to all hospital nurses.
The nurses in this study disagreed with any difficulty about patients' reporting their pain. Some studies searching for the patient perceived barriers reported obstacles, such as the reluctance to report pain, nonadherence to treatment regimens, fear of dependency, anxiety over being a bad patient, concerns about disturbing health care providers, and fear of side effects.4,12,21,23 The nurses in this study did not agree with the patient-related barrier with regard to patients' avoidance to complain pain to not to disturb the nurses, which was reported as a barrier in some studies.17,18
Pain has been regularly assessed in the clinics where the study was conducted. As nurses has been asking patients about their pain at designated intervals, nurses did not indicate any problem with the patients' reporting of pain. However, the nurses reported difficulty in collaborating with doctors to manage the reported pain.
A significant percentage of the participating nurses (45% to 79%) indicated that they have no idea with regard to 7 of 9 patient-related barrier items. This may reflect the time constrains that nurses have been experiencing because of the high patient-to-nurse ratio. A good-quality communication with patients to define pain-related issues requires time. Nurses spend most of their working hours to give curative treatment in these settings. This finding may also be related with nurses' awareness and knowledge on good pain management.2,27 We need further studies searching for the knowledge and attitude on pain management.
In this survey more than half of participating nurses disagreed with nurse-related barriers, except for inadequate time for patient education, which was reported by 65% the nurses. It has been shown that inadequate assessment and management were among the most commonly encountered barriers to pain control.18 In our survey, most of the nurses (64% to 82%) did not agree with 6 of 7 nurse-related barriers. Only a small percentage of the nurses agreed that nurses' inadequate knowledge of pain management (10%)and nurses' indifference (8%) were barriers to pain management.
The nurses' lack of knowledge on pain management was indicated as a pain barrier by only 16% of the participants. Although this study did not evaluate the nurses' knowledge and attitude on pain management, a number of studies indicate that knowledge deficits and inadequate pain assessment are the most important barriers for health care professionals in implementing pain management.1,20,22,26
Lack of regular and persistent assessment of pain by the doctors was the most commonly (63%) perceived physician-related barrier by the participating nurses in our survey. Doctors' indifference to pain (47%) was another perceived barrier. More than half of the nurses disagreed on inadequate knowledge, reluctance to prescribe adequate painkillers in patients for fear of overmedicating and lack of trust in nurses' assessment of pain. At least one fifth of the nurses indicated that they had no idea about the physician-related barriers addressed. This shows the negative impact of lack of communication between the nurses and doctors.
The nurses indicated that they had difficulty contacting or communicating with physicians to discuss treatment of pain. It has been reported that the barriers to effective pain management encountered by nurses were affected by their relationship with physicians.20 When the barriers were analyzed according to demographic variables, no significant differences were found among nurses according to age, education level, and the years of experience. However, significant differences were found among work settings; thenurses who worked in oncology clinics agreed more on the system-related barriers. This finding may be related to the high incidence of pain in patients with cancer.
In conclusion, this study showed that the system-related barriers, particularly high patient-to-nurse ratio and lack of psychosocial support services, were the most commonly perceived pain barriers by the nurses in our hospital. Institutional and governmental attempts are needed to increase the number of nurses in the clinics. This would help with increasing the time allotted to each patient.
Teamwork is essential for providing good-quality pain management in hospitals. It is important to establish a supportive team spirit between doctors and nurses. For this, meetings should be held between these two groups of health professionals to facilitate the discussion of pain management problems and to review recommendations for solutions.
There are studies showing that education is effective in eliminating the barriers standing in the way of the evaluation and management of pain. For this reason, there should be regular and continuous education programs for all health professionals who are involved in the pain management. We need to define the knowledge and attitude of nurses and doctors in our hospital with an aim to set up a continuous education program on pain management. In addition, evidence-based pain management guidelines should be drawn up for the clinical use of doctors and nurses.
The authors thank all nurses for their cooperation in carrying out this study.
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