How nurses assess breakthrough cancer pain, and the impact of this pain on patients' daily lives--results of a European survey

A rapid systematic review of breakthrough pain definitions and descriptions

Background

Breakthrough pain is common in life-limiting conditions and at end-of-life. Despite over 30 years of study, there is little consensus regarding the definition and characteristics of breakthrough pain.

Objective

This study aims to update and expand a 2010 systematic review by Haugen and colleagues to identify (1) all definitions of breakthrough pain and (2) all descriptions and classifications of breakthrough pain reported by patients, caregivers, clinicians, and experts.

Design

This rapid systematic review followed the Cochrane Rapid Review Methods Group guidelines. A protocol is published on PROSPERO (CRD42019155583).

Data sources

CINAHL, MEDLINE, PsycINFO, and the Web of Science were searched for breakthrough pain terms from the inception dates of each database to 26th August 2022.

Results

We identified 65 studies that included data on breakthrough pain definitions, descriptions, or classifications from patients (n = 30), clinicians (n = 6), and experts (n = 29), but none with data from caregivers. Most experts proposed that breakthrough pain was a sudden, severe, brief pain occurring in patients with adequately controlled mild-moderate background pain. However, definitions varied and there was no consensus. Pain characteristics were broadly similar across studies though temporal factors varied widely. Experts classified breakthrough pain into nociceptive, neuropathic, visceral, somatic, or mixed types. Patients with breakthrough pain commonly experienced depression, anxiety, and interference with daily life.

Conclusions

Despite ongoing efforts, there is still no consensus on the definition of breakthrough pain. A compromise is needed on breakthrough pain nomenclature to collect reliable incidence and prevalence data and to inform further refinement of the construct.

Definition and Assessment of Paediatric Breakthrough Pain: A Qualitative Interview Study

Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept.

Knowledge and practice of the management of breakthrough cancer pain among general practitioners providing palliative care in Shanghai, China: a cross-sectional survey

OBJECTIVE

This study examined knowledge and practice of breakthrough cancer pain (BTcP) management among general practitioners (GPs) providing palliative care in Shanghai.

DESIGN

Cross-sectional study using a self-administered questionnaire.

SETTING AND PARTICIPANTS

A total of 393 GPs providing palliative care in 32 community health service centres in Shanghai were recruited by stratified cluster random sampling between 1 May and 30 June 2022.

OUTCOME MEASURES

Knowledge and practice concerning BTcP management.

RESULTS

A total of 375 questionnaires were collected and declared valid. The median knowledge score was 11 out of 21 points. Only 36.3% (n=136) of the participating GPs scored 11 points or more, which was categorised as good knowledge. Only 24.8% (n=93) of the GPs used Davies' adapted diagnostic algorithm as the gold standard for diagnosis. All of the GPs assessed the intensity of BTcP; however, less than a quarter of the GPs evaluated the relationship between background pain and BTcP (22.1%, n=83), the impact of BTcP on activities of daily living (24.0%, n=90), the impact of BTcP on social relationships (14.4%, n=54) and the impact of BTcP on mood (10.1%, n=38). 56.5% (n=212) of the GPs reported that they used pain tools in the assessment of BTcP. All of the GPs prescribed immediate-release morphine as rescue medication for relieving BTcP; however, 60.5% (n=227) prescribed the dose based on their personal experiences, irrespective of the basal opioid dose, and 57.3% (n=215) did not conduct dose titration after providing the initial dose. No GPs reported that they ever administered interventional treatment to their patients.

CONCLUSIONS

Insufficient knowledge and inappropriate behaviours in BTcP diagnosis, assessment and treatment were identified. There is an urgent need to improve BTcP management among GPs providing palliative care in Shanghai.

Effect of a theory-driven educational intervention on the level of knowledge, attitudes, and assessment practices regarding breakthrough cancer pain (BTCP) management among medical nurses in Hong Kong

PURPOSE

To examine the effect of an educational intervention intended to improve medical nurses' adherence to breakthrough cancer pain (BTCP) assessment practices and their level of knowledge, attitudes and perceived assessment practices regarding BTCP management.

