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?

Libyan Healthcare Professionals', Patients' and Caregivers' Perceptions and Religious Beliefs about Cancer Pain and its Management: A Descriptive Qualitative Study

Cancer pain remains a significant problem worldwide. It is often undertreated and presents in about half of cancer patients. Although several guidelines and pharmacological interventions for cancer pain management (CPM) exist, inadequate assessment and undertreatment of cancer pain are well-documented globally, especially in developing countries, including Libya. Perceptions, cultural and religious beliefs of healthcare professionals (HCP), patients, and caregivers about cancer pain and opioids are reported as barriers to CPM globally. This qualitative descriptive study aimed to explore Libyan HCPs', patients', and caregivers' views and religious beliefs about CPM and involved semi-structured interviews with 36 participants: 18 Libyan cancer patients, 6 caregivers, and 12 Libyan HCPs. Thematic analysis was used to analyse the data. Patients, caregivers, and newly qualified HCPs were concerned about poor tolerance and drug addiction. HCPs perceived a lack of policies and guidelines, pain rating scales, and professional education and training as CPM barriers. Some patients were unable to pay for medicines if they faced financial difficulties. Instead, patients and caregivers emphasised religious and cultural beliefs for managing cancer pain, including the use of the Qur'an and cautery. Our results suggest that religious and cultural beliefs, lack of knowledge and training in CPM among HCPs, and economic and Libyan healthcare system-related factors negatively affect CPM in Libya.

Managing Pain in People with Cancer-a Systematic Review of the Attitudes and Knowledge of Professionals, Patients, Caregivers and Public

Cancer pain is a common symptom experienced by patients, caused either by the disease or its treatment. Morphine remains the most effective and recommended treatment for cancer pain. However, cancer patients still do not receive appropriate management for their pain, and under-treatment is common. Lack of knowledge and negative attitudes towards cancer pain and analgesia among professionals, patients and family caregivers are reported as one of the most common barriers to effective cancer pain management (CPM). To systematically review research on the nature and impact of attitudes and knowledge towards CPM, a systematic literature search of 6 databases (the Cochrane library, MEDLINE, PsycINFO, CINAHL, Web of Science and EMBASE) was undertaken in July 2018. Additionally, hand-searching of Google, Google Scholar and reference lists was conducted. The inclusion criteria were adult (18-65 years of age), studies which included attitudes and knowledge towards CPM, studies written in English, published literature only and cross-sectional design. Included studies were critically appraised by two researchers independently using the Joanna Briggs Institute Analytical Cross Sectional Studies Assessment (JBI-ACSSA). A total of 36 studies met the inclusion criteria. The main finding was that among professionals, patients, caregivers and the public there were similar attitudinal barriers to effective CPM. The most commonly cited barriers were fear of drug addiction, tolerance of medication and side effects of opioids. We also found differences between professional groups (physicians versus nurses) and between different countries based on their potential exposure to palliative care training and services. There are still barriers to effective CPM, which might result in unrelieved cancer pain. Therefore, more educational programmes and training for professionals on CPM are needed. Furthermore, patients, caregivers, and the public need more general awareness and adequate level of knowledge about CPM.

Cancer-related pain management: A review of knowledge and attitudes of healthcare professionals

Cancer-related pain (CRP) is common and many patients continue to experience pain in spite of advances in pain management modalities. The lack of knowledge, inadequate assessment of CRP and/or organisational factors, such as lack of time due to heavy workload, can be a barrier to effective pain management of healthcare professionals. The purpose was to examine the evidence with regard to the knowledge and attitudes towards practice of healthcare professionals in relation to CRP management. A search of the literature (1999-2015) was conducted searching databases and journals including CINAHL, MEDLINE, PsycINFO, PubMed, Science Direct and Wiley-Blackwell. The initial search revealed a total of 99 articles and following removal of those that did not meet the inclusion criteria, 19 articles were included in the final review. Recognition of the widespread under treatment of CRP has prompted recent corrective efforts in terms of education from healthcare professionals, however, there is a continuing deficit in healthcare professionals' knowledge with regard to CRP management and indicated that healthcare professionals still have negative attitudes that hinder the delivery of quality care to patients suffering from CRP. Further research on how and where education on this topic should be delivered is required.

Interventions for Nurse-Related Barriers in Cancer Pain Management

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
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Investigation and analysis of oncologists' knowledge of morphine usage in cancer pain treatment

Purpose

To examine oncologists’ knowledge of cancer pain and morphine’s clinical application in the People’s Republic of China. In addition, this study analyzes and discusses the negative factors that currently affect the clinical application of morphine.

