478
Journal ofPain and Symptom Management
vel
Vol.7 No. 8 November 1992
ofCancer
Baccalaureate Denice Kopchak Sheehan, RN, Adele Webb, PhD, Dolores Bower, PhD, and Richard Einsporn, PhD Hospiceofthel%sternResente,Mentor(D.K.S.); and theUniversity of Akron (A.@!,D.B., RE.), Akron, Ohio
I~&quate nursing education is a major impediment to effectivepain relieffm cancer patients throughout the world. This study was conducted to identify the level of cancer pain knowledgeamong baccalaureatestudent nurses and to d&ermine whetherspecific a-&&tiesaflect this level of knowledge.Two questionnaireswereadministered to 82 baccalaureatestudat nurses in the final course of their program. Although the students displayeda realisticperspectiveabout the severityand pr~alence of cancerpain and p~chological dependence, specijicknowledgedeficitsand negative attitudessuggest the possibilityof ina&quate pain management. Specifically,the students believedthat (a) maximal analgesic therapyshould be &layed until thepatient’sPrognosiswas less than 12 months; (6) theproptiion of@ztimts whosepain can be controlledby appr@riaS therapy is less than ti possible;(c) increasing pain is relatedto tolerancerather than to progressionof the disease; (d) the preferredroute of administration is intravenous rather than oral; and (e) the &gree of respiratq depression, rather than constipation,&es not decreasewith repeatedadministration. Significant positivecorrelations(P I 0.05j were found betweenage and cancer pain knowledgeand betweenattendance at seminars/ workshopsand time spent reading professional journal articles.Of the 30% of the participants whoperceived a particular person to be a sourcefor obtaining infmmation about cancer pain management, 52 % spe#ed a practicing registerednurse. Seminars and workshopswerechosen by 59% of the students as the mosteflectiveway ,for nurses to increase their knowbzdp. This study suggestsa needfor basic cancerpain mazug_mwnt education at the undergaduate levelas well as continuing education through seminars and workshops.J Pain Symptom Manage 1992; 7:4 78-484.
eYW&
Cancer pain, nursing education
AddraFsreprint requests to: Denice Sheehan, RN, Hospiceof the WesternReserve,5786 Heisley Road, Mentor,OH 44060. Acc+btedforpublica~~ion: July 31.1992.
In 1986, the World Health Organization estimated that at least 3.5 million people suffer from cancer pain every day, and that 25% of such patients die without obtaining pain relief.’ Although analgesic therapy is capable of controlling pain in up to 90% of
Q U.S. Cancer Pain Relief Committee, 1992 Published by Elsevier, New York, New York
08853924/92/$5.00
the fact that no single health profession for pain control; each e i.dentiQ the problem and Nurses spend many hours interac their patients and so are in a pivo to assess the patient’s pain, hrte priately to relieve the pain, and evaluate the effectiveness of the intervention. Unfortunately numerous smveysS7Jo suggest that medical and nursing students and practicing nurses tial in this an first-year medical students have a realistic knowledge of the causes and duration of cancer pain, as well as its incidence, but that less than 50% of graduating students could correctly answer simple questions about opioid pharmacology and t0xicity.s In a later study, Weissman aud ftrst-year students prior to their entry into medical school have negative attitudes redependence, adegarding psychologic ic therapy, cause of increasing quate anal te time to begin pain, and maximum tolerated analgesic “aPYs9 Similarly, Diekmann and sem noted that 83% of student nurses reported that they did not have adequate knowledge about cancer pain management. Although most of the respondents correctly identified the prevalence and duration of cancer pain, and the reality of undermedication, most had inadequate knowledge about the potential efficacy of treatment, the most appropriate time tO begin analgesic therapy, psychological dependence, opioid side effects, and preferred route of administration.*0 Graffam surveyed 305 randomly selected baccalaureate nursing programs and found that only 8% reported having someone on the faculty who specializes in pain management. The presence of an expert did ot influence the curriculum oduszewski and McCray surcontentl* veyed 12 nurses and found that preparation for the role of cancer pain management
(ONS) published a pain, which specific uate, and contiuuing education for nurses, as and pubhc information.
