Purpose/Objectives: To describe the findings and critique the studies of interventions for nursing staff to improve pain management in adults with cancer.
Data Sources: Publications were identified through database searches. Studies that describe interventions to overcome nurse-related barriers in cancer pain management practices were included in this review.
Data Synthesis: Nine studies were found that met the inclusion criteria. All studies were experimental and conducted from 1993–2013.
Conclusions: Increase in knowledge, change of attitudes and behaviors, and good relationships with specialists were found to be influential in overcoming existing nursing barriers to pain management in cancer survivors. Educational interventions are more effective in increasing knowledge than in improving attitudes. Specialists were acknowledged as important resources and role models for nurses, particularly when trust was established between the two.
Implications for Nursing: A number of interventions have been developed to address healthcare provider barriers. However, scarce literature exists on whether interventions that aim to overcome nurse-related barriers have been successful. This literature review provides critical insights on the effectiveness of interventions aimed to overcome barriers to effective pain management by nurses for adults with cancer.
Pain often accompanies cancer, and an estimated 60%–85% of patients with advanced cancer will experience pain during the disease process (Kwon, 2014). According to the Institute of Medicine ([IOM], 2011), pain affects function and quality of life, increases the use of healthcare resources, and contributes to loss of productivity. Therefore, effective pain management is critical for patients with cancer.
The healthcare system, healthcare providers, caregivers, and patients all play a role in creating barriers to effective pain management. The barriers that affect nurses have been well documented and include inadequate education about pain mechanisms and types of pain medications, the importance of proper pain assessment and documentation, a persistent suspicion about drug-seeking behaviors among opioids users and/or fear of over-sedation, and lack of specialists (Kwon, 2014). In a review of barriers to pain management, Fishman et al. (2013) noted that “inadequate education of health care professionals is a major and persistent barrier to safe and effective pain management” (p. 973). Nurses have inadequate education about how to manage different kinds of pain, how to combine various pain medications, and how to manage side effects such as constipation or nausea. Healthcare providers may be knowledgeable about pain assessment, but the knowledge may not be reflected in their behaviors and actions (Kwon, 2014). For example, nurses may not provide aggressive pain management—even though they know how to—when they are busy with other nursing cares.
Several interventions have been attempted (All & Huycke, 1999; Fishman et al., 2013; Kwon, 2014) to address provider-related barriers—particularly lack of knowledge, negative attitudes, and lack of specialist consultation—in cancer pain management. The initial goal of the current review was to describe studies of interventions aimed at overcoming nurse-related barriers to pain management for older adults (aged 65 years and older) with cancer. However, no studies were found that exclusively focused on nurses who cared for older adults with cancer. Therefore, the purpose of this literature review was to describe the effectiveness of interventions aimed at overcoming barriers in nursing when providing pain management to adults with cancer.
Comprehensive literature searches were conducted, with the help of a medical librarian using the PubMed, CINAHL®, PsycINFO®, Scopus, and ProQuest Dissertation and Theses databases. The following key words were combined in PubMed: aged OR older adults OR elderly AND attitude of health personnel OR barriers OR models OR perceptions AND nurses OR oncology nursing AND cancer AND pain. The filter for English language was applied to the search. Slightly different arrangements of the key words were used in other databases because of differences in the engines’ search preferences. PubMed returned 180 articles, CINAHL 75 articles, PsycINFO 182 articles, and Scopus 14 articles (none from ProQuest). The abstracts were screened, and final studies were selected by using the following inclusion criteria: (a) the study sample included nurses working in oncology with an older adult population (aged 65 years and older) and (b) the study tested an intervention to overcome a nurse-related barrier to cancer pain management.
Following these screening criteria, nine publications representing eight interventions studies were identified and systematically assessed by the authors to maintain rigor and quality (see Table 1). Torraco’s (2011) recommendations for conducting a review were used, and studies were analyzed for their methods, participants and settings, and the presence of implemented interventions.