Patients and methods

A questionnaire survey was given to a random sample of 150 oncologists from Tianjin Medical University Cancer Institute and Hospital. The statistical results were analyzed and processed using SPSS version 21.0 and Matlab version 2012a statistical software. Single-factor analysis of variance, Kruskal–Wallis nonparametric test, and independent samples t-test were adopted to analyze the difference in knowledge scores of morphine usage. The study also identified major impediment factors on clinical use of morphine.

Results

Among the 127 respondents, morphine controlled-release tablets were the most popular drug chosen to treat severe cancer pain (76 respondents, 35.8%). Participants who reported having received training in cancer pain management and drug use demonstrated a significantly higher mean score of basic knowledge compared with their untrained peers (11.51±2.60 versus 9.28±3.68, t=2.48, P=0.022). The top four barriers to widespread clinical use of morphine for cancer pain were 1) insufficient analgesia administration training for medical personnel, 2) poor patient compliance, 3) drug side effects, and 4) concerns surrounding drug addiction.

Conclusion

The oncologists in the People’s Republic of China simultaneously lack comprehensive knowledge and harbor misconceptions with regard to cancer pain treatment and morphine’s clinical application. Creating professional training initiatives for oncologists is necessary to enhance their awareness and expertise in morphine use for cancer pain treatment.

Degree of knowledge of health care professionals about pain management and use of opioids in pediatrics

OBJECTIVE

To evaluate the degree of knowledge about pain management and opioids use by professionals working at three pediatric units.

DESIGN

This is a cross-sectional study.

SETTING

This study was carried out at three pediatric units (pediatrics, intensive care unit, and oncology) of Hospital de Clínicas de Porto Alegre, which is a university hospital located in southern Brazil.

SUBJECT

The subjects of this study include physicians, pharmacists, physiotherapists, nurses, nursing technicians, and nursing assistants.

METHODS

Cross-sectional study carried out in a university hospital in southern Brazil. A self-applicable semi-structured questionnaire was handed out to 182 professionals from December 2011 to March 2012.

RESULTS

The response rate was 67% (122); the average percentage of correct answers was 63.2 ± 1.4%. The most frequent errors were: an opioid must not be used if the cause of pain is unknown (47%; 54/115); patients often develop respiratory depression (42.3%; 22/52); and confusion about symptoms of withdrawal, tolerance, and dependency syndromes (81.9%; 95/116). Only 8.8% (10/114) reported the use of pain scales to identify pain in children. The most often cited hindrance to control pain was the difficulty to measure and spot pain in pediatric patients. Finally, 50.8% (62/122) of them did not have any previous training in pain management.

CONCLUSIONS

Problems in the processes of pain identification, measurement, and treatment have been found. Results suggest that there is a need for both an investment in continuing education of professionals and the development of protocols to optimize the analgesic therapy, thus preventing increased child suffering.

Why are newly qualified doctors unprepared to care for patients at the end of life?

CONTEXT

Death and dying occur in almost all areas of medicine; it is essential to equip doctors with the knowledge, skills and attitudes they need to care for patients at the end of life. Little is known about what doctors learn about end-of-life care while at medical school and how they learn to care for dying patients in their first year as doctors.

METHODS

We carried out a qualitative study using face-to-face interviews with a purposive sample of 21 newly qualified doctors who trained in different medical schools.

RESULTS

Data were analysed using a constant comparative approach. Two main groups of themes emerged. The first pertained to medical school experiences of end-of-life care, including: lack of exposure; a culture of 'clerking and signs'; being kept and keeping away from dying patients; lack of examinations; variable experiences, and theoretical awareness. The second group of themes pertained to the experiences of recently qualified doctors and included: realising that patients really do die; learning by doing; the role of seniors; death and dying within the hospital culture; the role of nursing staff, and the role of the palliative care team.

CONCLUSIONS

Undergraduate medical education is currently failing to prepare junior doctors for their role in caring for dying patients by omitting to provide meaningful contact with these patients during medical school. This lack of exposure prevents trainee doctors from realising their own learning needs, which only become evident when they step onto the wards as doctors and are expected to care for these patients. Newly qualified doctors perceive that they receive little formal teaching about palliative or end-of-life care in their new role and the culture within the hospital setting does not encourage learning about this subject. They also report that they learn from 'trial and error' while 'doing the job', but that their skills and knowledge are limited and they therefore seek advice from those outside their usual medical team, mainly from nursing staff and members of palliative care teams.

Opioid analgesics for pain control: wisconsin physicians' knowledge, beliefs, attitudes, and prescribing practices

OBJECTIVE

Opioid analgesics are the drugs of choice for the treatment of moderate to severe acute and cancer pain. Although their role in the management of chronic pain not related to cancer is controversial, there is increasing evidence for their benefit in certain patient populations.

