Research
Iranian nurses’ perceptions of palliative care for patients with cancer pain Naimeh Seyedfatemi, Leili Borimnejad, Marjan Mardani Hamooleh, Mamak Tahmasebi
© 2014 MA Healthcare Ltd
I
t is estimated that more than 15 million people worldwide will experience cancer in 2020 (Higginson and Costantini, 2008). Cancer is an increasing problem in Middle Eastern countries. The Middle East includes a wide range of economically diverse countries, from technically advanced countries with highlevel cancer care to countries with little or no cancer treatment capabilities. In the majority of countries of this region, cancer is generally diagnosed when it is at a relatively advanced phase (Daher, 2011). In Iran, cancer is the third most common cause of death, after heart disease and road accidents. The incidence of cancer in Iran is estimated to be around 48–112 and 51–144 cases per year per million people for women and men, respectively (Mousavi et al, 2009). Pain is a common primary symptom of cancer, occurring in 50–70% of all cancer patients (Wiese et al, 2010). It may result from the primary tumour, metastasis, radiation, chemotherapy, surgery, or comorbidity (Modesto-Lowe et al, 2012). When a patient is suffering from cancer pain it is paramount to consider not only biochemical factors but also psychosocial influences (Mori et al, 2012). Of all of the physical and emotional symptoms of cancer, pain is often identified as the most distressing (Modesto-Lowe et al, 2012). Cancer pain can be regarded as ‘total pain,’ with physical, psychological, spiritual, and social dimensions (Raphael et al, 2010). Deandrea et al (2008) reported in their metaanalysis that, for 43% of patients with cancer pain, the pain was not controlled to a satisfactory level. Cancer pain negatively affects patients’ quality of life, and palliative care for such pain is essential. There is an urgent worldwide humanitarian need for palliative care for people with cancer (Human Rights Watch, 2011). Palliative care addresses somatic and psychosocial requirements (Farbicka and Nowicki, 2012), including the treatment of pain and suffering (Daher, 2011).
International Journal of Palliative Nursing 2014, Vol 20, No 2
Abstract
Aim: The purpose of this study was to identify Iranian nurses’ perceptions of palliative care for patients with cancer pain. Methods: The study took a qualitative approach. Semi-structured interviews were held with 15 nurses with Bachelor’s degrees working in three teaching hospitals in Iran. Transcripts of the interviews underwent content analysis, and categories were extracted from the material. Findings: The findings came under two main categories: management of physical pain and psychological empowerment. Management of physical pain had two subcategories: the importance of communication, and pain palliation using drugs. Psychological empowerment also had two subcategories: supportive behaviour and distress reduction. Conclusion: The sample felt that palliative care for patients with cancer pain must include psychological empowerment, support, and communication as well as physical pain relief. Key words: Cancer l Content analysis l Nurse l Palliative care l Pain
In the authors’ experience, although the majority of nurses working in cancer wards in Iran try to relieve cancer patients’ pain, these patients need much more palliative nursing attention than they currently receive. The authors believe that the quality of palliative care for patients with cancer pain can be improved through nursing collaboration. For oncology nurses, an understanding of other nurses’ perceptions of palliative pain care would provide an opportunity to improve their own care. Such information would assist oncology nurses in developing an effective pain management plan. However, the major problem in the palliative care of cancer patients in Iran is the lack of a transparent palliative care framework for nurses, and palliative care does not receive serious attention in formal nursing education curricula. Palliative care is still a topic of discussion in the Iranian health-care system. Despite its importance, studies of palliative care in Iran are limited and very little information is available. It is therefore appropriate to undertake
Naimeh Seyedfatemi is Associate Professor of Nursing, and Leili Borimnejad is Assistant Professor of Nursing, Department of Nursing, Center for Nursing Care Research, Iran University of Medical Sciences; Marjan Mardani Hamooleh is Nursing PhD Candidate, Department of Nursing, and Mamak Tahmasebi is Assistant Professor of Gynecology, Department of Medicine, and Consultant in Palliative Medicine, Cancer Institute, Tehran University of Medical Sciences, Tehran University of Medical Sciences, East Nosrat Street, Tohid Square, Tehran, Iran Correspondence to: Marjan Mardani Hamooleh mardani_m@ razi.tums.ac.ir
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Research
exploratory qualitative research into this littleknown area.
Aim This study aimed to identify Iranian nurses’ perceptions of palliative care for patients with cancer pain.
Method A qualitative study using conventional content analysis was conducted during 2013. Qualitative research is intended to describe human experiences. Content analysis is a systematic codingand-categorising approach, which can be used to unobtrusively explore a large amount of textual information (Gbrich, 2007). Through content analysis, it is possible to distill words into fewer content-related categories. The aim is to attain a condensed yet still broad description of a phenomenon, and the analysis outcomes are the categories that describe the phenomenon (Elo and Kyngäs, 2008). Content analysis is perhaps the most common approach used in qualitative research (Graneheim and Lundman, 2004).
Setting The research was conducted in the cancer wards of three teaching hospitals specialising in the treatment of cancer patients in Tehran, Iran. These wards have 15–32 beds and offer palliative care to cancer patients.
Ethical approval The ethics committee of Tehran University of Medical Sciences approved the study.
Participants Nurses with a Bachelor’s degree were recruited from the wards through purposeful maximumvariation sampling. Potential participants were introduced to the third author by the head of each ward. To ensure that all eligible nurses were provided with an opportunity to participate, the wards were repeatedly visited by the third author, covering all three nursing shifts (days, evenings, and nights). All of the nurses were informed about the study’s purpose and method and those who took part provided written consent. The nurses were informed that they had the right to withdraw from the study at any time during or after the interviews and that they could ask the researchers to return the audiotapes of their interviews. They were assured that their responses would be kept confidential and that their identity would not be revealed at any stage of the study. Fifteen nurses took part: eleven females and four males. Their ages ranged from
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26 to 49. Ten of the nurses were married; the rest were single. The nurses’ work experience varied from 4 years to 18 years.