All of the studies identified were experimental in nature. Four basic experimental designs were used (Bookbinder et al., 1996; Ferrell, Grant, Ritchey, Ropchan, & Rivera, 1993; Wells et al., 2001); one was a longitudinal, multilevel, randomized, controlled clinical trial (Vallerand, Riley-Doucet, Hasenau, & Templin, 2004); and four were quasiexperimental studies (de Rond, De Wit, Van Dam, & Muller, 2000; de Rond, De Wit, Van Dam, Van Campen, et al., 2000; Gustafsson & Borglin, 2013; Idell, Grant, & Kirk, 2007). The locations in these studies ranged from various acute inpatient settings to outpatient agencies. The postintervention follow-up period varied from immediate to one year.
All participants were nurses working with adults with cancer. The sample sizes in the studies ranged from 18 (McMillian, Tittle, Hagan, & Small, 2005) to 1,210 (Bookbinder et al., 1996). Demographic characteristics of nurses participating in all nine studies varied. The mean age ranged from 32.8–50 years. The majority of the nurses were women, ranging from 81%–100% in the studies. The majority of the nurses were BSN prepared, with a mean of 51.5%, and the average number of years in nursing ranged from 5–20 years. Five studies were conducted in the United States (Bookbinder et al., 1996; Ferrell et al., 1993; Idell et al., 2007; McMillan et al., 2005; Vallerand et al., 2004), and the others in Sweden (Gustafsson & Borglin, 2013), the Netherlands (de Rond, De Wit, Van Dam, & Muller, 2000; de Rond, De Wit, Van Dam, Van Campen, et al., 2000), and the United Kingdom (Wells et al., 2001).
Two types of interventions were identified in the studies. Two (Gustafsson & Borglin, 2013; Vallerand et al., 2004) of the nine studies had control groups, and the remaining seven studies delivered their interventions to all participants. The first type of intervention was an educational program to improve pain management (Bookbinder et al., 1996; de Rond, De Wit, Van Dam, & Muller, 2000; de Rond, De Wit, Van Dam, Van Campen, et al., 2000; Ferrell et al., 1993; Gustafsson & Borglin, 2013; McMillian et al., 2005; Vallerand et al., 2004). The second type of intervention combined pain education with a change leader or a role model (Idell et al., 2007; Wells et al., 2001).
Seven studies tested five different models of education regarding cancer pain. Two studies employed an intervention that consisted of two approaches to a multi-day, intense course to train pain resource nurses (PRNs) to lead and exemplify proper pain management (Ferrell et al., 1993; McMillian et al., 2005). The Power Over Pain (POP) model was employed to overcome barriers to pain management in homecare nurses (Vallerand et al., 2004). The Pain Monitoring Program was used to see the differences in nurses’ communication, assessment, documentation, pain knowledge, and attitude (de Rond, De Wit, Van Dam, & Muller, 2000; de Rond, De Wit, Van Dam, Van Campen, et al., 2000). The Pain Management Program aimed to shape structure, increase knowledge, and help with problem solving (Bookbinder et al., 1996). Lastly, the Theory of Planned Behavior (TPB) (Gustafsson & Borglin, 2013) provided the framework of an educational intervention that tested changes in knowledge and attitudes in nurses. The Pain Monitoring Program, the Pain Management Program, and TPB-based educational intervention were similar in combining pain knowledge components and proper pain assessment practices. The POP enhanced education and nurses’ assertiveness and improved their skills as patient advocates when working in homecare settings.
Two studies in the current review used an approach of implementing pain education and a change leader or role model simultaneously. One study used an application of research utilization model under the advanced practice nurse leadership for nurses in acute care settings (Idell et al., 2007), which is a framework conceived to change nurses’ behavior in a systematic and organized way. The second intervention evaluated if teaching sessions with the presence and role modeling of palliative team specialists can improve nurses’ knowledge and attitudes (Wells et al., 2001).
