The 'right kind' of pain: talking about symptoms in outpatient oncology consultations

Facilitating patient participation in physiotherapy: Symptom-talk during exercise therapy from an Asian context

Background and purpose: Patient participation is the cornerstone for effective physiotherapy intervention. The aim was to analyze how patients and physiotherapists negotiate symptoms during exercise therapy and describe patients' participation during this process. Methods: Nineteen consultations with sixteen patients and six physiotherapists were video-recorded in two Hong Kong outpatient settings. Conversation Analysis was used to uncover interactional aspects of symptom-talk, focusing on turn-taking, sequence organization, and vocabulary. Results: Physiotherapists explored patients' symptoms only minimally and their frequent use of closed-ended questions allowed limited opportunity for participation. For patient-initiated symptom-talk, less than half elicited actions from physiotherapists, whose minimal acknowledgments were often accepted. Yet, some patients achieved a more substantial contribution through: (1) pausing the exercise-in-progress; (2) gazing at the physiotherapist; (3) pointing at the painful area; and (4) interrupting the physiotherapist, thereby challenging the social order. While discussion about symptoms was often initiated by physiotherapists, some patients participated actively by engaging in certain communicative strategies. Conclusions: Patient participation can be improved by physiotherapists offering a supportive environment (i.e., question design, responding to patients' initiations, and promoting health literacy), and by patients embracing action-engendering communicative strategies. The fine details of interaction shed light onto the subtleties of symptom-talk initiated by patients or physiotherapists in physiotherapy.

Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care

Background

The feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.

Objectives

To (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.

Design

Two separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.

Interventions

Aggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.

Main outcome measures

Aggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.

Data sources

Searches of electronic databases and forwards and backwards citation tracking.

Review methods

Realist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.

Results

Providers were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.

Strengths and limitations

There was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.

Conclusions

PROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.

Future work

Future research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.

Study registration

This study is registered as PROSPERO CRD42013005938.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Learning to listen in primary care: some educational challenges

Effective clinician listening and communicating directly affects patients' health, satisfaction with healthcare, and complaints. This influences healthcare policy and clinician training/assessment. Listening skills and consultation frameworks underpin training but are often poorly used in everyday clinical work. Primary care doctors provide continuity of care using listening skills to develop long term relationships. Additionally, they listen to patients and colleagues in other ways such as surveys, participation groups, and significant event reviews. All these factors challenge educators to offer systematic training which ensures that future primary care clinicians/leaders develop conscious competence in listening at different levels and in differing contexts.

Assisting Older Adults to Communicate Their Postoperative Pain

An intervention assisting older adults to communicate their pain was tested in a posttest-only experiment. Thirty-eight preoperative older adults were randomly assigned to a communication group watching a videotape about communicating and managing postoperative pain or a comparison group watching a videotape about managing postoperative pain only. Pain was measured on Postoperative Days 1 and 2, and 1 and 7 days after hospital discharge by a data collector blind to the condition. The communication group reported greater pain relief and less pain interference on Postoperative Day 1. The comparison group reported greater pain relief on Postoperative Day 2 after attaining a pain interference level similar to the pain communication group. The pain communication intervention had modest effects for reducing pain interference with activities on Postoperative Day 1. Greater pain relief might be achieved when older adults and their health care providers are more knowledgeable about both pain communication and pain management.

Patients' experiences and actions when describing pain after surgery--a critical incident technique analysis

BACKGROUND

Postoperative pain assessment remains a significant problem in clinical care despite patients wanting to describe their pain and be treated as unique individuals. Deeper knowledge about variations in patients' experiences and actions could help healthcare professionals to improve pain management and could increase patients' participation in pain assessments.

OBJECTIVE

The aim of this study was, through an examination of critical incidents, to describe patients' experiences and actions when needing to describe pain after surgery.

METHODS

An explorative design involving the critical incident technique was used. Patients from one university and three county hospitals in both urban and rural areas were included. To ensure variation of patients a strategic sampling was made according to age, gender, education and surgery. A total of 25 patients who had undergone orthopaedic or general surgery was asked to participate in an interview, of whom three declined.