curricuhun c0utent related to cancer pain and its management. ~p~ort~~~~es should exist for nurses to develop corn areas of cancer pain assessment, management, and evaluation. A research component should k added at the graduate level. The position paper clearly states the importance g future nurses “to a r0le assessment and manageme pain and pain control regimens as an abs0 lute, irrefutable, professional, and ethical responsibility.“13 The effect of professional education on pain management h also been studied in the chnical settin education pro on cancer pain management was useful in decreasing nurses’ concerns about respiratory depression, addiction, and sedation;14 this pr also increased knowledge of
to 1984, Bruera and colleagues found a significant increase in nurses’ notes of references to painI which was ascribed to a higher level of interest in pain control. The present study was undertaken to identify the level of cancer pain knowledge among baccalaureate student nurses and to determine whether specific activities affect the level of cancer pain knowledge. In the context of the aforementioned studies, this information may be able to clarify the prqges that has been made in the education of nurses and the needs for additional efforts.
A descriptive correlational design was used in this study; The sample was taken from three colleges, which were randomly selected
480
Kopckak Skeekam et al.
from the seven National League of Nursingaccredited baccalaureate nursing programs in northeastern Ohio. The participants were student nurses in the find course of their program. The study was approved by the Institutional Review Board of the University of Akron. Permission to collect data was obtained in person after the investigator met with each dean of the selected programs. Each participant completed two questionnaires. The first was a Demographics/Activities Questionnaire, which elicited information about professional experiences and demographic data. The second was the Cancer Pain Knowledge Questionnaire, which was developed at the University of Wisconsin-Madison. For this instrument, the sum of correct answers yields a cancer pain knowledge score. The 3AS statistical package was used to analyze the data. An a level of 0.05 was chosen as the level of significance.
A total of 209 students were eligible to participate in this study: 82 completed the study for a response rate of 28%. The low response rate may be attributed to conflicting interests and responsibilities during the time the questionnaire was being distributed. Also, those who were not interested in cancer pain or believed their knowledge to be inadequate to complete the questionnaire may not have volunteered to be in the study. The male (5%) to female (95%) ratio was expected since the majority of people in the nursing profession are female. The ages of the participants ranged from 20 to 44 years with a mean of 25 and mode of 22. The educational level was predominantly (83%) high-school completion. The appendix lists the responses to the Cancer Pain Knowledge Questionnaire. The data analysis does not support a significant difference between the perception of adequate knowledge of cancer pain management and cancer pain knowledge scores. only 12% of the participants thought their hrmwledge of cancer pain management was adequate. No significant difference in cancer pain knowledge scores was found between those who thought they did possess adequate
til. 7 No. 8 Nazmker 1992
cancer pain knowledge and those who did
not. The cancer pain knowledge scores ranged from 24% to 76%, with a mean of 49%. Although the students had a realistic perspective about the severity and prevalence of cancer pain and psychological dependence, specific factual knowledge deficits and negative attitudes were identified. Seventy-three percent of the student nurses underestimated the potential efficacy of treatment. Although 62% of the students believed that the majority of cancer patients are undermedicated, 29% believed that maximai analgesic therapy should be given to patients with a prognosis of less than 12 months, and 28% believed the prognosis should be less than 6 weeks. A full 55% believed that increasing cancer pain was related to tolerance rather than to the progression of the disease. The preferred route of administration was intravenous (58%) rather than oral. Thirty-seven percent of the students believed that the degree of respiratory depression, rather than constipation, would not decrease with repeated administration of an opioid. Only age was associated with higher levels of cancer pain knowledge (P = 0.001). Most of the participants reported working with cancer patients in chronic pain occasionally. They reported an average of three personal experiences with cancer pain in the last 5 years. T’wenty-one percent of the participants reported attending at least one seminar or workshop on cancer pain management during the last 5 years (Table 1). The majority of the student nurses (64%) read at least one journal article on cancer pain management during the same time period. Time reading journal articles was significantly associated with attendance at seminars or workshops (P= 0.0001) and education (P= 0.04). There was also an association between education and age (P = 0.0001). The majority of the participants (70%) could not identify a particular person as a source for obtaining information on cancer pain management. Of the remaining 30%, the majority (52%) identified a practicing registered nurse and 28% identified a nursing instructor as the resource person. Other resource people included physician, student nurse, and clini-
Seminars/workshops 0 1 2
attended
Journal articles read
79% 14% 7%
N= 81
0 1 2 3 4 5 10
36% 21% 19% 11% 6% 5% 2% N=82
cal specialist. Table 2 lists spec c ways for nurses to increase their kn management. Se chosen by the majon (55%). Other sugge ti~ns of the listed ac ences witb cancer paaents. the participants reported reading at least one title on cancer pain professional journal management during past 5 years, only 6% identified this activity nurses to increase the topic. Only 13% of n management thought that cancer should be taught as curriculum.
