Background
Effective pain management cuts across professional boundaries with clinicians’ failure to routinely screen and assess for pain contributing to the burden of unrelieved cancer pain experienced by 39–66% of cancer patients [
1]. To date, most research has focused on testing new cancer pain treatments, with little attention payed to strengthening cancer pain screening and assessment practices. Evidence suggests that implementing routine screening and assessment and managing pain in accordance with evidence-based guidelines can improve quality of care and outcomes for cancer pain [
2‐
4].
Evidence of screening and assessment practices are increasingly being recognised as quality indicators of optimal cancer pain management internationally, with pain now recognised as the fifth vital sign and routinely recorded on inpatients’ observation charts [
5]. The subjective nature of pain makes measuring patient-reported outcomes the optimal source of clinical information [
6]. However, instead of routinely seeking a patient-reported Numerical Rating Scale (NRS) pain score, many clinicians adopt informal pain screening approaches [
7] and/or fail to comprehensively assess their patients’ pain [
8,
9]. A survey of Australian patients receiving community palliative care found that one-third experienced moderate to severe pain, restricting their activities over the preceding three days [
10]. When this survey was repeated with a different cohort, a similar burden of unrelieved pain was reported [
11].
It is recommended that a comprehensive pain assessment be undertaken for all cancer patients with an NRS pain score ≥ 2 [
12,
13]. Determining the location, temporal pattern(s), exacerbating and/or relieving factors associated with the patient’s pain and ascertaining whether the pain has nociceptive or neuropathic origin(s) [
14] is integral to determining a differential pain diagnosis and an individualised cancer pain management plan. Undertaking a comprehensive pain assessment is complex and too few clinicians have been formally taught how to assess across these pain domains, with most learning ‘on the run’, by observing their peers or through industry events. Yet, clinicians’ cancer pain assessment competencies [
15], their understanding of the most suitable pain assessment tools, commitment and capacity to integrate pain assessment findings into clinical decision-making [
16], communication skills and capacity to address their patients’ care needs within the context of multi-professional practice [
17], all impact on their patients’ pain outcomes.
Unfortunately, many interventions aimed at improving clinicians’ pain assessment have had a limited effect on cancer pain outcomes [
18‐
25]. The reasons for this failure are complex and varied and include failure to address the multiple barriers at the patient (i.e. failing to report the presence of pain), clinician (i.e. failing to adhere to recommended routine pain screening and assessment practices) [
18] and organisational/system (i.e. accreditation and funding not linked to meeting pain management standards) levels. Most previous clinician-targeted cancer pain management interventions have been based on intuition, as opposed to being theoretically driven [
26], which in part explains their ad-hoc success and limited transferability [
16]. While a small number of previous interventions have focused on inter-professional education [
18‐
23], not all have optimised the educational intervention ‘dose’ (strength) [
18‐
22] or effectively managed the complexity of the intervention [
20] and/or been underpinned by an evidence-based behavioural change framework [
26,
27].
Despite the complexity of undertaking a comprehensive pain assessment, very few, if any, interventions have targeted cancer pain assessment as a distinct learning component, with most embedding screening and assessment into a broader cancer pain management learning package, privileging pharmacological cancer pain management practices [
8]. In addition, few previous clinician targeted cancer pain management interventions have engaged both doctors and nurses, with most focusing exclusively on educating a single discipline as opposed to inter-professional practices [
19]. Yet, the interdisciplinary nature of cancer and palliative care necessitates the implementation of targeted inter-professional learning strategies addressing pain assessment as a stand-alone construct [
19]. Given this reality, there are opportunities to maximise the impact of any clinically focused cancer pain assessment behavioural change intervention by including evidence-based strategies, such as: (1) audit and feedback, which includes any summary of clinical performance over a defined period and can lead to potentially important improvements in practice [
28]; (2) comprehensive interventions, which are more effective when addressing patients’ pain, especially when documentation and monitoring interventions are combined [
18]; (3) more intense interventions involving extensive follow-up, a comprehensive educational program and greater resource allocation which are significantly more likely to impact positively on reducing cancer pain [
20]; and (4) explicit application of theory to identify contextual conditions necessary for their success and enhance learning [
26]. In addition, given the significant annual investments healthcare organisations make towards building clinical capabilities, few continuing professional development (CPD) activities are underpinned by evidence-based pedagogy and/or have been subjected to an economic analysis.
These gaps highlight the need to develop and test alternative strategies with a real potential to build cancer and palliative care clinicians’ cancer pain assessment capabilities, using effective and cost-effective pedagogically sound interventions underpinned by evidence-based behavioural change theories [
27].
The trial protocol reported here adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist [
29].
Discussion
This trial will evaluate a targeted inter-professional mHealth clinical education intervention designed to drive innovation in cancer pain assessment. An adequately powered RCT is required to confirm our pilot results and to determine if an mHealth intervention that integrates spaced learning, audit and feedback, and decision support prompts can reduce cancer patients’ reported pain scores. A cost-effectiveness analysis is also required to determine whether the intervention represents value for money and should be promoted more widely as a cost-effective evidence-based intervention. Our proposed multicentred approach will increase the strength of the study recommendations and extrapolation of this intervention to other clinical settings.
If our phase III trial reports effectiveness, in addition to improving cancer pain assessment practices, it will provide an evidence-based framework (output) that could readily be used to address other entrenched evidence practice gaps (i.e. handwashing, managing the deteriorating patient and opioid prescribing). This intervention is also scalable as its mHealth delivery format ensures that the intervention can be readily rolled out across multiple services in diverse geographical locations. In the longer term, if the results are positive, they will help transform the CPD paradigm from one focused on random personal interests to one where clinicians’ learning experiences are aligned with identified clinical practice gaps, ensuring that future CPD policy supports learning experiences that improve patient care outcomes. While mHealth initiatives are increasingly being used, there is little research on which technologies or pedagogical approaches are most effective in promoting clinical practice behavioural change. There is even less evidence around the cost-effectiveness of these CPD interventions, hence the importance and timeliness of this study. Given the scarcity of health resources, any intervention designed to build clinicians’ pain assessment capacity needs to be cost-effective [
43]. Clinicians and administrators can no longer afford to think of pain as an inevitable consequent of living with cancer, but rather view it as a modifiable factor that can be addressed through vigilant, evidence-based cancer screening and assessment practices.