FINDINGS

Pain experiences were described according to two main areas: "Patients' resources when in need of pain assessment" and "Ward resources for performing pain assessments". Patients were affected by their expectations and tolerance for pain. Ability to describe pain could be limited by a fear of coming into conflict with healthcare professionals or being perceived as whining. Furthermore, attitudes from healthcare professionals and their lack of adherence to procedures affected patients' ability to describe pain. Two main areas regarding actions emerged: "Patients used active strategies when needing to describe pain" and "Patients used passive strategies when needing to describe pain". Patients informed healthcare professionals about their pain and asked questions in order to make decisions about their pain situation. Selfcare was performed by distraction and avoiding pain or treating pain by themselves, while others were passive and endured pain or refrained from contact with healthcare professionals due to healthcare professionals' large work load.

Insights into Pain: A Review of Qualitative Research

Qualitative research exposes and explores important aspects of the pain experience that are inaccessible to other approaches.Qualitative work adopts a different epistemological and ontological perspective to quantitative work.Qualitative research is not well established in the field of pain, but is growing.More interpretative engagement with qualitative data is required.

A mapping of people's positions regarding the breaking of bad news to patients

The objective of this study was to map people's positions regarding the breaking of bad news to patients. One hundred forty adults who had in the past received bad medical news or whose elderly relatives had in the past received bad news, 25 nurses, and 28 nurse's aides indicated the acceptability of physicians' conduct in 72 vignettes of giving bad news to elderly patients. Vignettes were all combinations of five factors: (a) the severity of the disease (severe but not lethal, extremely severe and possibly lethal, or incurable), (b) the patient's wishes (insists on knowing the full truth vs. does not insist), (c) the level of social support during hospitalization, (d) the patient's psychological robustness, and (e) the physician's decision about communicating bad news (tell the patient that the illness is not severe and minimize the severity of the illness when talking to the patient's relatives, tell the full truth to her relatives, or tell the full truth to both the elderly patient and her relatives). Four qualitatively different positions were found. Twenty-eight percent of participants preferred the full truth to be told; 36% preferred the truth to be told but understood that the physician would inform the family first; 13% did not think that telling the full truth is best for patients; and 23% understood that the full truth would be told in some cases and not in others, depending on the physician's perception of the situation. The present mapping could be used to detect the position held by each patient and act accordingly. This would be made easier if breaking bad news was conceived as a communication process involving a range of health care professionals, rather than as a single occurrence in time.

Functionality and feedback: a protocol for a realist synthesis of the collation, interpretation and utilisation of PROMs data to improve patient care

INTRODUCTION

The feedback and public reporting of PROMs data aims to improve the quality of care provided to patients. Existing systematic reviews have found it difficult to draw overall conclusions about the effectiveness of PROMs feedback. We aim to execute a realist synthesis of the evidence to understand by what means and in what circumstances the feedback of PROMs data leads to the intended service improvements.

METHODS AND ANALYSIS

Realist synthesis involves (stage 1) identifying the ideas, assumptions or 'programme theories' which explain how PROMs feedback is supposed to work and in what circumstances and then (stage 2) reviewing the evidence to determine the extent to which these expectations are met in practice. For stage 1, six provisional 'functions' of PROMs feedback have been identified to structure our review (screening, monitoring, patient involvement, demand management, quality improvement and patient choice). For each function, we will identify the different programme theories that underlie these different goals and develop a logical map of the respective implementation processes. In stage 2, we will identify studies that will provide empirical tests of each component of the programme theories to evaluate the circumstances in which the potential obstacles can be overcome and whether and how the unintended consequences of PROMs feedback arise. We will synthesise this evidence to (1) identify the implementation processes which support or constrain the successful collation, interpretation and utilisation of PROMs data; (2) identify the implementation processes through which the unintended consequences of PROMs data arise and those where they can be avoided.

ETHICS AND DISSEMINATION

The study will not require NHS ethics approval. We have secured ethical approval for the study from the University of Leeds (LTSSP-019). We will disseminate the findings of the review through a briefing paper and dissemination event for National Health Service stakeholders, conferences and peer reviewed publications.

The colour of pain: can patients use colour to describe osteoarthritis pain?

OBJECTIVE

The aim of the present study was to explore patients' views on the acceptability and feasibility of using colour to describe osteoarthritis (OA) pain, and whether colour could be used to communicate pain to healthcare professionals.

METHODS

Six group interviews were conducted with 17 patients with knee OA. Discussion topics included first impressions about using colour to describe pain, whether participants could associate their pain with colour, how colours related to changes to intensity and different pain qualities, and whether they could envisage using colour to describe pain to healthcare professionals.