The nine studies measured one or more of four outcomes. The majority of studies used instruments with established validity and reliability. When researchers modified their instruments and/or used new tools, the validity and reliability was established (Gustafsson & Borglin, 2013; Idell et al., 2007; McMillan et al., 2005; Vallerand et al., 2004). All studies measured knowledge and attitudes, and four instruments or modified versions of the instruments were used to measure these concepts. The Pain Competency Evaluation (Idell et al., 2007), the Pain Survey (McMillan et al., 2005), the Pain Attitude Inventory (de Rond, De Wit, Van Dam, Van Campen, et al., 2000), and the Nurses Knowledge and Attitude Survey or its modified version (Gustafsson & Borglin, 2013; Idell et al., 2007; McMillan et al., 2005; Vallerand et al., 2004) were used to assess knowledge and attitudes. Perception of Control Over Pain (Vallerand et al., 2004) measured the sense of empowerment with regard to managing pain. Concordance on pain intensity between patient self-report and nurses’ assessment was evaluated by questionnaires (de Rond, De Wit, Van Dam, Van Campen, et al., 2000). Participants rated the helpfulness and value of role models, such as palliative care specialists and pain specialists, for improved pain management (Vallerand et al., 2004; Wells et al., 2001). Pain documentation practices and behaviors were measured with the Pain Reassessment Data Tool (Idell et al., 2007), Quality of Nurses’ Pain Assessment tool (de Rond, De Wit, Van Dam, & Muller, 2000), and by a review of pain documentation (Bookbinder et al., 1996).
Knowledge: All studies measured increased knowledge of pain management scores from pre- to postintervention; however, only four studies reported statistically significant results in knowledge increase (de Rond, De Wit, Van Dam, & Muller, 2000; de Rond, De Wit, Van Dam, Van Campen, et al., 2000; Gustafsson & Borglin, 2013; Idell et al., 2007; McMillan et al., 2005). Two studies looked at subgroups of knowledge questions on the questionnaires to learn where the highest learning and increase in pain competency levels took place and where it did not (McMillan et al., 2005; Wells et al., 2001). After the intervention, nurses’ knowledge about pain assessment improved, as evidenced by a closer match of pain scores between patient report of pain and nurse perceptions of their patients’ pain (de Rond, De Wit, Van Dam, & Muller, 2000). One study reported that many nurses had little to no formal pain education in their school curricula or clinical practice (Wells et al., 2001).
Attitudes: Four studies reported attitude change reaching statistically significant levels (de Rond, De Wit, Van Dam, Van Campen, et al., 2000; Gustafsson & Borglin, 2013; Idell et al., 2007; McMillan et al., 2005). Although studies found positive changes in attitudes, two studies concluded that attitudes in healthcare professionals are harder to change than knowledge (McMillan et al., 2005; Wells et al., 2001). After the educational intervention in one study, patient reports of the quality of pain education provided by nurses improved; however, this was not the case for older adult patients (p < 0.001) (de Rond, De Wit, Van Dam, & Muller, 2000). Vallerand et al. (2004) reported that nurses felt more in control over treating patients’ pain and they felt able to provide better pain management after the intervention. Nurses verbalized feeling more empowered and positively evaluated the interventions (Ferrell et al., 1993; Idell et al., 2007).
Role models or specialists: Role models and specialists were found to be highly valuable to nurses in two studies. Wells et al. (2001) found that nurses more than physicians reported satisfaction and valued working with palliative care specialists. In one study, PRNs reported greater empowerment and better understanding of interdisciplinary pain management approaches but still struggled to work efficiently with coworkers and physicians when functioning in this role (Ferrell et al., 1993). Nurses who practiced in inpatient settings and home care also valued access to specialists and resources when dealing with and reviewing complex cases of patients and pain (Vallerand et al., 2004).
Pain assessments and documentation: Three studies evaluated behavior changes in pain assessment, reassessment, and documentation (Bookbinder et al., 1996; de Rond, De Wit, Van Dam, & Muller, 2000; Idell et al., 2007). A notable increased frequency in documentation of pain and pain assessment, particularly for intensity, location, duration, and factors that alleviate or decrease the pain, as well as pain relief measures provided, were found in two studies (Bookbinder et al., 1996; de Rond, De Wit, Van Dam, & Muller, 2000). Another study found pain reassessment frequency and comprehensiveness increased from pre- to postintervention; however, this improvement did not reach statistical significance (Idell et al., 2007).