Although the knowledge to treat cancer pain exists, this study suggests that there is a knowledge deficit among graduating baccalaureate student nurses. The majority could not identify a source for obtaining information on cancer pain management, although 12% thought that this was the best way for nurses to increase their knowledge of cancer El& 2 J3estWarytokrease gnowledge Activity
%
In classas partOFcIlrriculum
!3
Independent study Professional journals Discussion with resource person Seminar/workshop Other N= 32
3 6 12 55 11
Resource person identified Nursing in ctor Practicing Physician Student nurse Clinical specialist
28% 52% 12% 4% 4%
N= 25
thought
best way for nurses to increase their knowledge of men& but ‘79% had not attended a wor op or seminar on cancer
tion about pain management at tbe undergies for educators, as e form of organizations
tion recommen er pain be incorporated into nursing medical school cunicula.20 It is imperative that nursing educators provide their students with both the content and a sense of responsibility for managing issman suggests the use of cancer pain. was also recomrole models,“8 and thfs asintheformof mended by Mooney and an independent study option in cancer nursing at the undergraduate level.lg These programs could potentially increase knowIedge and skills, and thereby decrease nurses’ feelings of helplessness.16 Nurses most often obtain knowledge about analgesics through clinical experience and seEinitiated learning rather than from basic education, thus increasing the need for mentors and role models.11*17 The ONS addressed the importance of improved pain management by identifying “comfort” as the fourth standard of care for oncology nursing practice and by issuing a position paper on cancer pain management
Kopchak She&n et al.
482
in 1990.21322Pain was rated third as a research priority in a survey of 700 ONS members.23 As a result of this survey, the ONS offered workshops in pain management nationwide during 1989-1991. The ONS has also formed a special interest group on the topic of cancer pain. These activities and other programs at state and local levelss4 may provide increasing opportunities for education in this area. There is a clear need for nurses who are experts in cancer pain management to educate other nurses. Opportunities are available through formal seminars and workshops as well as informal discussions and in-service programs in the clinical arena. It is important for nurses who work with oncology patients to become involved with groups to support their educational needs. Nurses who are expert in cancer pain management should become actively involved as consultants in cmriculum development in colleges of nursing.
Kd 7 No. 8 Novtw&r I992
9. Weissman DE, Dahl JL. Attitudes about cancer pain: a survey of Wisconsin’s first-year medical students. J Pain Symptom Manage 1990;5:34.5-349. 10. Diekmann JM, Wassem RA. A survey of nursing students’ knowledge of cancer pain control. Cancer Nurs 1991;6:314-320. 11. Graffam S. Pain content in the curriculum: a survey. Nurse Educ 1990;15:26-23. 12. Mioduszewski J, McCray N. The evolving role of the oncology nurse in managing cancer pain. Sem Oncol Nurs 1985;1:123-125. 13. Spross J, MC&ire D, Schmitt R Oncology Nursing Society position paper on cancer pain. Oncol Nurs Forum 1990;17:751-760. 14. Degner L, Fujii S, Levitt M. Implementing a program to control chronic pain of malignant disease in an extended care facility. Cancer Nurs 1982;5:263-268. 15. Bruera E, Fox R, Chadwick S, Brenneis C, MacDonald N. Changing patterns in ‘the treatment of pain and other symptoms in advanced cancer patients. J Pain Symptom Manage 1987;2:139-144. 16. CraytorJ, Brown J, Morrow G. Assessing learning needs of nurses who care for persons with cancer. Cancer Nurs 1978;1:211-220.
1. Daut R, Cleeland C. The prevalence and severity of pain in cancer. Cancer 1982;50:1913-1918.
17. Cohen F. Postsurgicai pain relief: patient status and nurses’ medication choices. Pain 1980;9:265274.
2. Takeda F. Results of field testing in Japan of the WHO draft interim guidelines on relief of cancer pain. Pain Clin 1986;1:83-89.
18. Weissman DE. Cancer pain education: a call for role models. J Clin Oncol 1988;6:1793-1794.
3. Spross J. Cancer pain and suffering: clinical lessons from lie, literature and legend. Oncol Nurs Forum 1985;12:23-31.