RESULTS

The group interviews indicated that, although the idea of using colour was generally acceptable, it did not suit all participants as a way of describing their pain. The majority of participants chose red to describe high-intensity pain; the reasons given were because red symbolized inflammation, fire, anger and the stop signal in a traffic light system. Colours used to describe the absence of pain were chosen because of their association with positive emotional feelings, such as purity, calmness and happiness. A range of colours was chosen to represent changes in pain intensity. Aching pain was consistently identified as being associated with colours such as grey or black, whereas sharp pain was described using a wider selection of colours. The majority of participants thought that they would be able to use colour to describe their pain to healthcare professionals, although issues around the interpretability and standardization of colour were raised.

CONCLUSIONS

For some patients, using colour to describe their pain experience may be a useful tool to improve doctor-patient communication.

Trialing to pain control: a grounded theory

The aim of this study was to examine the basic social psychological process of managing inadequately relieved pain in adults. Transcribed data from 23 ambulatory medical visits of adults with pain and interviews with four practitioners and four patients with pain were analyzed using constant comparative analysis. The basic problem was perception of running out of treatment options. Trialing was the process used to resolve the problem and consisted of four phases: finding the right practitioner, initiating the trial, adjusting treatments, and continuing to monitor with the patient taking control over the pain. Failure to achieve control over pain occurred when providers were unclear or failed to listen or when patients disagreed about treatment. Improving patient-provider communication may enhance trialing.

The palliative care needs for fibrotic interstitial lung disease: a qualitative study of patients, informal caregivers and health professionals

BACKGROUND

While there have been some studies looking at the impact on quality of life of patients with idiopathic pulmonary fibrosis, to date no qualitative research looking at the specialist palliative needs of these patients has been conducted.

AIM

This study aims to explore the specialist palliative care needs of people living with end-stage progressive idiopathic fibrotic interstitial lung disease. DESIGN AND SETTINGS/PARTICIPANTS: In total, 18 qualitative semi-structured in-depth interviews were conducted with patients, their informal caregivers and health professionals across two specialist interstitial lung disease centres in London and in the community.

RESULTS

Many participants reported uncontrolled symptoms of shortness of breath, cough and insomnia, which profoundly impacted every part of patients' and informal caregivers' lives. Psychologically, patients were frustrated and angry at the way in which their illness severely limited their ability to engage in activities of daily living and compromised their independence. Furthermore, both patients and informal caregivers also reported that the disease seriously affected family relationships where strain was pronounced. There was varied knowledge and confidence among health professionals in managing symptoms, and psychosocial needs were often underestimated.

CONCLUSION

This study is the first of its kind to examine in depth the impact of symptoms and psychosocial needs revealing the profound effect on every aspect of progressive idiopathic fibrotic interstitial lung disease patients' and informal caregivers' lives. Education and guidance of appropriate palliative care interventions to improve symptom control are needed. A case conference intervention with individualised care plans may help in addressing the substantial symptom control and psychosocial needs of these patients and informal caregivers.

Assessment and management of adult cancer pain: a systematic review and synthesis of recent qualitative studies aimed at developing insights for managing barriers and optimizing facilitators within a comprehensive framework of patient care

CONTEXT

Cancer pain is a common, burdensome problem, which is not well managed despite evidence-based guidelines.

OBJECTIVES

To develop insights for managing barriers and optimizing facilitators to adult cancer pain assessment and management within a comprehensive framework of patient care.

METHODS

We undertook a systematic review and synthesis of qualitative studies. Medline, PsycINFO, Embase, AMED, CINAHL, and Sociological Abstracts were searched from May 20 to 26, 2011. To be included, the articles had to be published in a peer-reviewed journal since 2000; written in English; and report original qualitative studies on the perspectives of patients, their significant others, or health care providers. Article quality was rated using the checklist of Kitto et al. Thematic synthesis followed a three-stage approach using Evidence for Policy and Practice Information and Co-ordinating Centre-Reviewer 4 software: 1) free line-by-line coding of "Results," 2) organization into "descriptive" themes, and 3) development of "analytical" themes informative to our objective. At Stage 3, a conceptual framework was selected from the peer-reviewed literature according to prima facie "fit" for descriptive themes.

RESULTS

Of 659 articles screened, 70 met the criteria, reporting 65 studies with 48 patient, 19 caregiver, and 21 health care provider samples. Authors rarely reported reflexivity or negative cases. Mead and Bower's model of patient-centered care accommodated 85% of the descriptive themes; 12% more related to the caregiver and service/system factors. Three themes could not be accommodated.