All of the studies reviewed included nurses who care for adults of all ages with cancer. The original aim of this review was to explore the effectiveness of interventions to reduce barriers to pain management in nurses working with older adults with cancer; the inability to accomplish this goal is a limitation of this review.
All studies included in this review were experimental, with a specific intervention implemented and manipulated to influence knowledge, attitude, and/or behavior change. Most studies did not employ randomization, limiting the reader’s ability to determine if the intervention was the source of improvements. Only two studies had control groups (Gustafsson & Borglin, 2013; Vallerand et al., 2004). Inadequate sample sizes, attrition pre- and postintervention, or inability to recruit the needed number of nurses limited statistical significance (Bookbinder et al., 1996; Ferrell et al., 1993; Vallerand et al., 2004; Wells et al., 2001). Also, all studies used convenience samples. Most of the participants were self-selected or required to participate (Bookbinder et al., 1996), creating possible selection bias. Some studies used modified versions of tests and/or investigator-developed tools; however, authors reported the validity and reliability of the new instruments (Gustafsson & Borglin, 2013; Idell et al., 2007; McMillan et al., 2005; Vallerand et al., 2004).
No apparent differences were noted in reported knowledge, attitudes, perceptions, and behaviors between studies that employed an educational intervention only and the intervention with a role model/change leader. The results suggest that knowledge, attitudes, perceptions of role leaders, and behavioral changes as measured by pain documentation and pain reassessment seemed to be positively influenced and changed by various interventions. However, because statistical significance was obtained by a small number of studies, the interventions’ effectiveness remains questionable.
Knowledge was easier to manipulate than attitudes. All participants gained knowledge on pain management, as evidenced by increases in scores on post-tests. Attitudes were harder to influence and manipulate. Attitudes (trust, in particular) affected nurses’ perception of working with palliative specialists (Wells et al., 2001). However, because many studies did not have control groups, it was difficult to ascertain if the interventions were effective or whether the results were affected by other factors. In addition, all studies implemented different educational programs or approaches and, therefore, limited the ability to compare and contrast the interventions and the results.
Wells et al. (2001) found that nurses were more responsive to learning from a palliative care team and the relationship strengthened the learning processes and, consequently, outcomes. In addition, the authors speculated that teamwork and trust were predictive of the learning by noticing that the palliative care team did not succeed on wards where trust was compromised between team members (Wells et al., 2001). Nurses also positively received the presence of the advanced practice nurse in supporting practice change in pain management (Idell et al., 2007). These findings match recommendations suggested by Kwon (2014) on overcoming barriers in nurses by providing education and the presence of palliative care specialists. Two studies indicated that PRNs could be effectively educated and bring positive change in pain practices for oncology nurses (Ferrell et al., 1993; McMillan et al., 2005). However, the researchers did not evaluate if the presence of PRNs on the unit would bring the same results for other staff nurses as the presence of palliative specialists.
Of nine studies, only three measured behavior change by looking at pain documentation and assessment and reassessment practices. Behavior change and the action it produces is an important outcome measure. As noted by Kwon (2014), a discrepancy exists between what healthcare providers think they know and what they actually practice. Therefore, measuring behavior change is imperative because of practical implications and the importance of obtaining the true picture of providers’ pain management practices. Finding only three studies that measured this outcome limits drawing conclusions as to whether the interventions resulted in noticeable positive practice change.
The number of studies that tested interventions for overcoming the barriers in healthcare providers to the provision of more effective pain management is small. Studies adequately powered to test the intervention and use of randomized, controlled designs are needed to confirm if the interventions hold their effectiveness over time and if the results can be replicated. Also, innovative approaches and models are needed to provide new solutions and creative ways to change current practices, attitudes, and beliefs.
The original goal of the current review was to describe provider-related barriers to cancer pain management in older adults. Not even one study reviewed tested interventions designed to address the unique barriers to pain management experienced by older adults with cancer. Because older adults are a growing and vulnerable patient population that will experience pain, they will require effective interventions and models to employ to deal with this issue effectively. Research studies are needed to verify the barriers and evaluate interventions aimed at nurses working with older adults with cancer pain.
