Pain Management in Cancer Patients

No cancer patient should needlessly suffer due to inadequacies in pain management. Nurses should continually strive to improve pain relief for cancer patients. Holly Cope

Best Practices for Pain Management in Cancer Patients
No cancer patient should needlessly suffer due to inadequacies in pain management. Nurses should continually strive to improve pain relief for cancer patients. Ideally the goal is to equip nurses with the capability of providing consistent, improved pain management for all patients. Throughout this paper, best nursing practices for pain management in cancer patients will be illustrated.
There is no question that cancer causes pain, and constant, unrelieved pain, can be torturous. Unrelieved pain has profound effects, including decreased quality of life, impaired functionality, and reduced productivity (Woodward, 2005, p.261). Several sources address the process of developing pain management programs using various improvement strategies. These combined sources acknowledge the effects of unrelieved pain, while shedding light on how improvement practices should be implemented. Through the course of this paper, three aspects of pain management will be examined: nurse assessment, documentation and patient education. Identification of key processes and barriers for effective pain management is paramount to improving pain relief (Woodward, 2005 p. 263). Every nurse that cares for a cancer patient should be asking, “Is there more that can be done to alleviate this patient’s pain?” By creating a pain management program, nurses are taking proactive measures in their patient care as well as creating an allowance for patients to be involved in their own healthcare. However none of this can be put into practice if nurses themselves are not instituting proper pain assessment. The first step in improving pain for cancer patients is to have proper, thorough and consistent nurse assessment of pain.
Support for this is given through research showing that poor staff assessment and reassessment practices impede pain relief for patients (Idell, Grant, &Kirk, 2007, p.661). Nursing efforts geared towards proper assessment are essential to maintaining successful pain management planning. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates not only pain assessment in all patients but also pain reassessment in response to interventions. Unfortunately, compliance with JCAHO standards remains problematic for many institutions (Idell, et al., 2007). However, barriers that impede proper assessment can be removed.
Research indicates that by increasing the frequency with which a patient’s pain is evaluated, interventions to reduce pain are implemented earlier. Analyzing nurse competency regarding assessment practices, and providing a team leader that holds nurses accountable has proven to be effective in increasing compliance with JCAHO standards (Idell, Grant, & Kirk, 2007, p. 662). Enhancing nurse availability and accessibility to assessment tools via a unit based educator that oversees all activities to ensure consistent implementation of said tools, has also increased compliance within institutions (Woodward, 2005, p.265). When pain assessment for all patients becomes consistent, management of pain increases and patient pain is better relieved.
Assessment can also be effectively executed with the implementation of pain management rounds. These rounds would include nurses evaluating each patient’s pain level and pain frequency trends on set days of the week. Those patients with pain would then be discussed by the interdisciplinary team and proper changes made to their pain management regimen if appropriate. Studies have shown that institutions using this assessment format have 70% of patients reporting being very satisfied with nurses’ treatment of their pain. Prior to the initiation of this assessment program, no patients rated themselves as very satisfied (Sterman, Gauker, & Krieger, 2003, p.860).
Documentation is a key factor in creating an effective pain program to aid in the relief of cancer pain for patients. An example of problematic documentation is explained in Woodward’s article. While conducting chart reviews, discrepancies in pain level documentation were revealed. The patient’s numerical pain rating was documented 60% of the time before medicating while only 12% of the time was a patient’s pain reevaluated and documented within 2 hours after a pain medication was administered (Woodward, 2005, p.263). These statistics illustrate that without proper documentation there is no record of patient care and therefore no way of addressing how to improve said care. Improper or zero documentation will result in inconsistent pain management (Sterman, Gauker, & Krieger, 2003, p. 859).
Lack of documenting a patient’s pain level is in direct opposition to best nursing practices. Various strategies to attend to this problem include the creation of better suited accountability measures for nurses, as well as the standardization of both basic and ongoing pain education for all members of the nursing care team relevant to their scope of practice (Woodward, 2005, p.265). With proper documentation, a patient’s pain level can be tracked and their pain treated without delay. Continuous accountability for documenting and follow up care pertaining to said documentation is a key element in successful pain management (Idell, Grant, & Kirk, 2007, p. 670).
Aside from nursing assessment and documentation, patient education plays a vital role in pain management. One valuable tool involves patients tracking their daily pain progress. Nurses can teach patients how to develop and use a pain management diary. The diary will provide the nurse with valuable information about their patient’s pain issues. Studies have stated the importance of patients documenting daily accounts of their pain level, the medications taken to relieve their pain and their response to the medications (Kim et al., 2004, p.1138). This strategy, coupled with nursing documentation, will provide nurses with more information with which to treat their patient’s pain.
One way to enhance a patient education strategy is through a tool called the Pain Experience Scale. This is a scale that measures patient’s knowledge regarding cancer pain management. These surveys are then evaluated to determine an effective patient education program. Most patient education programs focus on these basic principles: personalized pain management, how to better communicate with healthcare providers, and how to contact a provider. After experimentation with education programs such as these, patients demonstrated a 12% increase in knowledge when compared to patients who had not undergone such programs (Kim, et. al., 2004, 1138).
By determining where a patient’s knowledge deficit exists, a nurse will be better equipped to educate on cancer pain. A nurse can then expand and reinforce a patient’s knowledge base with information designed to facilitate pain relief (Kim, et al., 2004, p. 1142). Through education, patients are encouraged to be involved in their own pain management (Woodward, 2005, p. 261). The patient has expert knowledge about their pain level. A nurse has the obligation to teach and listen to the patient regarding what the patient is feeling and how specific interventions are working to relieve pain (Sterman, Gauker & Krieger, 2003, p.861). Patients need to be taught to use their voice in order to enable the nursing staff to better help alleviate their pain.
In summary, the overall goal for developing a pain management program is to provide consistent, improved pain management for cancer patients. This goal has been shown to be attainable through the best nursing practices of assessment, documentation and patient education. These three key elements are interrelated and work together to provide nurses with the assurance that they are doing everything in their power to alleviate their patient’s pain.