CONCLUSION

Findings highlight the need to integrate patient/family education within improved communication, individualize care, use more nonpharmacological strategies, empower patients/families to self-manage pain, and reorganize multidisciplinary roles around patient-centered care and outcomes. These conclusions require validation via consensus and intervention trials.

How doctors move from generic goals to specific communicative behavior in real practice consultations

OBJECTIVE

To understand how recommendations for communication can be brought into alignment with clinical communication routines, we explored how doctors select communicative actions during consultations.

METHODS

We conducted stimulated recall interviews with 15 GPs (general practitioners), asking them to comment on recordings of two consultations. The data analysis was based on the principles of grounded theory.

RESULTS

A model describing how doctors select communicative actions during consultations was developed. This model illustrates how GPs constantly adapt their selection of communicative actions to their evaluation of the situation. These evaluations culminate in the selection of situation-specific goals. These multiple and often dynamic goals require constant revision and adaptation of communication strategies, leading to constant readjustments of the selection of communicative actions. When selecting consultation goals GPs weigh patients' needs and preferences as well as the medical situation and its consequences.

CONCLUSIONS

GPs' selection of communicative actions during consultations is situational and goal driven.

PRACTICE IMPLICATIONS

To help doctors develop communicative competence tailored to the specific situation of each consultation, holistic communication training courses, which pay attention to the selection of consultation goals and matching communication strategies besides training specific communication skills, seem preferable to current generic communication skills training.

Influence of patient coaching on analgesic treatment adjustment: secondary analysis of a randomized controlled trial

CONTEXT

For patients with cancer-related pain and their physicians, routine oncology visits are an opportunity to adjust the analgesic regimen and secure better pain control. However, treatment intensification occurs haphazardly in practice.

OBJECTIVES

To estimate the effect of patient-centered tailored education and coaching (TEC) on the likelihood of analgesic treatment adjustment during oncology visits, and in turn, the influence of treatment adjustment on subsequent cancer pain control, we studied patients enrolled in a randomized trial of TEC.

METHODS

Just before a scheduled oncology visit, 258 patients with at least moderate baseline pain received TEC or control; just after the same visit, they reported on whether the physician recommended a new pain medicine or a change in dose of an existing medicine. Pain severity and pain-related impairment were measured two, six, and 12 weeks later.

RESULTS

Patients assigned to TEC were more likely than controls to report a change in the analgesic treatment regimen (60% vs. 36%, P<0.01); significant effects persisted after adjustment for baseline pain, study site, and physician (adjusted odds ratio 2.61, 95% confidence interval 1.55, 4.40, P<0.01). In a mixed-effects repeated measures regression, analgesic change (but not TEC itself) was associated with a sustained decrease in pain severity (P<0.05).

CONCLUSION

TEC increases the likelihood of self-reported, physician-directed adjustments in analgesic prescribing, and treatment intensification is associated with better cancer pain outcomes.

Communication about patient pain in primary care: development of the Physician-Patient Communication about Pain scale (PCAP)

OBJECTIVE

This paper describes the development of the 47-item Physician-Patient Communication about Pain (PCAP) scale for use with audiotaped medical visit interactions.

METHODS

Patient pain was assessed with the Medical Outcomes Study SF-36 Bodily Pain Scale. Four raters assessed 181 audiotaped patient interactions with 68 physicians. Descriptive statistics of PCAP items were computed. Principal components analyses with 20 scale items were used to reduce the scale to composite variables for analyses. Validity was assessed through (1) comparing PCAP composite scores for patients with high versus low pain and (2) correlating PCAP composites with a separate communication rating scale.

RESULTS

Principal components analyses yielded four physician and five patient communication composites (mean alpha=.77). Some evidence for concurrent validity was provided (5 of 18 correlations with communication validation rating scale were significant). Paired-sample t tests showed significant differences for 4 patient PCAP composites, showing the PCAP scale discriminates between high and low pain patients' communication.

CONCLUSION

The PCAP scale shows partial evidence of reliability and two forms of validity.

PRACTICE IMPLICATIONS

More research with this scale (developing more reliable and valid composites) is needed to extend these preliminary findings before this scale is applicable for use in practice.

SAGE & THYME: a model for training health and social care professionals in patient-focussed support

OBJECTIVE

To develop a model for addressing the emotional concerns of patients or their caregivers; to teach the model in a three-hour workshop and to assess the impact of that training on a wide range of health and social care staff.