19. Mooney M, Ludas S. Undergraduate independent study in cancer nursing. Oncol Nurs Forum 1987;14:51-53.
N, McCaffery M. Pain: A nursing approach to assesment and analysis.East Norwalk,
20. World Health Organization pain relief. Geneva: WHO, 1986.
4. Meinhart
CD Appleton-Century-Crofts,
(WHO).
Cancer
1983.
5. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1975;173-181.
21. Oncology Nursing Society. Outcome standards for cancer nursing practice. Ransas City: American Nurses’ Association, 1979.
22. Spross JA, McGuire DB, Schmitt RM. Oncology
6. Hauck S. Pain: Problem for the person with cancer. Cancer Nuts 1986;9:66-76.
Nursing Society position paper on cancer pain. Oncol Nurs Forum 1990;17:595-614.
7. Myers J. Cancer pain assessment of nurses’ knowledge and attitudes. Oncol Nurs Forum 1985; 1262-66.
23. Funkhouser S, Grant M. 1988 ONS survey of research priorities. Oncol Nut-s Forum 1989;16:413416.
8. Weissman DE, Dahl JL. Cancer pain-attitudes and knowledge among Wisconsin medical students [abst 691. J Pain Symptom Manage 1988;3 (suppl):S28.
24. DahlJ, Joranson D, Engber D, et al. The cancer pain problem: Wisconsin’s response-a report on the Wisconsin Cancer Pain Initiative. J Pain Symp tom Manage 1988;3(suppl):l-20.
Vol.7 No. 8 Noumber I992
I feel I have managing cant True Palse
Cancer Paiaiaz KnowLt?dge Among Nurses
te knowledge
What percentage of cancer think suffer pain at some po illness? 20% 40% 60% “80% IOO%
Frequently I2 88
6 40 49
ntage of cancer patients. do you r pain longer than 1 mon 6 7 40% 60% 26 48 “80% 13 100% at percentage of cancer-related pain do you think can be relieved with appropriate treatment with anti-cancer drugs, radiation therapy, and/or pain-relieving drugs? 17 20% 22 40% 34 60% 25 *so% 2 100% In your opinion, which of the following statements best describes the use of painrelieving medications for cancer pain in the United States at the present time? 29 Most patients receive adequate treatment for pain Patients receive more pain 9 medication than necessary 62 “The majority of patients in pain are under-medicate Psychological dependen narcotics as a result of prescribed by a physician to patients with cancer-related pain occurs 7 Very frequently * Preferred answer.
483
17 36 40
an overdose of narcotic drugs appropriately to control cancerI 5 42 52 dge of the intensity of 1 0 95 4 a family member of yours is given more to control cancer-related pain, what ern would you have about your family member becoming addicted? * 34 44 15 7 At what stage would you feel it is ap for a patient to receive maximum therapy with pain relievers for severe pain? 36 ‘Prognosis less than 24 months 29 Prognosis less than 12 months Prognosis less than 6 weeks 28 7 Prognosis less than 1 week When a cancer patient develops pain, it is most likely due to: 12 Treatments for cancer 88 *Cancer itself 0 Preexisting conditions se often in is a subjective res accompanied by considerable anxiety, 5 It cannot be measured quantitatively 9I “Nurse must believe patient’s report of pain 2 Patients should be encouraged to endure it without medication 2 Treatment should be with antianxiety drugs
484
KopchakSheehanet aL
When a cancer patient requests increasing amounts of analgesia to control pain, this usually indicates 1 Patient is psychologically addicted 0 Patient is acting like he is ill when he is not 42 *Patient is experiencing increasing pain 2 Patient is experiencing increasing anxiety/depression 55 Patient has developed tolerante to the drug Pain is better controlled when analgesics are administered aroung the clock rather than each time the patient asks for the medication. 90 *True 10 False Giving the patient sterile water is often a useful test to determine if the pain is real. 20 True 80 *False
Ir,l. 7 No. 8 Nowmber 1992
The incidence of psychological dependence as a result of the legitimate use of narcotic pain relieving drugs in cancer patients with pain is 17 *Iess than 1 in 10 One in 10 to 1 in 100 42 One in 100 to 1 in 1000 25 16 Greater than 1 in 1000 The preferred route of administration of narcotic pain relievers to patients with cancer-related pain is 58 Intravenous 16 Intramuscularly 1 Subcutaneously *orally 25 0 Rectally After repeated administration of narcotics, the degree of side effects of all but one side effect will decrease I8 Sedation Nausea 21 *Constipation 24 Respiratory depression 37
Journal ofPain and Symptom Management
vel