Pain in populations of patients with cancer continues to be a major problem. Interventions to overcome barriers to pain assessment and management by healthcare providers are needed. This review summarized findings from nine studies that implemented interventions aimed at overcoming barriers to the provision of effective pain management for patients. The review concludes that available interventions may be effective in knowledge improvement, but not so in changing attitudes. Specialists and role models for pain practices are valuable to nurses, particularly when trusting relationships are established. Finally, interventions that measure behavior changes such as assessment, documentation, and delivery of pain management interventions are needed. Additional research is needed to verify and replicate the findings, particularly in older adults with cancer pain.
All, C.A., & Huycke, L.I. (1999). Pain, cancer and older adults. Geriatric Nursing, 10, 241–247.
Bookbinder, M., Coyle, N., Kiss, M., Goldstain, M.L., Holritz, K., Thanlen, H., . . . Portenoy, R. (1996). Implementing national standard for cancer pain management: Program model and evaluation. Journal of Pain and Symptom Management. 12, 334–347.
de Rond, M.E., De Wit, R., Van Dam, F.S., & Muller, M.J. (2000). A pain monitoring program for nurses: Effects on communication, assessment and documentation of patients’ pain. Journal of Pain and Symptom Management, 20, 424–439.
de Rond, M.E., De Wit, R., Van Dam, F.S., Van Campen, B., Den Hartog, Y.M., & Klievink, R.M.A. (2000). A pain monitoring program for nurses: Effects on nurses’ pain knowledge and attitude. Journal of Pain and Symptom Management, 19, 457–467.
Ferrell, B.R., Grant, M., Ritchey, K.J., Ropchan, R., & Rivera, L.M. (1993). The pain resource nurse training program: A unique approach to pain management. Journal of Pain and Symptom Management, 8, 549–556.
Fishman, S.M., Young, H.M., Arwood, E.L., Chou, R., Herr, K., Murinson, B.B., . . . Strassels, S.A. (2013). Core competencies for pain management: Results of an interprofessional consensus summit. Pain Medicine, 14, 971–981.
Gustafsson, M., & Borglin, G. (2013). Can a theory-based educational intervention change nurses’ knowledge and attitudes concerning cancer pain management? A quasi-experimental design. BMC Health Services Research, 13(328), 1–11.
Idell, C.S., Grant, M., & Kirk, C. (2007). Alignment of pain reassessment practices and national comprehensive cancer network guidelines. Oncology Nursing Forum, 34, 661–671.
Institute of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research (Brief report). Washington, DC: National Academies Press.
Kwon, J.H. (2014). Overcoming barriers in cancer pain management. Journal of Clinical Nursing, 32, 1727–1733.
McMillan, S.C., Tittle, M., Hagan, S.J., & Small, B.J. (2005). Training pain resource nurses: Changes in their knowledge and attitudes. Oncology Nursing Forum, 32, 835–842.
Torraco, R.J. (2011). Writing integrative literature reviews: Guidelines and examples. Human Resource Development Review, 4, 356–367. doi:10.1177/1534484305278283
Vallerand, A.H., Riley-Doucet, C., Hasenau, S.M., & Templin, T. (2004). Improving cancer pain management by homecare nurses. Oncology Nursing Forum, 31, 809–816.
Wells, M., Dryden, H., Guild, P., Levack, P., Farrer, K., & Mowat, P. (2001). The knowledge and attitudes of surgical staff towards the use of opioids in cancer pain management: Can the hospital palliative care team make a difference? European Journal of Cancer Care, 10, 201–211.
Dorota A. Bartoszczyk, RN, MSN, OCN®, is a PhD student in the College of Nursing at the University of Iowa and is an RN at the University of Iowa Hospitals and Clinics, and Stephanie Gilbertson-White, RN, PhD, is an assistant professor in the College of Nursing at the University of Iowa, both in Iowa City. Bartoszczyk is the recipient of a pain and associate symptoms research T32 predoctoral fellowship from the University of Iowa. Bartoszczyk can be reached at firstname.lastname@example.org, with copy to editor at ONFEditor@ons.org. (Submitted March 2015. Accepted for publication April 29, 2015.)