METHODS

A multi-specialty team, including a cancer patient, developed a model based on the evidence relating to emotional support and communication skills. The model (SAGE & THYME) consists of nine steps (see Box 1). The purpose of the model is to enable staff of all grades and roles to fulfil the most important objectives of support: enabling patients to describe their concerns and emotions if they wish to do so, holding and respecting those concerns; identifying the patients' support structures; exploring the patients' own ideas and solutions before offering advice or information. Over 800 health and social care staff of all grades and students have participated in the three-hour SAGE & THYME training workshops.

RESULTS

Analysis from 412 participants suggests that the workshops had a significant positive effect on self-confidence (p<.0005), self-perception of competence (p<.0005) and willingness to explore the emotional concerns of patients (p<.0005). 95% felt that the workshop would be very likely to have an impact on their practice.

CONCLUSIONS

The workshops have been successful in increasing the self-perceptions of confidence, competence and willingness to explore the emotional concerns of patients. The model 'SAGE & THYME' has been welcomed by participants.

PRACTICE IMPLICATIONS

Staff groups will require training for patients or their caregivers to have their concerns heard without interruption and to be allowed to explore their own resolutions. The three-hour SAGE & THYME training may go some way towards helping patients and staff form sound partnerships which assist patients to participate constructively in their own care.

Can cancer patients influence the pain agenda in oncology outpatient consultations?

Pain in cancer patients is common, yet it is often inadequately managed. Although poor assessment has been implicated, how patients contribute to this process has not been explicated. This study aims to uncover patients' contributions to discussions about pain during oncology outpatient consultations. Seventy-four medical encounters were observed and audiotaped. Verbatim transcriptions of pain talk were examined using conversational analysis. Thirty-nine of 74 patients talked about pain with 15 different doctors during consultations for follow-up or active treatment. Patients' talk about pain varied consistently according to how pain talk was initiated. In 20 consultations where pain was put on the agenda by patients, they used communication tactics that emphasized their pain experiences, seemingly to attract and maintain their doctors' attention. These tactics appear necessary, as the cancer treatment agenda restricts opportunities for patients to have supportive care needs addressed. On the other hand, in 19 consultations where doctors elicited information about pain, patients used communication tactics that minimized their pain experiences, seemingly to conceal potential disease progression or recurrence, the very focus of these specialist consultations. Where cancer was implicated as the source of pain, chemotherapy or radiotherapy was offered, and where cancer was suspected, referrals for investigations were made. Two of the 20 patients appeared to influence the treatment-focused agenda and were given referrals to pain clinic rather than further cancer therapy as initially recommended.

The use of morphine to treat cancer-related pain: a synthesis of quantitative and qualitative research

Morphine is the most commonly used opioid for severe cancer-related pain. Despite its established effectiveness, it is often used cautiously in clinical practice, particularly outside specialist palliative care. This review identifies the key social, contextual, and physical concerns held by patients, carers, and health care professionals when using morphine, which might explain the caution taken in its use. The review used an approach called critical interpretive synthesis (CIS), which combines conventional systematic review techniques with methods for interpretative synthesis of qualitative research. An existing review examining the effectiveness of morphine and a guideline on its use were synthesized with 19 qualitative articles to establish understanding of how context of use can affect the established effectiveness of morphine. The article argues for the appropriateness of CIS for answering questions of this type. The results demonstrate that using morphine is a balancing act and a trade-off between pain relief and adverse effects. Deep-seated concerns regarding the symbolism of morphine, addiction, and tolerance are held by patients, carers, and clinicians, which influence prescription and use. Cancer pain is a referent for disease status and has existential meaning, with the introduction of morphine becoming a metaphor for impending death. Cancer pain is intersubjective, with its perception and reporting influenced by those with whom the patient interacts. By understanding the context and social meaning surrounding the use of morphine to treat cancer pain, health care professionals can begin to anticipate, acknowledge, and address some of the barriers to its use, thereby enhancing pain control.