Data collection Face-to-face, semi-structured individual interviews lasting around 30–45 minutes were held in convenient quiet locations on the cancer wards on which the nurses worked. An interview guide was used and the interviews were audiorecorded. The interviews were conducted in the Persian language by the third author. Those parts of the interviews that were relevant to this article were translated into English by a professional translator and then the English version was translated back into Persian for verification by the fourth author, who is an Iranian bilingual translator. The major question asked in the interviews was: ‘What is your perception of palliative care of pain in cancer patients?’. Additional probing questions were also asked to follow the participants’ thoughts and clarify their responses during the interviews. The data collection and analysis proceeded concurrently. Once categories had been identified and data saturation achieved, the interviews were discontinued.
Data analysis Content analysis was used to categorise the interview data. The following steps were taken (Graneheim and Lundman, 2004): ●●The interview transcripts were read several times in order to obtain the sense of the whole ●●The text was divided into condensed meaning units ●●The condensed meaning units were abstracted and labelled with codes ●●The codes were sorted into subcategories and categories, based on comparisons of their similarities and differences ●●Categories were formulated as expressions of the latent content of the text. Trustworthiness was established in accordance with Graneheim and Lundman (2004). Maximum-variation sampling increased the confirmability and credibility of the data by ensuring its depth and authenticity. The authors analysed the findings independently to identify and categorise the initial codes and then compared their codes and categories. The credibility of the data was further established through member checking and peer checking. A brief of the interviews was returned to the nurses, who confirmed that their experiences were accurately represented. Peer checking was carried out by the authors and two doctoral nursing students, and resulted in similar findings.
© 2014 MA Healthcare Ltd
❛... the major problem in the palliative care of cancer patients in Iran is the lack of a transparent palliative care framework for nurses ...❜
International Journal of Palliative Nursing 2014, Vol 20, No 2
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Research
Findings Two main categories emerged from the content analysis: management of physical pain and psychological empowerment. Management of physical pain had two subcategories: mental readiness preparation and pain palliation using drugs. Mental readiness preparation also had two sub-categories: supportive behaviour and distress reduction.
Management of physical pain Management of physical pain takes place through mental readiness preparation and pain palliation using drugs. The importance of communication Management of physical pain occurs not only through provision of relieving drugs but also through actions such as talking to patients and informing them about potential side effects. The nurses believed that talking to patients provokes them to express their inner feelings and helps to relieve their physical pain. ‘Before injecting opioids, if we talk to the patients, the patients start talking about their illnesses, and it relieves their pain a lot. In such cases, the patients come to the conclusion that they aren’t in need of any opioids.’ (Participant (P) 9)
This quote also illustrates another finding: that several of the nurses reported trying to talk patients out of taking opioids. ‘Maybe it’s said that palliative care is just giving drugs, but I don’t think so, at all. For patients being hospitalised for a rather long time, like cancer patients, talking is really important because you can convince the patient not to take any drugs for his pain relief.’ (P3)
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‘It happened that morphine and pethidine were prescribed for a cancer patient, but I asked him if he had thought what destructive side effects such drugs could have, and if he got addicted to the opioids, what consequences it could bring forth. I also talked a lot about side effects such as constipation because it really bothers the patients … Maybe these words last not so long, but it’s satisfactory enough to make the patient give up the opioids.’ (P15).
However, the nurses also recognised that opioids can provide essential relief for patients. The nurses’ communication with patients included keeping them informed about their future access to such drugs.
International Journal of Palliative Nursing 2014, Vol 20, No 2
‘When opioids are in short supply, it takes a long time for arrangements to be made by hospital managers. In that time, we try to calm patients by saying “Don’t worry; we are going to inject it to you as soon as possible after getting opioids.” … These opioid shortages are reducing the quality of palliative care.’ (P12)
Pain palliation using drugs Despite the nurses’ comments about talking patients out of taking opioids, the participants stated that opioids are routinely scheduled. ‘It’s routine here to give opioid injection to patients every 4 hours even if they don’t feel aching. Without patients calling or requesting, opioids are injected regularly ...’ (P4)
❛... several of the nurses reported trying to talk patients out of taking opioids ... However, the nurses also recognised that opioids can provide essential relief for patients.❜
‘For palliative care, when a cancer patient feels pain, opioids are injected. When a patient calls us, we immediately go to him because these patients suffer from severe pain, and their pain requires relieving …Through injection of opioids, they feel comfortable.’ (P6)
One of the participants reported an extreme experience regarding one cancer patient’s receipt of opioids: ‘I have to say that sometimes the cancer patients shout and ask us to inject them with something to make them die. They say they can’t stand it anymore. Maybe you don’t believe it, but I’ve seen patients biting the metal bars of their beds! In such conditions, we inject opioids immediately to make them calm.’ (P4)
Another nurse talked about patients being concerned about not being able to access opioids following discharge from hospital: ‘Receiving opioids is the major cause for patients who are dissatisfied with being discharged, and they ask us if they can be hospitalised more. They say if they’re at home, the pains may start again, and there’s no one to give them a shot.’ (P5)
Psychological empowerment Psychological empowerment was found to be achieved through nurses supporting patients and reducing their distress. Supportive behaviour The participants believed that for cancer patients to be psychologically empowered, nurses must
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undetake supportive behaviour, and that such behaviour relieves the patients’ pain. ‘… Physical pain is not everything that cancer patients suffer from. They sometimes have deeper pains which can be relieved through supporting them. Cancer patients need support, especially from the nurses. They expect them to be their confidant and sympathisers in order to be able to go on with their lives.’ (P11) ‘If a patient is well-supported by a nurse, they better accept the palliative treatment and care. They show more interest in treatment, and they feel less pain because they think they’ve got a support. If a patient is supported by nurses, even if he is suffering a lot, he can handle it.’ (P13) ‘All people must help each other, and in difficult circumstances nurses must say “Hey, I’m standing by you to help you relieve your pain.” Palliative pain care for cancer patients is a subcategory of supporting, and we, as nurses, do our best to help them any time they need.’ (P2)
Supportive behaviour as part of palliative care for cancer patients was thought so important that one nurse stated she would not deserve to offer services to patients if she were unable to support them. ‘I think because cancer patients suffer for a life-long time, feel pain consistently and are hospitalised regularly, they need care. If I can’t support him, I don’t deserve to work in this ward, and I don’t deserve to be working as a nurse.’ (P8)