METHODS

Nurses working in a regional hospital were recruited to this quasi-experimental study. The intervention group received a 3-h educational workshop and one session of individual clinical instruction, whilst the control group did not receive any intervention. Chart audits were performed to examine adherence to BTCP assessment practices as the primary outcome. A self-developed questionnaire was used to measure nurses' knowledge, attitudes and perceived assessment practices regarding BTCP management as the secondary outcomes. The chi-square or Fisher's exact test was used to compare the rate of adherence to BTCP assessment practices between groups. A generalised estimating equation was used to compare changes in knowledge, attitudes, and perceived assessment practices between groups over time.

RESULTS

One hundred and five nurses completed the study. The chart audits revealed a significantly higher rate of adherence to BTCP assessment practices in the intervention group after the intervention (p < .05). The intervention group exhibited significant positive changes in scores for knowledge (β = 25.49, p < .001), attitude (β = 0.98 to 2.81, p < .01), and their perceived assessment practices (β = 1.33 to 3.14, p < .002) when compared with the control group.

CONCLUSIONS

This theory-driven educational intervention significantly improved the medical nurses' adherence to BTCP assessment practices and their level of knowledge attitudes and perceived assessment practices regarding BTCP management.

Effectiveness of Education Program on Nursing Knowledge and Attitude toward Pain Management

Objective:

Nurses have an integral role in pain assessment and management. Adequate knowledge and positive attitudes toward pain management are essential to provide high-quality nursing care for cancer pain. The purposes of this study are to evaluate nurses' knowledge and attitude toward cancer-related pain and to assess the effectiveness of a pain management education program on nurses' knowledge and attitude toward pain.

Methods:

A quantitative, experimental design was used.

Results:

The total number of participants who were surveyed at three measurement points was 131, with a completion rate of 87.3%. Findings revealed that the score of knowledge and attitude toward cancer-related pain ranged from 14 to 35, with a mean of 23.6 (standard deviation [SD] = 4.38). The mean scores of the intervention group and the control group at two measurement points regarding knowledge and attitude toward cancer-related pain were 32.7 (SD = 2.8) and 32.8 (SD = 4.3) and 23 (SD = 5.5) and 22.2 (SD = 3.8), respectively. There were significant differences at three measurement points among the intervention group (F = 114.3, P < 0.0005). There were no differences in the three measurement points among the control group (F = 3.4, P = 0.055).

Conclusions:

Nurses have essential roles in cancer pain. A pain management education program can improve nurses' knowledge and attitude toward cancer-related pain.

Knowledge and Attitudes Toward Cancer Pain Management Among Nurses at Oncology Units

Nurses have major responsibilities to treat cancer pain in an optimal way. Their knowledge and attitudes are the key to success cancer pain management (CPM) process and impact the outcomes of pain treatment. This study aimed to evaluate the knowledge and attitudes toward CPM among Jordanian nurses working at oncology units. A cross-sectional descriptive design was used to collect data from 135 nurses who were working at four oncology units using Knowledge and Attitudes Survey Regarding Pain. The percentage of correct answers was 51.5% indicating that participants had fair knowledge and attitudes toward CPM. Nurses appeared knowledgeable about CPM guidelines but were unfamiliar regarding pharmacological management and had negative attitudes toward opioids addiction and pain assessment. Significantly, knowledge and attitudes were higher among nurses who had previous education programs (P < .001) and worked in a pain team (P < .001). Therefore, including CPM topics in nursing curricula and postgraduate educational programs is needed. Additionally, initiating pain management teams and using CPM guidelines will contribute to effective treatment of cancer pain.

Using education and support strategies to improve the way nurses assess regular and transient pain – A quality improvement study of three hospitals

Background and aims

Systematic and regular pain assessment has been shown to improve pain management. Well-functioning pain assessments require using strategies informed by well-established theory. This study evaluates documented pain assessments reported in medical records and by patients, including reassessment using a Numeric Rating Scale (NRS) after patients receive rescue medication.

Methods

Documentation surveys (DS) and patient surveys (PS) were performed at baseline (BL), after six months, and after 12 months in 44 in-patient wards at the three hospitals in Östergötland County, Sweden. Nurses and nurse assistants received training on pain assessment and support. The Knowledge to Action Framework guided the implementation of new routines.