The effect of pain question phrasing on older adult pain information

The aim of this study was to test how practitioners' pain communication affected the pain information provided by older adults. A post-test only, double-blind experiment was used to test how the phrasing of practitioners' pain questions-open-ended and without social desirability bias; closed-ended and without social desirability bias; or open-ended and with social desirability bias-affected the pain information provided by 312 community-living older adults with osteoarthritis pain. Older adults were randomly assigned to one of the three pain phrasing conditions to watch and orally respond to a computer-displayed videotape of a practitioner asking about their pain. All responded to a second videotape of the practitioner asking if there was anything further they wanted to communicate. Lastly, all responded to a third videotape asking if there was anything further they wanted to communicate about their pain. Transcripts of the audiotaped responses were content analyzed using 16 a priori criteria from national guidelines to identify important pain information for osteoarthritis pain management. Older adults described significantly more pain information in response to the open-ended question without social desirability. The two follow-up questions elicited significant additional information for all three groups, but did not compensate for the initial reduced pain information from the closed-ended and social desirability-biased groups. Initial use of an open-ended pain question without social desirability bias and use of follow-up questions significantly increase the amount of important pain information provided by older adults with osteoarthritis pain.

Oncology outpatient and provider responses to a computerized symptom assessment system

PURPOSE/OBJECTIVES

To assess patient and provider responses to a computerized symptom assessment system.

DESIGN

Descriptive, longitudinal study with retrospective, longitudinal medical records review.

SETTING

University-based National Cancer Institute-designated outpatient cancer center.

SAMPLE

80 oncology outpatients receiving chemotherapy, 8 providers, and 30 medical records.

METHODS

Patients completed the computerized assessment during three chemotherapy follow-up clinic appointments (times 1, 2, and 3). Patient usability was recorded via an observer checklist (ease of use) and the computer (completion time). Patient satisfaction and impact were assessed during telephone interviews two to three days after times 1 and 3 only. Provider usability and impact were assessed at the end of the study using a questionnaire and focus groups, whereas effect on provider documentation was assessed through chart audits.

MAIN RESEARCH VARIABLES

Patient usability (ease of use, completion time), satisfaction, and impact; provider usability and impact.

FINDINGS

Patients reported good usability, high satisfaction, and modest impact on discussions with their providers. Providers reported modest usability, modest impact on discussions with patients, and had varied reactions as to how the system affected practice. Documentation of symptoms was largely absent before and after implementation.

CONCLUSIONS

This system demonstrated good usability and satisfaction but had only a modest impact on symptom-related discussions and no impact on documentation.

IMPLICATIONS FOR NURSING

A computerized system can help address barriers to symptom assessment but may not improve documentation unless it can be integrated into existing medical records systems.

Cultural meanings of pain: a qualitative study of Black Caribbean and White British patients with advanced cancer

Pain is a common cancer-related symptom, but little research has been conducted that explores the meanings of this symptom across different ethnic groups. This study involved qualitative interviews to explore and compare the meanings of pain among 26 Black Caribbean and 19 White patients with advanced cancer. Patients were recruited from oncology outpatient clinics, a lung clinic and palliative care teams. Interview transcripts were analysed using the framework approach. A total of 23/26 Black Caribbean and 15/19 White patients reported cancer-related pain. Accounts of Black Caribbean and White patients identified pain as a 'challenge' that needed to be mastered by the individual, not necessarily by drugs and identified pain as an 'enemy' that represented an unfair attack. Two further meanings of pain emerged from Black Caribbean patients' accounts: pain as a 'test of faith' that referred to confirmation and strengthening of religious belief, and pain as a 'punishment' that was associated with wrongdoing. These meanings influenced the extent patients were able to accommodate their distress. Pain assessment needs to consider the patients' narratives that include the meanings they attribute to this symptom, and which may be governed by culture.

Cancer information and support needs of statutory and voluntary sector staff working with people from ethnically diverse communities

Cancer is difficult for people from ethnically diverse communities to cope with, because there is inequality in getting information and services to meet their needs for prevention, prompt diagnosis, treatment, care and support. Research with black minority ethnic (BME) communities indicates a lack of knowledge about cancer, and a desire for more information, yet research is highly equivocal with regard to health and social care workers' ability to provide this. The study described in this article aimed to identify the educational and support needs of health and social care workers from statutory and voluntary sectors, working with people affected by cancer in one London borough. Qualitative research methods of one-to-one interview and focus group discussion were used among 33 staff working in various community, organizational and professional settings. Two focus groups were held with cancer patients and carers to gain complementary understanding of their needs for support and information. Health and social care workers are challenged when providing cancer information and support to people from BME communities, even when the worker is of the same cultural background as the person affected by cancer. Interviewees considered that in most respects, the challenges for improving cancer care for people from BME communities are those common for all, and that the difficulty in providing and sustaining improved cancer information and support services to BME communities in their borough lies in poverty, low literacy and social exclusion as much as cultural difference.