Distress reduction The nurses believed that distress reduction is another aspect of palliative care for patients with cancer pain. They felt that by understanding patients’ aggressiveness and being a good listener, a nurse can help to relieve their pain. ‘[To provide] palliative pain care for cancer patients is to understand their situation and that they have pain, and let them be aggressive. Then, we try to make them calm and never be sad ... When they see we’re joking and talking to them friendly and informally, they forget their severe pain.’ (P10) ‘We try to accept the patient as he is and with all his pains and to be a good listener when
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working with him. In my idea, an important point in palliative pain care for cancer patients is to be a good listener.’ (P1)
One nurse said that she believed distress reduction is necessary and described the nature of the pain experienced by cancer patients as follows: ‘Cancer is naturally accompanied with a lot of pain, and cancer patients are mentally distorted. This illness affects all the dimensions of their lives. That’s why they need support to help them tolerate better the incoming stress and make their life more comfortable.’ (P7)
Discussion The study findings show that the nurses believed palliative care for patients with cancer pain includes both management of physical pain and facilitation of psychological empowerment. Waterkemper and Reibnitz (2010) wrote that cancer pain manifests physically at first, and then gradually has psychological effects. Therefore, it is necessary for nurses performing palliative care for cancer patients to have adequate information about the different kinds of pain such patients suffer (Mehta et al, 2011). The nurses reported that they initially try to discourage patients from taking opioids by talking about their potential side effects, for example constipation. Semi-structured interviews with 12 cancer patients in the USA showed that constipation due to opioid use caused psychological distress in the form of depression and anxiety, and this affected the patients’ decisions on taking opioids again in future (Dhingra et al, 2013). Nevertheless, this practice of discouragement is not in accordance with international standards for cancer pain control, which state that pain management should use sufficient opioids to achieve patient comfort (Oliver et al, 2012). The nurses’ primary concern was that patients might become addicted to opioids. However, the evidence indicates that this need not be a concern for people with cancer (Agar, 2011). Thus, this approach to nursing management of cancer pain, which may be widespread in Iran, must be addressed. Nurses are ethically obliged to palliate pain sufficiently. Potential side effects should not be considered a reason to withhold opioids, and so the findings indicate that the Iranian Ministry of Health should attend to nursing education with regard to international pain management standards.
© 2014 MA Healthcare Ltd
❛... the nurses believed palliative care for patients with cancer pain includes both management of physical pain and facilitation of psychological empowerment.❜
International Journal of Palliative Nursing 2014, Vol 20, No 2
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights r
© 2014 MA Healthcare Ltd
Research
The nurses in the present study did demonstrate awareness that opioids can be of enormous benefit to patients. For cases of severe pain, the nurses provided opioids and then tried to manage their side effects. With regard to their attempts to initially dissuade patients from taking opioids, it appears the nurses felt it is essential to ensure that patients are fully informed about the potential side effects of opioids before resorting to them, but also that they perceived that nonpharmacological interventions sometimes provide sufficient relief. The participants stated that palliative care for patients with cancer pain is based on the needs of the patients, and should involve more than attention only to physical pains. They emphasised that nurses must be physically present for patients when necessary and must also undertake supportive behaviours and distress reduction as forms of psychological empowerment. With regard to being physically present, Schluter et al (2011) stated that being present beside the patient and offering services at the bedside are signs of a good nurse. The participants in the present study mentioned that supportive behaviour not only relieves pain but also helps patients carry on with their lives. Nurses caring for cancer patients may help them develop the ability to self-manage their pain and protect themselves in vulnerable situations (Vallerand et al, 2011). Several other studies, conducted in multiple countries with differing levels of development, including the USA, Canada, and Sri Lanka, have emphasised the necessity of supporting cancer patients (Stenberg et al, 2010; De Silva and Rolls, 2011; Mehta et al, 2011; Marchessault et al, 2012; Rhondali et al, 2013). The results of a study in Australia suggested that supporting cancer patients helps them to communicate better (Jones et al, 2011). It is therefore clear that support is an important part of palliative care for patients with cancer pain. Psychological distress is a primary component of cancer pain (Porter and Keefe, 2011). Jacobsen et al’s (2010) study in Denmark concerning pain management in cancer patients showed that pain intensity depends on the patient’s emotional distress. O’Mahony et al (2010) in the USA found that untreated emotional distress negatively affected the pain of cancer patients and that its alleviation could be a valid form of pain treatment. Valizadeh et al (2012) in Iran found that nurses helped to treat cancer patients’ psychological distress. Moreover, a study in India found that palliative care that relieves cancer pain improves patients’
International Journal of Palliative Nursing 2014, Vol 20, No 2
quality of life (Bisht et al, 2010). Despite the cultural diversity in these studies, the findings are very similar. Hence it is clear that distress reduction is also an essential part of palliative care for patients with cancer pain. The psychological support strategies the nurses in the present study reported using mainly consisted of listening to and talking with patients. The nurses felt that empowering patients could help them to overcome their disability and distress themselves, even up to the very last moments of their lives. However, other strategies for psychological support are available to nurses, and support alone will never adequately relieve severe cancer pain. Another finding of the present study was that Iran’s frequent opioid shortages might be one reason why nurses try to alleviate pain through mental and emotional care. Iranians are faced with shortages of different types of medicine because of economic sanctions (Shariatirad and Maarefvand, 2013). The participants described how cancer patients in Iran like to remain hospitalised so that they can receive opioids regularly, and stated that patients worry about being discharged. This study indicates that there is potential for further exploration of nurses’ understanding of and reservations about the use of medications such as opioids in pain management in different cultures. The findings also indicate a need for further study into how nurses can psychologically empower cancer patients and enhance their opportunities for a better quality of life with less pain, and how this can most effectively sit alongside other treatment approaches.
❛The psychological support strategies the nurses in the present study reported using mainly consisted of listening to and talking with patients.❜
Limitations The small sample size and the qualitative nature of the study limit the generalisability of the findings. However, as with all qualitative studies, the intention was not generalisation. Nonetheless, the results add to the body of knowledge in this field. This study focused on nurses’ experiences; the perspectives of other health-care team members, such as physicians, were not collected. However, the authors believe that the results are innovative and noteworthy despite the limitations.
Conclusion and recommendations Palliative relief of physical pain must be associated with psychological empowerment. The results of the present study show a deep appreciation of palliative care for patients with cancer pain among Iranian nurses, who consider both physical and psychological aspects important.