Vol.7 No. 8 November 1992
ofCancer
Baccalaureate Denice Kopchak Sheehan, RN, Adele Webb, PhD, Dolores Bower, PhD, and Richard Einsporn, PhD Hospiceofthel%sternResente,Mentor(D.K.S.); and theUniversity of Akron (A.@!,D.B., RE.), Akron, Ohio
I~&quate nursing education is a major impediment to effectivepain relieffm cancer patients throughout the world. This study was conducted to identify the level of cancer pain knowledgeamong baccalaureatestudent nurses and to d&ermine whetherspecific a-&&tiesaflect this level of knowledge.Two questionnaireswereadministered to 82 baccalaureatestudat nurses in the final course of their program. Although the students displayeda realisticperspectiveabout the severityand pr~alence of cancerpain and p~chological dependence, specijicknowledgedeficitsand negative attitudessuggest the possibilityof ina&quate pain management. Specifically,the students believedthat (a) maximal analgesic therapyshould be &layed until thepatient’sPrognosiswas less than 12 months; (6) theproptiion of@ztimts whosepain can be controlledby appr@riaS therapy is less than ti possible;(c) increasing pain is relatedto tolerancerather than to progressionof the disease; (d) the preferredroute of administration is intravenous rather than oral; and (e) the &gree of respiratq depression, rather than constipation,&es not decreasewith repeatedadministration. Significant positivecorrelations(P I 0.05j were found betweenage and cancer pain knowledgeand betweenattendance at seminars/ workshopsand time spent reading professional journal articles.Of the 30% of the participants whoperceived a particular person to be a sourcefor obtaining infmmation about cancer pain management, 52 % spe#ed a practicing registerednurse. Seminars and workshopswerechosen by 59% of the students as the mosteflectiveway ,for nurses to increase their knowbzdp. This study suggestsa needfor basic cancerpain mazug_mwnt education at the undergaduate levelas well as continuing education through seminars and workshops.J Pain Symptom Manage 1992; 7:4 78-484.
eYW&
Cancer pain, nursing education
AddraFsreprint requests to: Denice Sheehan, RN, Hospiceof the WesternReserve,5786 Heisley Road, Mentor,OH 44060. Acc+btedforpublica~~ion: July 31.1992.
In 1986, the World Health Organization estimated that at least 3.5 million people suffer from cancer pain every day, and that 25% of such patients die without obtaining pain relief.’ Although analgesic therapy is capable of controlling pain in up to 90% of
Q U.S. Cancer Pain Relief Committee, 1992 Published by Elsevier, New York, New York
08853924/92/$5.00
the fact that no single health profession for pain control; each e i.dentiQ the problem and Nurses spend many hours interac their patients and so are in a pivo to assess the patient’s pain, hrte priately to relieve the pain, and evaluate the effectiveness of the intervention. Unfortunately numerous smveysS7Jo suggest that medical and nursing students and practicing nurses tial in this an first-year medical students have a realistic knowledge of the causes and duration of cancer pain, as well as its incidence, but that less than 50% of graduating students could correctly answer simple questions about opioid pharmacology and t0xicity.s In a later study, Weissman aud ftrst-year students prior to their entry into medical school have negative attitudes redependence, adegarding psychologic ic therapy, cause of increasing quate anal te time to begin pain, and maximum tolerated analgesic “aPYs9 Similarly, Diekmann and sem noted that 83% of student nurses reported that they did not have adequate knowledge about cancer pain management. Although most of the respondents correctly identified the prevalence and duration of cancer pain, and the reality of undermedication, most had inadequate knowledge about the potential efficacy of treatment, the most appropriate time tO begin analgesic therapy, psychological dependence, opioid side effects, and preferred route of administration.*0 Graffam surveyed 305 randomly selected baccalaureate nursing programs and found that only 8% reported having someone on the faculty who specializes in pain management. The presence of an expert did ot influence the curriculum oduszewski and McCray surcontentl* veyed 12 nurses and found that preparation for the role of cancer pain management
(ONS) published a pain, which specific uate, and contiuuing education for nurses, as and pubhc information.