Results

According to DS pain assessment using NRS, pain assessment increased significantly: from 7% at baseline to 36% at 12 months (p < 0.001). For PS, corresponding numbers were 33% and 50% (p < 0.001). According to the PS, the proportion of patients who received rescue medication and who had been reassessed increased from 73% to 86% (p = 0.003). The use of NRS to document pain assessment after patients received rescue medication increased significantly (4% vs. 17%; p < 0.001).

Conclusions

After implementing education and support strategies, systematic pain assessment increased, an encouraging finding considering the complex contexts of in-patient facilities. However, the achieved assessment levels and especially reassessments related to rescue medication were clinically unsatisfactory. Future studies should include nursing staff and physicians and increase interactivity such as providing online education support. A discrepancy between documented and reported reassessment in association with given rescue medication might indicate that nurses need better ways to provide pain relief.

Implications

The fairly low level of patient-reported pain via NRS and documented use of NRS before and 12 months after the educational programme stresses the need for education on pain management in nursing education. Implementations differing from traditional educational attempts such as interactive implementations might complement educational programmes given at the work place. Standardized routines for pain management that include the possibility for nurses to deliver pain medication within well-defined margins might improve pain management and increase the use of pain assessments. Further research is needed that examines the large discrepancy between patient-reported pain management and documentation in the medical recording system of transient pain.

Nurse-based monitoring and management of breakthrough pain in an acute pain relief and palliative care unit

OBJECTIVES

To assess the nurses' performance in assessing, treating, and documenting breakthrough pain (BTP) in a palliative care unit where traditionally there is continuous training.

METHODS

The study was performed in an acute palliative care unit. Once a week, a research nurse examined the documentation regarding all the episodes of BTP registered in a specific pain chart, designed by the institutional nurse board, as part of the routine nurse activity.

RESULTS

The charts of 50 consecutive eligible patients (32 M/18 F), were analysed. The mean number of episodes/patient was 3.3 (SD 1.61; range 1-7). 166 episodes occurred. The main BTP pain intensity was 7.06 (SD 0.82). In 7 episodes, pain intensity was not evaluated at T0. The pain intensity after 15 minutes after BTP medication was 3.01 (SD1.19). In 28 episodes, pain intensity was not evaluated at T15. The change in pain intensity was highly significant (P < 0.0005). BTP episodes were distributed normally through different day intervals. No relevant adverse event attributable to BTP medication was reported in the nurse diary.

CONCLUSION

Training in a research environment allows a good nurse capability in evaluating and treating BTP, and above all, providing documentation for each BTP episode. The theoretical work and recommendations around BTP need to be translated into day-to-day clinical practice.

Canadian recommendations for the management of breakthrough cancer pain

Breakthrough cancer pain (btcp) represents an important element in the spectrum of cancer pain management. Because most btcp episodes peak in intensity within a few minutes, speed of medication onset is crucial for proper control. In Canada, several current provincial guidelines for the management of cancer pain include a brief discussion about the treatment of btcp; however, there are no uniform national recommendations for the management of btcp. That lack, accompanied by unequal access to pain medication across the country, contributes to both regional and provincial variability in the management of btcp. Currently, immediate-release oral opioids are the treatment of choice for btcp. This approach might not always offer optimal speed for onset of action and duration to match the rapid nature of an episode of btcp. Novel transmucosal fentanyl formulations might be more appropriate for some types of btcp, but limited access to such drugs hinders their use. In addition, the recognition of btcp and its proper assessment, which are crucial steps toward appropriate treatment selection, remain challenging for many health care professionals. To facilitate appropriate management of btcp, a group of prominent Canadian specialists in palliative care, oncology, and anesthesiology convened to develop a set of recommendations and suggestions to assist Canadian health care providers in the treatment of btcp and the alleviation of the suffering and discomfort experienced by adult cancer patients.

Breakthrough cancer pain: the role of the nurse

Breakthrough pain is common in patients with cancer and is a significant cause of morbidity in this group of patients. Breakthrough pain is a heterogeneous condition, and so its management needs to be individualised. This paper describes the management of breakthrough pain and, specifically, the recently published guidelines of the European Oncology Nursing Society.