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The findings may prove helpful for nurses working in cancer wards. As this was the first qualitative study on palliative care for patients with cancer pain in Iran, the results unveiled some previously unseen aspects of such care in this country. In addition, it is recommended that all physicians, psychologists, psychiatrists, psychiatric nurses, and other related professions in Iran have joint meetings to design consolidated treatment techniques to relieve pain in cancer patients. It is also recommended that more comprehensive qualitative studies be done in this field. Studies on the perspectives of other health-care team members would increase our knowledge of palliative care for patients with cancer pain. I● JPN Acknowledgments The authors are grateful to all of the nurses who participated in this study. Without their help and cooperation, this research could not have been conducted. The work reported in this article was conducted as part of the third author’s doctoral study and was supported by Tehran University of Medical Sciences. Declaration of interest This work had no external sources of funding. The authors have no conflicts of interest to declare.
Agar M (2011) Pain and opioid dependence: is it a matter of concern. Indian J Palliat Care 17(Suppl): S36–8 Bisht M, Bist SS, Dhasmana DC, Saini S (2010) Quality of life as an outcome variable in the management of advanced cancer. Indian J Med Paediatr Oncol 31(4): 121–5 Daher M (2011) Opioids for cancer pain in the Middle Eastern countries: a physician point of view. J Pediatr Hematol Oncol 33(Suppl 1): S23–8 Deandrea S, Montanari M, Moja L, Apolone G (2008) Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol 19(12): 1985–91 De Silva BS, Rolls C (2011) Attitudes, beliefs, and practices of Sri Lankan nurses toward cancer pain management: an ethnographic study. Nurs Health Sci 13(4): 419–24 Dhingra L, Shuk E, Grossman B et al (2013) A qualitative study to explore psychological distress and illness burden associated with opioid-induced constipation in cancer patients with advanced disease. Palliat Med 27(5): 447–56 Elo S, Kyngäs H (2008) The qualitative content analysis process. J Adv Nurs 62(1): 107–15 Farbicka P, Nowicki A (2012) Selected aspects of palliative care and quality of life at the terminal stage of neoplastic disease. Contemp Oncol (Pozn) 16(6): 506–11 Gbrich C (2007) Qualitative Data Analysis: An Introduction. 1st edn. Sage, London Graneheim UH, Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 24(2): 105–12 Higginson IJ, Costantini M (2008) Dying with cancer, living well with advanced cancer. Eur J Cancer 44(10): 1414–24
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Human Rights Watch (2011) Global State of Pain Treatment. Palliative Care as a Human Right. www.hrw. org/reports/2011/06/02/global-state-pain-treatment-0 (accessed 21 January 2014) Jacobsen R, Møldrup C, Christrup L, Sjøgren P, Hansen OB (2010) Psychological and behavioural predictors of pain management outcomes in patients with cancer. Scand J Caring Sci 24(4): 781–90 Jones R, Regan M, Ristevski E, Breen S (2011) Patients’ perception of communication with clinicians during screening and discussion of cancer supportive care needs. Patient Educ Couns 85(3): e209–15 Marchessault J, Legault A, Martinez AM (2012) Providing in-home palliative care within a generalist caseload: a chance for nurses to reflect on life and death. Int J Palliat Nurs 18(3): 135–41 Mehta A, Cohen SR, Ezer H, Carnevale FA, Ducharme F (2011) Striving to respond to palliative care patients’ pain at home: a puzzle for family caregivers. Oncol Nurs Forum 38(1): E37–45 Modesto-Lowe V, Girard L, Chaplin M (2012) Cancer pain in the opioid-addicted patient: can we treat it right? J Opioid Manag 8(3): 167–75 Mori M, Elsayem A, Reddy SK, Bruera E, Fadul NA (2012)Unrelieved pain and suffering in patients with advanced cancer. Am J Hosp Palliat Care 29(3): 236–40 Mousavi SM, Gouya MM, Ramazani R, Davanlou M, Hajsadeghi N, Seddighi Z (2009) Cancer incidence and mortality in Iran. Ann Oncol 20(3): 556–63 Oliver J, Coggins C, Compton P et al (2012) American Society for Pain Management nursing position statement: pain management in patients with substance use disorders. Pain Manag Nurs 13(3): 169–83 O’Mahony S, Goulet JL, Payne R (2010) Psychosocial distress in patients treated for cancer pain: a prospective observational study. J Opioid Manag 6(3): 211–22 Porter LS, Keefe FJ (2011) Psychosocial issues in cancer pain. Curr Pain Headache Rep 15(4): 263–70 Raphael J, Ahmedzai S, Hester J et al (2010) Cancer pain: part 1: Pathophysiology; oncological, pharmacological, and psychological treatments: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. Pain Med 11(5): 742–64 Rhondali W, Burt S, Wittenberg-Lyles E, Bruera E, Dalal S (2013) Medical oncologists’ perception of palliative care programs and the impact of name change to supportive care on communication with patients during the referral process. A qualitative study. A qualitative study. Palliat Support Care 11(5): 397–404 Schluter J, Seaton P, Chaboyer W (2011) Understanding nursing scope of practice: a qualitative study. Int J Nurs Stud 48(10): 1211–22 Shariatirad S, Maarefvand M (2013) Sanctions against Iran and the impact on drug use and addiction treatment. Int J Drug Policy 24(6): 636–7 Stenberg U, Ruland CM, Miaskowski C (2010) Review of the literature on the effects of caring for a patient with cancer. Psychooncology 19(10): 1013–25 Valizadeh L, Zamanzadeh V, Rahmani A, Howard F, Nikanfar AR, Ferguson C (2012) Cancer disclosure: experiences of Iranian cancer patients. Nurs Health Sci 14(2): 250–6 Vallerand AH, Musto S, Polomano RC (2011) Nursing’s role in cancer pain management. Curr Pain Headache Rep 15(4): 250–62 Waterkemper R, Reibnitz KS (2010) Palliative care: the nurses’ contributions in pain assessment. [In Portuguese] Rev Gaucha Enferm 31(1): 84–91 Wiese CH, Löffler EK, Vormelker J et al (2010) Cancer pain therapy in palliative care patients: knowledge of prehospital emergency physicians in training. Prospective questionnaire-based investigation. [In German] Schmerz 24(5): 508–16
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International Journal of Palliative Nursing 2014, Vol 20, No 2
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights r
Iranian nurses’ perceptions of palliative care for patients with cancer pain Naimeh Seyedfatemi, Leili Borimnejad, Marjan Mardani Hamooleh, Mamak Tahmasebi
© 2014 MA Healthcare Ltd
I