curricuhun c0utent related to cancer pain and its management. ~p~ort~~~~es should exist for nurses to develop corn areas of cancer pain assessment, management, and evaluation. A research component should k added at the graduate level. The position paper clearly states the importance g future nurses “to a r0le assessment and manageme pain and pain control regimens as an abs0 lute, irrefutable, professional, and ethical responsibility.“13 The effect of professional education on pain management h also been studied in the chnical settin education pro on cancer pain management was useful in decreasing nurses’ concerns about respiratory depression, addiction, and sedation;14 this pr also increased knowledge of
to 1984, Bruera and colleagues found a significant increase in nurses’ notes of references to painI which was ascribed to a higher level of interest in pain control. The present study was undertaken to identify the level of cancer pain knowledge among baccalaureate student nurses and to determine whether specific activities affect the level of cancer pain knowledge. In the context of the aforementioned studies, this information may be able to clarify the prqges that has been made in the education of nurses and the needs for additional efforts.
A descriptive correlational design was used in this study; The sample was taken from three colleges, which were randomly selected
480
Kopckak Skeekam et al.
from the seven National League of Nursingaccredited baccalaureate nursing programs in northeastern Ohio. The participants were student nurses in the find course of their program. The study was approved by the Institutional Review Board of the University of Akron. Permission to collect data was obtained in person after the investigator met with each dean of the selected programs. Each participant completed two questionnaires. The first was a Demographics/Activities Questionnaire, which elicited information about professional experiences and demographic data. The second was the Cancer Pain Knowledge Questionnaire, which was developed at the University of Wisconsin-Madison. For this instrument, the sum of correct answers yields a cancer pain knowledge score. The 3AS statistical package was used to analyze the data. An a level of 0.05 was chosen as the level of significance.
A total of 209 students were eligible to participate in this study: 82 completed the study for a response rate of 28%. The low response rate may be attributed to conflicting interests and responsibilities during the time the questionnaire was being distributed. Also, those who were not interested in cancer pain or believed their knowledge to be inadequate to complete the questionnaire may not have volunteered to be in the study. The male (5%) to female (95%) ratio was expected since the majority of people in the nursing profession are female. The ages of the participants ranged from 20 to 44 years with a mean of 25 and mode of 22. The educational level was predominantly (83%) high-school completion. The appendix lists the responses to the Cancer Pain Knowledge Questionnaire. The data analysis does not support a significant difference between the perception of adequate knowledge of cancer pain management and cancer pain knowledge scores. only 12% of the participants thought their hrmwledge of cancer pain management was adequate. No significant difference in cancer pain knowledge scores was found between those who thought they did possess adequate
til. 7 No. 8 Nazmker 1992
cancer pain knowledge and those who did
not. The cancer pain knowledge scores ranged from 24% to 76%, with a mean of 49%. Although the students had a realistic perspective about the severity and prevalence of cancer pain and psychological dependence, specific factual knowledge deficits and negative attitudes were identified. Seventy-three percent of the student nurses underestimated the potential efficacy of treatment. Although 62% of the students believed that the majority of cancer patients are undermedicated, 29% believed that maximai analgesic therapy should be given to patients with a prognosis of less than 12 months, and 28% believed the prognosis should be less than 6 weeks. A full 55% believed that increasing cancer pain was related to tolerance rather than to the progression of the disease. The preferred route of administration was intravenous (58%) rather than oral. Thirty-seven percent of the students believed that the degree of respiratory depression, rather than constipation, would not decrease with repeated administration of an opioid. Only age was associated with higher levels of cancer pain knowledge (P = 0.001). Most of the participants reported working with cancer patients in chronic pain occasionally. They reported an average of three personal experiences with cancer pain in the last 5 years. T’wenty-one percent of the participants reported attending at least one seminar or workshop on cancer pain management during the last 5 years (Table 1). The majority of the student nurses (64%) read at least one journal article on cancer pain management during the same time period. Time reading journal articles was significantly associated with attendance at seminars or workshops (P= 0.0001) and education (P= 0.04). There was also an association between education and age (P = 0.0001). The majority of the participants (70%) could not identify a particular person as a source for obtaining information on cancer pain management. Of the remaining 30%, the majority (52%) identified a practicing registered nurse and 28% identified a nursing instructor as the resource person. Other resource people included physician, student nurse, and clini-
Seminars/workshops 0 1 2
attended
Journal articles read
79% 14% 7%
N= 81
0 1 2 3 4 5 10
36% 21% 19% 11% 6% 5% 2% N=82
cal specialist. Table 2 lists spec c ways for nurses to increase their kn management. Se chosen by the majon (55%). Other sugge ti~ns of the listed ac ences witb cancer paaents. the participants reported reading at least one title on cancer pain professional journal management during past 5 years, only 6% identified this activity nurses to increase the topic. Only 13% of n management thought that cancer should be taught as curriculum.