DESIGN

A 32-item survey to assess Wisconsin physicians' knowledge, beliefs, and attitudes toward opioid analgesic use was mailed to 600 randomly selected licensed physicians, resulting in a 36% response rate.

RESULTS

Half of the respondents considered diversion a moderate or severe problem in Wisconsin. A majority considered addiction to be a combination of physiological and behavioral characteristics, rather than defining it solely as a behavioral syndrome. Most physicians felt it lawful and acceptable medical practice to prescribe opioids for chronic cancer pain, but only half held this view if the pain was not related to cancer. Fewer physicians considered such prescribing as lawful and generally accepted medical practice if the patient had a history of substance abuse. About two-thirds of physicians were not concerned about being investigated for their opioid prescribing practices, but some admitted that fear of investigation led them to lower the dose prescribed, limit the number of refills, or prescribe a Schedule III or IV rather than a Schedule II opioid.

CONCLUSION

Wisconsin physicians who responded to this survey held many misconceptions about the prescribing of opioids. Such views, coupled with a lack of knowledge about laws and regulations governing the prescribing of controlled substances, may result in inadequate prescribing of opioids with resultant inadequate management of pain.

Delivering palliative care in an acute hospital setting: views of referrers and specialist providers

There has been a steady expansion of hospital-based palliative care in the United Kingdom but limited published research on health professionals' views of hospital multidisciplinary specialist palliative care services (SPCS). The aim of the study was to describe referrer (SPCS user) and provider (SPCS staff) perspectives on delivery of specialist palliative care in hospital. Interviews were conducted with referrers, including five junior doctors, 13 consultants, and six clinical nurse specialists, to investigate the reasons for referral, beneficial aspects, and barriers to use. Focus groups were conducted with providers, six medical and five nursing, to identify their perspective on delivering the specialist service in hospital. Discussions were tape recorded and transcribed verbatim. Data were analyzed thematically using a framework analysis approach. The study found large areas of agreement between referrers and providers on what hospital palliative care teams should be providing for patients, that is, expertise in managing difficult symptoms and complex psychosocial problems, and this was being achieved locally. Access to the specialist team was also important: visibility on the wards, informal routes of access to advice and a timely response by specialists. However, discordance in views of providing palliative care was also identified; in particular, whether specialists should be providing generalist palliative care (such as basic psychological support) neglected by ward teams and implementation of specialist advice by referrers. Such perspectives on the interface of generalist and specialist provision provide insights into improving care for palliative patients in the acute hospital setting.

Types of nursing knowledge used to guide care of hospitalized patients

AIM

This paper is a report of a study to identify the types of nursing knowledge used to guide care of hospitalized patients.

BACKGROUND

The history of nursing knowledge is discerned in three distinct moments. The first historical moment conceives nursing knowledge as the acquisition of a set of descriptive rules, the second as the development of dualist explanatory theories and the third as the production of critical and/or integrative understandings. It remains unclear how these different types of knowledge are implemented in practice and how they affect the care of hospitalized patients.

METHOD

A secondary qualitative analysis was conducted in 2007 on original data collected in 2002. The data were read with focus on the knowledge used by participants to confront practice situations. They were interpreted, classified and indexed to identify types of knowledge nurses use to care for hospitalized patients.

FINDINGS

Five discrete types of nursing knowledge that nurses use in practice emerged: personal practice knowledge, theoretical knowledge, procedural knowledge, ward cultural knowledge and reflexive knowledge.

CONCLUSION

All three moments in the history of nursing knowledge were found to be concurrently present in nursing practice. Ward cultural knowledge and procedural knowledge reflect the rule-based descriptive knowledge of the first moment, theoretical knowledge and personal practice knowledge reflect the explanatory dualist knowledge of the second moment and reflexive knowledge reflects the critical and integrative knowledge of the third moment.

Opioid use in dying patients in hospice and hospital, with and without specialist palliative care team involvement

Newspapers claim that patients in hospices have their opioid doses increased to a point at which doctors know that they will die. However, research has produced conflicting results about whether hospice patients receive higher doses of opioids. This study investigated the differences in opioid prescribing between cancer patients dying in hospice and hospital with and without hospital palliative care team (HPCT) involvement and non-cancer patients dying in hospital, in Dundee, UK. The only statistically significant difference in the mean dose of opioids was that the cancer patients were prescribed and received higher doses of opioids than non-cancer patients. There was no statistically significant difference in the mean dose of opioids prescribed to and given to the different groups of cancer patients dying in different settings, indicating that the claims of the press are untrue. The cancer patients dying in hospital who were not on the HPCT records more commonly received Tramadol, which may indicate a reluctance of hospital doctors to move from weak opioids to strong opioids.

Evaluation of a Cancer Pain Education Module

PURPOSE/OBJECTIVES

To assess whether a case-based cancer pain education module would lead to acquisition and retention of knowledge and attitudes at the graduate nursing student level.