Nurses' response to pain communication from patients: a post-test experimental study

BACKGROUND

Inadequate communication about pain can result in increased pain for patients.

OBJECTIVES

The purpose of the current pilot study was to test how nurses respond when patients use their own words, a pain intensity scale, or both to communicate pain.

DESIGN

A post-test only experimental design was used with three pain description conditions, personal and numeric; personal only; numeric only.

SETTING

The setting included six hospitals and one school of nursing located in the northeastern United States.

PARTICIPANTS

PARTICIPANTS included 122 registered medical surgical nurses.

METHODS

Nurses were randomly assigned to condition, and read a vignette about a trauma patient with moderately severe pain. The vignettes were identical except for the patient's pain description and age. The nurses then wrote how they would respond to the patient's pain. Two blind raters content analyzed the responses, giving nurses one point for including each of six a priori criteria derived from the Acute Pain Management Panel [1992. Acute Pain Management: operative or medical procedures and trauma. Clinical practice guideline (AHCPR Publication No. 92-0032)., Rockville, MD, USA] and the American Pain Society [2003. Principles of analgesic use in the treatment of acute pain and cancer pain, Glenville, IL, USA].

RESULTS

Nurses planned similar numbers of pain management strategies across the three conditions, with a mean of 2.1 (SD=1.14) strategies out of the recommended six.

CONCLUSIONS

Nurses did not respond with more pain management strategies when patients describe pain in their own words, or in their own words and a pain intensity scale. The relatively small number of pain management strategies planned by the nurses suggests that nurses use few strategies to respond to moderately severe pain problems.

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.

Concordance in cancer medication management

This article explores how the concept of concordance can help to identify gaps and opportunities for research on consumer-provider communication related to cancer medication management. The relationship of concordance, patient-centered care and shared decision making is examined. Research on unmet patient agendas, quality of life issues related to symptom management and tools to assist communication about patient somatic experience are discussed. The need for research on patient communication with pharmacists, nurses and other health team members beyond physicians is noted. Research implications for longitudinal, descriptive and intervention studies are offered.

The communication of palliative care for the elderly cancer patient

Palliative care (PC) is often recommended by physicians for their elderly patients who are terminally ill. In contrast to hospice care, which precludes the use of any curative treatment at life's end stages, PC seeks primarily to comfort patients and to keep them pain free, yet it does not necessarily preclude medical treatment. It does seek to attend to patients' physical as well as psychological, emotional, spiritual, and existential needs in an attempt to enhance overall quality of life. A review of current literature in PC for oncology patients, elderly and otherwise, reveals a curious irony: Although PC plausibly entails a holistic, patient-centered approach to health care, much of the research on PC and, apparently, many of the practices in PC focus almost exclusively on the biomedical approach to patient care, particularly in regard to pain and symptom management. Furthermore, few methods in PC research incorporate patients' narratives and lived experiences in the final stages of their lives. We argue that a holistic, patient-centered approach must guide research in PC, including the treatment of elderly patients as "active interpreters, managers, and creators of the meaning of their health and illness" (Vanderford, Jenks, & Sharf, 1997, p.14) and of the meaning of their lives.

Orofacial pain-related communication patterns: sex and residential setting differences among community-dwelling adults

This study documented orofacial pain-related communication patterns among community-dwelling dentate adults, health care providers, and persons in the respondent's social network. We report communication patterns for orofacial pain by symptom (toothache pain, pain when chewing, temperature sensitivity of the teeth, painful oral sores, and jaw joint pain). The subjects for the study were 724 participants in the 42-month interview of the Florida Dental Care Study, a longitudinal study of oral health among dentate adults, age 45 and older at baseline. The data were collected using a standardized telephone interview. Pain was more likely to be discussed with a lay consultant (41-66% depending on the symptom) than a health care professional (21-62%). Consistent with studies that report females tend to rely on social networks to cope with pain, more female respondents than males reported having talked to a lay consultant about orofacial pain for most of the symptoms. We also found that rural Black adults were less likely to speak to a health care professional about their orofacial pain. The findings highlight the importance of family, friends, and neighbors within the lay consultation and support network for persons with pain. Recent interest in self-care and the use of complementary and alternative approaches to treatment suggest the importance of considering influences acting within the environment of persons with pain.