Although the knowledge to treat cancer pain exists, this study suggests that there is a knowledge deficit among graduating baccalaureate student nurses. The majority could not identify a source for obtaining information on cancer pain management, although 12% thought that this was the best way for nurses to increase their knowledge of cancer El& 2 J3estWarytokrease gnowledge Activity
%
In classas partOFcIlrriculum
!3
Independent study Professional journals Discussion with resource person Seminar/workshop Other N= 32
3 6 12 55 11
Resource person identified Nursing in ctor Practicing Physician Student nurse Clinical specialist
28% 52% 12% 4% 4%
N= 25
thought
best way for nurses to increase their knowledge of men& but ‘79% had not attended a wor op or seminar on cancer
tion about pain management at tbe undergies for educators, as e form of organizations
tion recommen er pain be incorporated into nursing medical school cunicula.20 It is imperative that nursing educators provide their students with both the content and a sense of responsibility for managing issman suggests the use of cancer pain. was also recomrole models,“8 and thfs asintheformof mended by Mooney and an independent study option in cancer nursing at the undergraduate level.lg These programs could potentially increase knowIedge and skills, and thereby decrease nurses’ feelings of helplessness.16 Nurses most often obtain knowledge about analgesics through clinical experience and seEinitiated learning rather than from basic education, thus increasing the need for mentors and role models.11*17 The ONS addressed the importance of improved pain management by identifying “comfort” as the fourth standard of care for oncology nursing practice and by issuing a position paper on cancer pain management
Kopchak She&n et al.
482
in 1990.21322Pain was rated third as a research priority in a survey of 700 ONS members.23 As a result of this survey, the ONS offered workshops in pain management nationwide during 1989-1991. The ONS has also formed a special interest group on the topic of cancer pain. These activities and other programs at state and local levelss4 may provide increasing opportunities for education in this area. There is a clear need for nurses who are experts in cancer pain management to educate other nurses. Opportunities are available through formal seminars and workshops as well as informal discussions and in-service programs in the clinical arena. It is important for nurses who work with oncology patients to become involved with groups to support their educational needs. Nurses who are expert in cancer pain management should become actively involved as consultants in cmriculum development in colleges of nursing.
Kd 7 No. 8 Novtw&r I992
9. Weissman DE, Dahl JL. Attitudes about cancer pain: a survey of Wisconsin’s first-year medical students. J Pain Symptom Manage 1990;5:34.5-349. 10. Diekmann JM, Wassem RA. A survey of nursing students’ knowledge of cancer pain control. Cancer Nurs 1991;6:314-320. 11. Graffam S. Pain content in the curriculum: a survey. Nurse Educ 1990;15:26-23. 12. Mioduszewski J, McCray N. The evolving role of the oncology nurse in managing cancer pain. Sem Oncol Nurs 1985;1:123-125. 13. Spross J, MC&ire D, Schmitt R Oncology Nursing Society position paper on cancer pain. Oncol Nurs Forum 1990;17:751-760. 14. Degner L, Fujii S, Levitt M. Implementing a program to control chronic pain of malignant disease in an extended care facility. Cancer Nurs 1982;5:263-268. 15. Bruera E, Fox R, Chadwick S, Brenneis C, MacDonald N. Changing patterns in ‘the treatment of pain and other symptoms in advanced cancer patients. J Pain Symptom Manage 1987;2:139-144. 16. CraytorJ, Brown J, Morrow G. Assessing learning needs of nurses who care for persons with cancer. Cancer Nurs 1978;1:211-220.
1. Daut R, Cleeland C. The prevalence and severity of pain in cancer. Cancer 1982;50:1913-1918.
17. Cohen F. Postsurgicai pain relief: patient status and nurses’ medication choices. Pain 1980;9:265274.
2. Takeda F. Results of field testing in Japan of the WHO draft interim guidelines on relief of cancer pain. Pain Clin 1986;1:83-89.
18. Weissman DE. Cancer pain education: a call for role models. J Clin Oncol 1988;6:1793-1794.
3. Spross J. Cancer pain and suffering: clinical lessons from lie, literature and legend. Oncol Nurs Forum 1985;12:23-31.