DESIGN

Quasi-experimental pretest, post-test, and follow-up.

SETTING

Three nursing schools in the New England area.

SAMPLE

92 graduate nursing students.

METHODS

An oncology nurse specialist delivered seven two- to four-hour seminars integrated in existing pharmacology, primary care, or adult health courses. Participants' cancer pain knowledge was assessed at four time points with a paper-and-pencil test: before the seminar, immediately after, and approximately 6 and 24 months after the seminar.

MAIN RESEARCH VARIABLE

Cancer pain knowledge.

FINDINGS

The intervention was effective in improving students' knowledge of cancer pain management and assessment (p = 0.0001), and the effect was retained at 6 and 24 months (p = 0.0001 and p = 0.0024, respectively).

CONCLUSIONS

Policymakers, clinicians, and professional organizations have recommended providing cancer pain education during professional training to overcome the continuing problem of the undertreatment of cancer pain. The education module used was effective in changing students' knowledge of cancer pain management, and the results suggest that this knowledge is lasting.

IMPLICATIONS FOR NURSING

Early cancer pain education for nurses may play an important role in improving pain control for patients with cancer. Although this study did not evaluate the application of cancer pain knowledge to clinical practice, the results support the notion that advanced practice nurses can improve their cancer pain management knowledge and attitudes while in training. One implication is that this shift in attitudes and knowledge will translate to effective management of pain in varied healthcare settings.

A randomized controlled trial of an educational intervention on Hellenic nursing staff's knowledge and attitudes on cancer pain management

The purpose of this randomized controlled study was to explore the effectiveness of an educational intervention on nurses' attitudes and knowledge regarding pain management and to explore associations with nurses' characteristics. A four Solomon group experimental design was employed to assess the effect of the intervention and potential effects of pre-intervention testing. One hundred and twelve nurses were randomized to two intervention and two control groups. The intervention was based on viewing a series of educational videotapes and case scenarios. The Validated Hellenic version of the Nurses Knowledge and Attitudes Survey Regarding Pain (GV-NKASRP) was used. Pre-intervention scores revealed various limitations in regard to pain assessment and management. At the pre-test, the average number of correct answers was 17.58+/-7.58 (45.1%+/-19.3% of total questions). Pre-intervention scores differed significantly among participants with different educational backgrounds (P < 0.0001). A significant effect of pain education on total knowledge scores as well as regarding specific questions was detected. Intervention group participants provided 6.11+/-5.55 additional correct answers (15.66%+/-14.23% improvement, P < 0.0001), and they exhibited significantly improved post-test scores compared to controls (26.49+/-5.24 vs. 18.75+/-4.48; P < 0.0001). A potential negative effect of pre-test on knowledge gain for specific items and for total scores was detected. These findings suggest low pre-test knowledge scores among Hellenic oncology nurses and a significant effect of the intervention.

Healthcare providers' priorities for cancer care: A Delphi study in Greece

Cancer is a major problem globally and effective cancer care services are needed to lessen its burden on the community. In Greece, oncology health services provision is not located efficiently, resulting in few patients receiving high-quality care. Furthermore, shortages of health professionals and underdeveloped services such as primary care, home care and palliative care have aggravated the problem. The absence of a national cancer registry means that the extent of cancer incidence cannot be evaluated effectively. Dissatisfaction with the Greek NHS is well established, despite the reforms proposed by consecutive Greek governments. It remains that limited research exists in the area of cancer services and cancer care. The aim of this study was to identify the key areas of cancer care and services that needed to be developed or improved in Greece and their prioritisation within the Greek healthcare system. A Delphi technique was used to collect data from a sample of 30 healthcare providers, in three rounds. The response rate for each round was over 77%. The priorities for healthcare providers were focused on staff shortages, working conditions, pain management, home care, day units and communication. Based on the priorities provided by the participants and supporting literature, it is suggested that a national cancer registry, the employment of nurses to develop primary care, home care, day care and palliative care services need to be established. Furthermore, education in communication skills and the redistribution of the bio-medical technology are needed in order to provide more effective cancer services in Greece. More research is needed to validate the actual level of cancer services provided in Greece.

Cancer pain in palliative care: why is management so difficult?

Pain is the major source of anxiety and distress at the end of life, particularly in cases of end-stage cancer. However, pain management is not always effective or effectively implemented. This article identifies several barriers to effective pain relief in terminal cancer--the complexity of pain; difficulties in physical, emotional and spiritual assessment; difficulties in the delivery of medication--that challenge the skills of all professionals involved in palliative care. There are no simple answers, but awareness of the breadth of the issues may help focus nurses' minds on the patient in every encounter.