References

Aubin, M., Vezina, L., Parent, R., Fillion, L., Allard, P., & Bergeron, R., et al. (2006, November). Impact of an educational program on pain management in patients with cancer living at home. Oncology Nursing Forum, 33(6), 1183-1188. Retrieved February 1, 2008 from CINAHL database.
Harper, K., Bell, S. (2006, August). A pain assessment tool for patients with limited communication ability. Nursing Standard, 20(51), 40-44. Retrieved February 2, 2008 from CINAHL database.
Idell, C., Grant, M., & Kirk, C. (2007, May). Alignment of pain reassessment practices and national comprehensive cancer network guidelines. Oncology Nursing Forum, 34(3), 661-671. Retrieved October 30, 2007 from CINAHL database.
Kim, J., Dodd, M., West, C., Paul, S., Facione, N., & Schumacher, et al. (2004, November). The PRO-SELF pain control program improves patients’ knowledge of cancer pain management. Oncology Nursing Forum, 31(6), 1137-1143. Retrieved November 1, 2007 from CINAHL database.
Michales, T., Hubbartt, E., Carroll, S., Hudson-Barr, D. (2007, July-September). Evaluating an educational approach to improve pain assessment in hospitalized patients. Journal of Nursing Care Quality, 22(3), 260-265. Retrieved February 3, 2008 from CINAHL database.
Sterman, E., Gauker, S., & Krieger, J. (2003, September-October). A comprehensive approach to improving cancer pain management and patient satisfaction. Oncology Nursing Forum, 30(5), 857 – 864. Retrieved October 28, 2007 from CINAHL database.
Woodward, D. (2005, July-September). Developing a pain management program through continuous improvement strategies. Journal of Nursing Care Quality, 20(3), 261-267. Retrieved October 10, 2007 from CINAHL database.
a. Intervention 1: Instituting proper pain assessment is critical to cancer pain management
i. Disadvantage 1: Thorough education regarding proper pain assessment may not be readily available to many nurses.
Knowledge deficits in pain assessment practices among nurses are some of the most common contributing factors to under treatment of cancer pain in adults. Many health care institutions rely solely on the education the nurse received in school and provide no additional training. Proper Assessment is a key factor in pain management but lack of education for nursing staff will undermine this critical intervention. Common assumption is that all nurses have the same baseline knowledge about pain. Nurses have varied experiences in education and pain management.
Michales, T., Hubbartt, E., Carroll, S., Hudson-Barr, D. (2007, July-September). Evaluating an educational approach to improve pain assessment in hospitalized patients. Journal of Nursing Care Quality, 22(3), 260-265. Retrieved February 3, 2008 from CINAHL database.

ii. Disadvantage 2: Some patients may not be able to participate in the assessment process.
Every patient is different and assessing pain varies from patient to patient.Assessment of pain in patients with impaired communication due to the severity or progression of their cancer or even cognitive impairment, represents one of the most significant challenges in pain management. Nurses have difficulty knowing when these patients are in pain and when they are experiencing pain relief. This makes the patient vulnerable to under and over treatment.

Harper, K., Bell, S. (2006, August). A pain assessment tool for patients with limited communication ability. Nursing Standard, 20(51), 40-44. Retrieved February 2, 2008 from CINAHL database.

b. Intervention 2: Patient education plays a vital role in pain management
i. Disadvantage 1: Patients may not have the willingness or desire to participate in their pain relief plan depending on the severity of their cancer.
Patient education and participation is important in order to help the nurse better treat a patient’s pain, but should not replace the nurse’s role of providing a plan of care for pain relief. Unfortunately, not all patients want to participate in this aspect of their care. Some are too sick and just want their pain relieved, while others look to the nurse to provide the expert care. Patients may participate in a pain control plan if they are not consumed with illness and pain. Studies have indicated that many patients want to be taken care of when faced with a terminal illness and are not focused on learning about their pain. Many patients just want their pain relieved by the nurse that is providing care for them.
Kim, J., Dodd, M., West, C., Paul, S., Facione, N., & Schumacher, et al. (2004, November). The PRO-SELF pain control program improves patients’ knowledge of cancer pain management. Oncology Nursing Forum, 31(6), 1137-1143. Retrieved November 1, 2007 from CINAHL database.


ii. Disadvantage 2: Nursing staff may put too much responsibility on the patient to report their pain issues.
Nurses may rely too heavily on the patient to report their need for pain relief. By putting an emphasis on educating the patient regarding their pain, some nurses may depend entirely on the patient to tell them what they need. There needs to be a balance and partnership between the patient and the nurse that is providing care. Educational interventions to modify patient’s attitudes and misbeliefs, coupled with consistent nursing follow through, contribute to improved pain management in patients living with cancer. Nurses should not put the burden of pain relief on the patient and many will.
Aubin, M., Vezina, L., Parent, R., Fillion, L., Allard, P., & Bergeron, R., et al. (2006, November). Impact of an educational program on pain management in patients with cancer living at home. Oncology Nursing Forum, 33(6), 1183-1188. Retrieved February 1, 2008 from CINAHL database.


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