19. Mooney M, Ludas S. Undergraduate independent study in cancer nursing. Oncol Nurs Forum 1987;14:51-53.
N, McCaffery M. Pain: A nursing approach to assesment and analysis.East Norwalk,
20. World Health Organization pain relief. Geneva: WHO, 1986.
4. Meinhart
CD Appleton-Century-Crofts,
(WHO).
Cancer
1983.
5. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1975;173-181.
21. Oncology Nursing Society. Outcome standards for cancer nursing practice. Ransas City: American Nurses’ Association, 1979.
22. Spross JA, McGuire DB, Schmitt RM. Oncology
6. Hauck S. Pain: Problem for the person with cancer. Cancer Nuts 1986;9:66-76.
Nursing Society position paper on cancer pain. Oncol Nurs Forum 1990;17:595-614.
7. Myers J. Cancer pain assessment of nurses’ knowledge and attitudes. Oncol Nurs Forum 1985; 1262-66.
23. Funkhouser S, Grant M. 1988 ONS survey of research priorities. Oncol Nut-s Forum 1989;16:413416.
8. Weissman DE, Dahl JL. Cancer pain-attitudes and knowledge among Wisconsin medical students [abst 691. J Pain Symptom Manage 1988;3 (suppl):S28.
24. DahlJ, Joranson D, Engber D, et al. The cancer pain problem: Wisconsin’s response-a report on the Wisconsin Cancer Pain Initiative. J Pain Symp tom Manage 1988;3(suppl):l-20.
Vol.7 No. 8 Noumber I992
I feel I have managing cant True Palse
Cancer Paiaiaz KnowLt?dge Among Nurses
te knowledge
What percentage of cancer think suffer pain at some po illness? 20% 40% 60% “80% IOO%
Frequently I2 88
6 40 49
ntage of cancer patients. do you r pain longer than 1 mon 6 7 40% 60% 26 48 “80% 13 100% at percentage of cancer-related pain do you think can be relieved with appropriate treatment with anti-cancer drugs, radiation therapy, and/or pain-relieving drugs? 17 20% 22 40% 34 60% 25 *so% 2 100% In your opinion, which of the following statements best describes the use of painrelieving medications for cancer pain in the United States at the present time? 29 Most patients receive adequate treatment for pain Patients receive more pain 9 medication than necessary 62 “The majority of patients in pain are under-medicate Psychological dependen narcotics as a result of prescribed by a physician to patients with cancer-related pain occurs 7 Very frequently * Preferred answer.
483
17 36 40
an overdose of narcotic drugs appropriately to control cancerI 5 42 52 dge of the intensity of 1 0 95 4 a family member of yours is given more to control cancer-related pain, what ern would you have about your family member becoming addicted? * 34 44 15 7 At what stage would you feel it is ap for a patient to receive maximum therapy with pain relievers for severe pain? 36 ‘Prognosis less than 24 months 29 Prognosis less than 12 months Prognosis less than 6 weeks 28 7 Prognosis less than 1 week When a cancer patient develops pain, it is most likely due to: 12 Treatments for cancer 88 *Cancer itself 0 Preexisting conditions se often in is a subjective res accompanied by considerable anxiety, 5 It cannot be measured quantitatively 9I “Nurse must believe patient’s report of pain 2 Patients should be encouraged to endure it without medication 2 Treatment should be with antianxiety drugs
484
KopchakSheehanet aL
When a cancer patient requests increasing amounts of analgesia to control pain, this usually indicates 1 Patient is psychologically addicted 0 Patient is acting like he is ill when he is not 42 *Patient is experiencing increasing pain 2 Patient is experiencing increasing anxiety/depression 55 Patient has developed tolerante to the drug Pain is better controlled when analgesics are administered aroung the clock rather than each time the patient asks for the medication. 90 *True 10 False Giving the patient sterile water is often a useful test to determine if the pain is real. 20 True 80 *False
Ir,l. 7 No. 8 Nowmber 1992
The incidence of psychological dependence as a result of the legitimate use of narcotic pain relieving drugs in cancer patients with pain is 17 *Iess than 1 in 10 One in 10 to 1 in 100 42 One in 100 to 1 in 1000 25 16 Greater than 1 in 1000 The preferred route of administration of narcotic pain relievers to patients with cancer-related pain is 58 Intravenous 16 Intramuscularly 1 Subcutaneously *orally 25 0 Rectally After repeated administration of narcotics, the degree of side effects of all but one side effect will decrease I8 Sedation Nausea 21 *Constipation 24 Respiratory depression 37
