A randomized controlled trial of a nurse-administered educational intervention for improving cancer pain management in ambulatory settings

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Abstract

The persistence of negative attitudes towards cancer pain and its treatment suggests there is scope for identifying more effective pain education strategies. This randomized controlled trial involving 189 ambulatory cancer patients evaluated an educational intervention that aimed to optimize patients’ ability to manage pain. One week post-intervention, patients receiving the pain management intervention (PMI) had a significantly greater increase in self-reported pain knowledge, perceived control over pain, and number of pain treatments recommended. Intervention group patients also demonstrated a greater reduction in willingness to tolerate pain, concerns about addiction and side effects, being a “good” patient, and tolerance to pain relieving medication. The results suggest that targeted educational interventions that utilize individualized instructional techniques may alter cancer patient attitudes, which can potentially act as barriers to effective pain management.

Introduction

Despite some remarkable achievements in cancer pain management, studies continue to demonstrate that many people with cancer are reluctant to report pain and do not adhere to prescribed pain therapy. Weiss et al. found that while more than one half of their sample of terminally ill patients experienced moderate or severe pain, only a third sought more drug therapy, and one in ten wanted to stop or reduce their pain medication [1]. Similarly, a study by Zhukovsky et al. reported that 44% of cancer patients experienced moderate to greater than moderate pain, but only 41% of those patients were dissatisfied with their pain management [2].

Numerous reasons have been proposed for this paradox, including health care provider and patient beliefs, fears and concerns. Studies consistently identify patient concerns about addiction, side effects, and developing tolerance to analgesics, and a fear that increases in pain signify disease progression. These studies also report patients often want to be “good” and not distract their physician from the disease by reporting their pain [1], [3], [4], [5], [6].

The persistence of these widely held views about cancer pain and its treatment suggest there is scope for identifying more effective patient and family education strategies to achieve optimal pain control. The purpose of this study is to evaluate the effectiveness of an educational intervention in overcoming attitudinal barriers and improving ambulatory cancer patients’ ability to more effectively prevent and manage pain.

Section snippets

Literature review

Surprisingly few studies have systematically evaluated different approaches to improving pain management through patient education. An early study by Rimer et al. [7] demonstrated that 1 month after participating in an individualized patient education intervention consisting of nurse counseling and printed materials, patients in the experimental group were more likely than controls to have taken the correct schedule and dose of pain medication. In addition, the experimental group was

Conceptual framework

The present study is based on Green’s PRECEDE model of health behavior [15]. This model identifies three categories of factors that may potentially influence a health behavior such as the use of effective strategies to minimize pain. These three categories include: predisposing factors, such as beliefs, attitudes and perceptions that might facilitate or hinder a person’s motivation to perform a desired behavior; enabling factors, or the skills and resources necessary to perform the behavior;

Results

Fig. 2 illustrates recruitment rates and retention for the study.

Of the 189 eligible patients from the two centers who completed the baseline assessment (T0) and who were subsequently randomized, 166 (87.8%) completed the T1 follow up assessment, and 140 (74.1%) completed the T2 follow up assessment. Attrition rates did not differ between intervention and control groups, with the main reason for attrition being deteriorating condition or death.

Details of the sample are included in Table 3.

Discussion

The purpose of this study was to evaluate the effectiveness of a brief nurse-administered educational intervention in overcoming attitudinal and behavioral barriers to cancer pain management for patients receiving treatment in ambulatory settings. Our results suggest the intervention is effective in decreasing a number of commonly held patient concerns regarding cancer pain and its treatment. The intervention also appears to have been effective in achieving a greater reported willingness for

Practice implications

Despite the additional questions raised by this work, the findings from the present study add to the growing body of evidence that nurse-administered educational interventions are able to correct important beliefs that may impact on pain severity and emotional wellbeing, such as concerns about addiction and tolerance. Moreover, the intervention evaluated in the present study was delivered in an outpatient setting, did not require extensive resources and was not time-intensive, and is thus

Acknowledgements

This study was funded by the National Health and Medical Research Council. The authors would like to thank the research assistants who undertook data collection and the patients from the Division of Oncology at Royal Brisbane Hospital, Brisbane and Oncology Unit at St. Vincent’s Hospital, Melbourne who participated in this study.

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