t is estimated that more than 15 million people worldwide will experience cancer in 2020 (Higginson and Costantini, 2008). Cancer is an increasing problem in Middle Eastern countries. The Middle East includes a wide range of economically diverse countries, from technically advanced countries with highlevel cancer care to countries with little or no cancer treatment capabilities. In the majority of countries of this region, cancer is generally diagnosed when it is at a relatively advanced phase (Daher, 2011). In Iran, cancer is the third most common cause of death, after heart disease and road accidents. The incidence of cancer in Iran is estimated to be around 48–112 and 51–144 cases per year per million people for women and men, respectively (Mousavi et al, 2009). Pain is a common primary symptom of cancer, occurring in 50–70% of all cancer patients (Wiese et al, 2010). It may result from the primary tumour, metastasis, radiation, chemotherapy, surgery, or comorbidity (Modesto-Lowe et al, 2012). When a patient is suffering from cancer pain it is paramount to consider not only biochemical factors but also psychosocial influences (Mori et al, 2012). Of all of the physical and emotional symptoms of cancer, pain is often identified as the most distressing (Modesto-Lowe et al, 2012). Cancer pain can be regarded as ‘total pain,’ with physical, psychological, spiritual, and social dimensions (Raphael et al, 2010). Deandrea et al (2008) reported in their metaanalysis that, for 43% of patients with cancer pain, the pain was not controlled to a satisfactory level. Cancer pain negatively affects patients’ quality of life, and palliative care for such pain is essential. There is an urgent worldwide humanitarian need for palliative care for people with cancer (Human Rights Watch, 2011). Palliative care addresses somatic and psychosocial requirements (Farbicka and Nowicki, 2012), including the treatment of pain and suffering (Daher, 2011).
International Journal of Palliative Nursing 2014, Vol 20, No 2
Abstract
Aim: The purpose of this study was to identify Iranian nurses’ perceptions of palliative care for patients with cancer pain. Methods: The study took a qualitative approach. Semi-structured interviews were held with 15 nurses with Bachelor’s degrees working in three teaching hospitals in Iran. Transcripts of the interviews underwent content analysis, and categories were extracted from the material. Findings: The findings came under two main categories: management of physical pain and psychological empowerment. Management of physical pain had two subcategories: the importance of communication, and pain palliation using drugs. Psychological empowerment also had two subcategories: supportive behaviour and distress reduction. Conclusion: The sample felt that palliative care for patients with cancer pain must include psychological empowerment, support, and communication as well as physical pain relief. Key words: Cancer l Content analysis l Nurse l Palliative care l Pain
In the authors’ experience, although the majority of nurses working in cancer wards in Iran try to relieve cancer patients’ pain, these patients need much more palliative nursing attention than they currently receive. The authors believe that the quality of palliative care for patients with cancer pain can be improved through nursing collaboration. For oncology nurses, an understanding of other nurses’ perceptions of palliative pain care would provide an opportunity to improve their own care. Such information would assist oncology nurses in developing an effective pain management plan. However, the major problem in the palliative care of cancer patients in Iran is the lack of a transparent palliative care framework for nurses, and palliative care does not receive serious attention in formal nursing education curricula. Palliative care is still a topic of discussion in the Iranian health-care system. Despite its importance, studies of palliative care in Iran are limited and very little information is available. It is therefore appropriate to undertake
Naimeh Seyedfatemi is Associate Professor of Nursing, and Leili Borimnejad is Assistant Professor of Nursing, Department of Nursing, Center for Nursing Care Research, Iran University of Medical Sciences; Marjan Mardani Hamooleh is Nursing PhD Candidate, Department of Nursing, and Mamak Tahmasebi is Assistant Professor of Gynecology, Department of Medicine, and Consultant in Palliative Medicine, Cancer Institute, Tehran University of Medical Sciences, Tehran University of Medical Sciences, East Nosrat Street, Tohid Square, Tehran, Iran Correspondence to: Marjan Mardani Hamooleh mardani_m@ razi.tums.ac.ir
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onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 21, 2015. For personal use only. No other uses without permission. . All rights r
Research
exploratory qualitative research into this littleknown area.
Aim This study aimed to identify Iranian nurses’ perceptions of palliative care for patients with cancer pain.
Method A qualitative study using conventional content analysis was conducted during 2013. Qualitative research is intended to describe human experiences. Content analysis is a systematic codingand-categorising approach, which can be used to unobtrusively explore a large amount of textual information (Gbrich, 2007). Through content analysis, it is possible to distill words into fewer content-related categories. The aim is to attain a condensed yet still broad description of a phenomenon, and the analysis outcomes are the categories that describe the phenomenon (Elo and Kyngäs, 2008). Content analysis is perhaps the most common approach used in qualitative research (Graneheim and Lundman, 2004).
Setting The research was conducted in the cancer wards of three teaching hospitals specialising in the treatment of cancer patients in Tehran, Iran. These wards have 15–32 beds and offer palliative care to cancer patients.
Ethical approval The ethics committee of Tehran University of Medical Sciences approved the study.
Participants Nurses with a Bachelor’s degree were recruited from the wards through purposeful maximumvariation sampling. Potential participants were introduced to the third author by the head of each ward. To ensure that all eligible nurses were provided with an opportunity to participate, the wards were repeatedly visited by the third author, covering all three nursing shifts (days, evenings, and nights). All of the nurses were informed about the study’s purpose and method and those who took part provided written consent. The nurses were informed that they had the right to withdraw from the study at any time during or after the interviews and that they could ask the researchers to return the audiotapes of their interviews. They were assured that their responses would be kept confidential and that their identity would not be revealed at any stage of the study. Fifteen nurses took part: eleven females and four males. Their ages ranged from
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26 to 49. Ten of the nurses were married; the rest were single. The nurses’ work experience varied from 4 years to 18 years.
Data collection Face-to-face, semi-structured individual interviews lasting around 30–45 minutes were held in convenient quiet locations on the cancer wards on which the nurses worked. An interview guide was used and the interviews were audiorecorded. The interviews were conducted in the Persian language by the third author. Those parts of the interviews that were relevant to this article were translated into English by a professional translator and then the English version was translated back into Persian for verification by the fourth author, who is an Iranian bilingual translator. The major question asked in the interviews was: ‘What is your perception of palliative care of pain in cancer patients?’. Additional probing questions were also asked to follow the participants’ thoughts and clarify their responses during the interviews. The data collection and analysis proceeded concurrently. Once categories had been identified and data saturation achieved, the interviews were discontinued.
Data analysis Content analysis was used to categorise the interview data. The following steps were taken (Graneheim and Lundman, 2004): ●●The interview transcripts were read several times in order to obtain the sense of the whole ●●The text was divided into condensed meaning units ●●The condensed meaning units were abstracted and labelled with codes ●●The codes were sorted into subcategories and categories, based on comparisons of their similarities and differences ●●Categories were formulated as expressions of the latent content of the text. Trustworthiness was established in accordance with Graneheim and Lundman (2004). Maximum-variation sampling increased the confirmability and credibility of the data by ensuring its depth and authenticity. The authors analysed the findings independently to identify and categorise the initial codes and then compared their codes and categories. The credibility of the data was further established through member checking and peer checking. A brief of the interviews was returned to the nurses, who confirmed that their experiences were accurately represented. Peer checking was carried out by the authors and two doctoral nursing students, and resulted in similar findings.
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❛... the major problem in the palliative care of cancer patients in Iran is the lack of a transparent palliative care framework for nurses ...❜
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Findings Two main categories emerged from the content analysis: management of physical pain and psychological empowerment. Management of physical pain had two subcategories: mental readiness preparation and pain palliation using drugs. Mental readiness preparation also had two sub-categories: supportive behaviour and distress reduction.
Management of physical pain Management of physical pain takes place through mental readiness preparation and pain palliation using drugs. The importance of communication Management of physical pain occurs not only through provision of relieving drugs but also through actions such as talking to patients and informing them about potential side effects. The nurses believed that talking to patients provokes them to express their inner feelings and helps to relieve their physical pain. ‘Before injecting opioids, if we talk to the patients, the patients start talking about their illnesses, and it relieves their pain a lot. In such cases, the patients come to the conclusion that they aren’t in need of any opioids.’ (Participant (P) 9)
This quote also illustrates another finding: that several of the nurses reported trying to talk patients out of taking opioids. ‘Maybe it’s said that palliative care is just giving drugs, but I don’t think so, at all. For patients being hospitalised for a rather long time, like cancer patients, talking is really important because you can convince the patient not to take any drugs for his pain relief.’ (P3)
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‘It happened that morphine and pethidine were prescribed for a cancer patient, but I asked him if he had thought what destructive side effects such drugs could have, and if he got addicted to the opioids, what consequences it could bring forth. I also talked a lot about side effects such as constipation because it really bothers the patients … Maybe these words last not so long, but it’s satisfactory enough to make the patient give up the opioids.’ (P15).
However, the nurses also recognised that opioids can provide essential relief for patients. The nurses’ communication with patients included keeping them informed about their future access to such drugs.
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‘When opioids are in short supply, it takes a long time for arrangements to be made by hospital managers. In that time, we try to calm patients by saying “Don’t worry; we are going to inject it to you as soon as possible after getting opioids.” … These opioid shortages are reducing the quality of palliative care.’ (P12)
Pain palliation using drugs Despite the nurses’ comments about talking patients out of taking opioids, the participants stated that opioids are routinely scheduled. ‘It’s routine here to give opioid injection to patients every 4 hours even if they don’t feel aching. Without patients calling or requesting, opioids are injected regularly ...’ (P4)
❛... several of the nurses reported trying to talk patients out of taking opioids ... However, the nurses also recognised that opioids can provide essential relief for patients.❜
‘For palliative care, when a cancer patient feels pain, opioids are injected. When a patient calls us, we immediately go to him because these patients suffer from severe pain, and their pain requires relieving …Through injection of opioids, they feel comfortable.’ (P6)
One of the participants reported an extreme experience regarding one cancer patient’s receipt of opioids: ‘I have to say that sometimes the cancer patients shout and ask us to inject them with something to make them die. They say they can’t stand it anymore. Maybe you don’t believe it, but I’ve seen patients biting the metal bars of their beds! In such conditions, we inject opioids immediately to make them calm.’ (P4)
Another nurse talked about patients being concerned about not being able to access opioids following discharge from hospital: ‘Receiving opioids is the major cause for patients who are dissatisfied with being discharged, and they ask us if they can be hospitalised more. They say if they’re at home, the pains may start again, and there’s no one to give them a shot.’ (P5)
Psychological empowerment Psychological empowerment was found to be achieved through nurses supporting patients and reducing their distress. Supportive behaviour The participants believed that for cancer patients to be psychologically empowered, nurses must
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undetake supportive behaviour, and that such behaviour relieves the patients’ pain. ‘… Physical pain is not everything that cancer patients suffer from. They sometimes have deeper pains which can be relieved through supporting them. Cancer patients need support, especially from the nurses. They expect them to be their confidant and sympathisers in order to be able to go on with their lives.’ (P11) ‘If a patient is well-supported by a nurse, they better accept the palliative treatment and care. They show more interest in treatment, and they feel less pain because they think they’ve got a support. If a patient is supported by nurses, even if he is suffering a lot, he can handle it.’ (P13) ‘All people must help each other, and in difficult circumstances nurses must say “Hey, I’m standing by you to help you relieve your pain.” Palliative pain care for cancer patients is a subcategory of supporting, and we, as nurses, do our best to help them any time they need.’ (P2)
Supportive behaviour as part of palliative care for cancer patients was thought so important that one nurse stated she would not deserve to offer services to patients if she were unable to support them. ‘I think because cancer patients suffer for a life-long time, feel pain consistently and are hospitalised regularly, they need care. If I can’t support him, I don’t deserve to work in this ward, and I don’t deserve to be working as a nurse.’ (P8)
Distress reduction The nurses believed that distress reduction is another aspect of palliative care for patients with cancer pain. They felt that by understanding patients’ aggressiveness and being a good listener, a nurse can help to relieve their pain. ‘[To provide] palliative pain care for cancer patients is to understand their situation and that they have pain, and let them be aggressive. Then, we try to make them calm and never be sad ... When they see we’re joking and talking to them friendly and informally, they forget their severe pain.’ (P10) ‘We try to accept the patient as he is and with all his pains and to be a good listener when
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working with him. In my idea, an important point in palliative pain care for cancer patients is to be a good listener.’ (P1)
One nurse said that she believed distress reduction is necessary and described the nature of the pain experienced by cancer patients as follows: ‘Cancer is naturally accompanied with a lot of pain, and cancer patients are mentally distorted. This illness affects all the dimensions of their lives. That’s why they need support to help them tolerate better the incoming stress and make their life more comfortable.’ (P7)
Discussion The study findings show that the nurses believed palliative care for patients with cancer pain includes both management of physical pain and facilitation of psychological empowerment. Waterkemper and Reibnitz (2010) wrote that cancer pain manifests physically at first, and then gradually has psychological effects. Therefore, it is necessary for nurses performing palliative care for cancer patients to have adequate information about the different kinds of pain such patients suffer (Mehta et al, 2011). The nurses reported that they initially try to discourage patients from taking opioids by talking about their potential side effects, for example constipation. Semi-structured interviews with 12 cancer patients in the USA showed that constipation due to opioid use caused psychological distress in the form of depression and anxiety, and this affected the patients’ decisions on taking opioids again in future (Dhingra et al, 2013). Nevertheless, this practice of discouragement is not in accordance with international standards for cancer pain control, which state that pain management should use sufficient opioids to achieve patient comfort (Oliver et al, 2012). The nurses’ primary concern was that patients might become addicted to opioids. However, the evidence indicates that this need not be a concern for people with cancer (Agar, 2011). Thus, this approach to nursing management of cancer pain, which may be widespread in Iran, must be addressed. Nurses are ethically obliged to palliate pain sufficiently. Potential side effects should not be considered a reason to withhold opioids, and so the findings indicate that the Iranian Ministry of Health should attend to nursing education with regard to international pain management standards.
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❛... the nurses believed palliative care for patients with cancer pain includes both management of physical pain and facilitation of psychological empowerment.❜
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The nurses in the present study did demonstrate awareness that opioids can be of enormous benefit to patients. For cases of severe pain, the nurses provided opioids and then tried to manage their side effects. With regard to their attempts to initially dissuade patients from taking opioids, it appears the nurses felt it is essential to ensure that patients are fully informed about the potential side effects of opioids before resorting to them, but also that they perceived that nonpharmacological interventions sometimes provide sufficient relief. The participants stated that palliative care for patients with cancer pain is based on the needs of the patients, and should involve more than attention only to physical pains. They emphasised that nurses must be physically present for patients when necessary and must also undertake supportive behaviours and distress reduction as forms of psychological empowerment. With regard to being physically present, Schluter et al (2011) stated that being present beside the patient and offering services at the bedside are signs of a good nurse. The participants in the present study mentioned that supportive behaviour not only relieves pain but also helps patients carry on with their lives. Nurses caring for cancer patients may help them develop the ability to self-manage their pain and protect themselves in vulnerable situations (Vallerand et al, 2011). Several other studies, conducted in multiple countries with differing levels of development, including the USA, Canada, and Sri Lanka, have emphasised the necessity of supporting cancer patients (Stenberg et al, 2010; De Silva and Rolls, 2011; Mehta et al, 2011; Marchessault et al, 2012; Rhondali et al, 2013). The results of a study in Australia suggested that supporting cancer patients helps them to communicate better (Jones et al, 2011). It is therefore clear that support is an important part of palliative care for patients with cancer pain. Psychological distress is a primary component of cancer pain (Porter and Keefe, 2011). Jacobsen et al’s (2010) study in Denmark concerning pain management in cancer patients showed that pain intensity depends on the patient’s emotional distress. O’Mahony et al (2010) in the USA found that untreated emotional distress negatively affected the pain of cancer patients and that its alleviation could be a valid form of pain treatment. Valizadeh et al (2012) in Iran found that nurses helped to treat cancer patients’ psychological distress. Moreover, a study in India found that palliative care that relieves cancer pain improves patients’
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quality of life (Bisht et al, 2010). Despite the cultural diversity in these studies, the findings are very similar. Hence it is clear that distress reduction is also an essential part of palliative care for patients with cancer pain. The psychological support strategies the nurses in the present study reported using mainly consisted of listening to and talking with patients. The nurses felt that empowering patients could help them to overcome their disability and distress themselves, even up to the very last moments of their lives. However, other strategies for psychological support are available to nurses, and support alone will never adequately relieve severe cancer pain. Another finding of the present study was that Iran’s frequent opioid shortages might be one reason why nurses try to alleviate pain through mental and emotional care. Iranians are faced with shortages of different types of medicine because of economic sanctions (Shariatirad and Maarefvand, 2013). The participants described how cancer patients in Iran like to remain hospitalised so that they can receive opioids regularly, and stated that patients worry about being discharged. This study indicates that there is potential for further exploration of nurses’ understanding of and reservations about the use of medications such as opioids in pain management in different cultures. The findings also indicate a need for further study into how nurses can psychologically empower cancer patients and enhance their opportunities for a better quality of life with less pain, and how this can most effectively sit alongside other treatment approaches.
❛The psychological support strategies the nurses in the present study reported using mainly consisted of listening to and talking with patients.❜
Limitations The small sample size and the qualitative nature of the study limit the generalisability of the findings. However, as with all qualitative studies, the intention was not generalisation. Nonetheless, the results add to the body of knowledge in this field. This study focused on nurses’ experiences; the perspectives of other health-care team members, such as physicians, were not collected. However, the authors believe that the results are innovative and noteworthy despite the limitations.
Conclusion and recommendations Palliative relief of physical pain must be associated with psychological empowerment. The results of the present study show a deep appreciation of palliative care for patients with cancer pain among Iranian nurses, who consider both physical and psychological aspects important.
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The findings may prove helpful for nurses working in cancer wards. As this was the first qualitative study on palliative care for patients with cancer pain in Iran, the results unveiled some previously unseen aspects of such care in this country. In addition, it is recommended that all physicians, psychologists, psychiatrists, psychiatric nurses, and other related professions in Iran have joint meetings to design consolidated treatment techniques to relieve pain in cancer patients. It is also recommended that more comprehensive qualitative studies be done in this field. Studies on the perspectives of other health-care team members would increase our knowledge of palliative care for patients with cancer pain. I● JPN Acknowledgments The authors are grateful to all of the nurses who participated in this study. Without their help and cooperation, this research could not have been conducted. The work reported in this article was conducted as part of the third author’s doctoral study and was supported by Tehran University of Medical Sciences. Declaration of interest This work had no external sources of funding. The authors have no conflicts of interest to declare.
Agar M (2011) Pain and opioid dependence: is it a matter of concern. Indian J Palliat Care 17(Suppl): S36–8 Bisht M, Bist SS, Dhasmana DC, Saini S (2010) Quality of life as an outcome variable in the management of advanced cancer. Indian J Med Paediatr Oncol 31(4): 121–5 Daher M (2011) Opioids for cancer pain in the Middle Eastern countries: a physician point of view. J Pediatr Hematol Oncol 33(Suppl 1): S23–8 Deandrea S, Montanari M, Moja L, Apolone G (2008) Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol 19(12): 1985–91 De Silva BS, Rolls C (2011) Attitudes, beliefs, and practices of Sri Lankan nurses toward cancer pain management: an ethnographic study. Nurs Health Sci 13(4): 419–24 Dhingra L, Shuk E, Grossman B et al (2013) A qualitative study to explore psychological distress and illness burden associated with opioid-induced constipation in cancer patients with advanced disease. Palliat Med 27(5): 447–56 Elo S, Kyngäs H (2008) The qualitative content analysis process. J Adv Nurs 62(1): 107–15 Farbicka P, Nowicki A (2012) Selected aspects of palliative care and quality of life at the terminal stage of neoplastic disease. Contemp Oncol (Pozn) 16(6): 506–11 Gbrich C (2007) Qualitative Data Analysis: An Introduction. 1st edn. Sage, London Graneheim UH, Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 24(2): 105–12 Higginson IJ, Costantini M (2008) Dying with cancer, living well with advanced cancer. Eur J Cancer 44(10): 1414–24
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Human Rights Watch (2011) Global State of Pain Treatment. Palliative Care as a Human Right. www.hrw. org/reports/2011/06/02/global-state-pain-treatment-0 (accessed 21 January 2014) Jacobsen R, Møldrup C, Christrup L, Sjøgren P, Hansen OB (2010) Psychological and behavioural predictors of pain management outcomes in patients with cancer. Scand J Caring Sci 24(4): 781–90 Jones R, Regan M, Ristevski E, Breen S (2011) Patients’ perception of communication with clinicians during screening and discussion of cancer supportive care needs. Patient Educ Couns 85(3): e209–15 Marchessault J, Legault A, Martinez AM (2012) Providing in-home palliative care within a generalist caseload: a chance for nurses to reflect on life and death. Int J Palliat Nurs 18(3): 135–41 Mehta A, Cohen SR, Ezer H, Carnevale FA, Ducharme F (2011) Striving to respond to palliative care patients’ pain at home: a puzzle for family caregivers. Oncol Nurs Forum 38(1): E37–45 Modesto-Lowe V, Girard L, Chaplin M (2012) Cancer pain in the opioid-addicted patient: can we treat it right? J Opioid Manag 8(3): 167–75 Mori M, Elsayem A, Reddy SK, Bruera E, Fadul NA (2012)Unrelieved pain and suffering in patients with advanced cancer. Am J Hosp Palliat Care 29(3): 236–40 Mousavi SM, Gouya MM, Ramazani R, Davanlou M, Hajsadeghi N, Seddighi Z (2009) Cancer incidence and mortality in Iran. Ann Oncol 20(3): 556–63 Oliver J, Coggins C, Compton P et al (2012) American Society for Pain Management nursing position statement: pain management in patients with substance use disorders. Pain Manag Nurs 13(3): 169–83 O’Mahony S, Goulet JL, Payne R (2010) Psychosocial distress in patients treated for cancer pain: a prospective observational study. J Opioid Manag 6(3): 211–22 Porter LS, Keefe FJ (2011) Psychosocial issues in cancer pain. Curr Pain Headache Rep 15(4): 263–70 Raphael J, Ahmedzai S, Hester J et al (2010) Cancer pain: part 1: Pathophysiology; oncological, pharmacological, and psychological treatments: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. Pain Med 11(5): 742–64 Rhondali W, Burt S, Wittenberg-Lyles E, Bruera E, Dalal S (2013) Medical oncologists’ perception of palliative care programs and the impact of name change to supportive care on communication with patients during the referral process. A qualitative study. A qualitative study. Palliat Support Care 11(5): 397–404 Schluter J, Seaton P, Chaboyer W (2011) Understanding nursing scope of practice: a qualitative study. Int J Nurs Stud 48(10): 1211–22 Shariatirad S, Maarefvand M (2013) Sanctions against Iran and the impact on drug use and addiction treatment. Int J Drug Policy 24(6): 636–7 Stenberg U, Ruland CM, Miaskowski C (2010) Review of the literature on the effects of caring for a patient with cancer. Psychooncology 19(10): 1013–25 Valizadeh L, Zamanzadeh V, Rahmani A, Howard F, Nikanfar AR, Ferguson C (2012) Cancer disclosure: experiences of Iranian cancer patients. Nurs Health Sci 14(2): 250–6 Vallerand AH, Musto S, Polomano RC (2011) Nursing’s role in cancer pain management. Curr Pain Headache Rep 15(4): 250–62 Waterkemper R, Reibnitz KS (2010) Palliative care: the nurses’ contributions in pain assessment. [In Portuguese] Rev Gaucha Enferm 31(1): 84–91 Wiese CH, Löffler EK, Vormelker J et al (2010) Cancer pain therapy in palliative care patients: knowledge of prehospital emergency physicians in training. Prospective questionnaire-based investigation. [In German] Schmerz 24(5): 508–16
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