The aim of this project is to a literature review to emphasize the occurrence of inadequate assessment of pain in cancer patients and to identify the significant role of the nurse in the modern multi-professional team in delivering pain treatments for cancer patients. Pain is one of the most prevalent and distressing symptoms in patients with advanced cancer. Almost 70% of patients with cancer experiences pain at a point through the progression of their diseases. Even though most patients achieve adequate pain control, patients with more complex pain syndromes continues to fail to obtain adequate pain management, Fainsinger et al (2010)
The Literatures searches was carried out on a major data base through journal and researched publications relating to the subject the role of the nurse in effective cancer pain assessment. However, 5 main articles were critically analysed using the Critical Analysis Framework.
176 of papers of potential interest were identified through database searching and 4 additional records identified from other books and publications. Out of these 180 literatures, 79 were found to be duplication. The quality of these literatures were each critically analysed and evaluated using the framework for critical Appraisal research tool. Using these criteria, I identify 25 literatures search as not directly appropriately related to the topic cancer pain but rather authors writing about various issues on cancer diseases. 20 results were eliminated as they were also directly linked with children or the palliative care.
Finally, 8 core articles were carefully selected as the core articles for this project as they provide recommendations through consensus to provide a useful cancer-related evidenced base pain guide for practice.
Further research and education need to be carried out in supporting clinicians particularly, the nurses who are in constant contact with cancer patients. These training and support will enhance the effectiveness of implementing cancer pain assessments and treatments to patients thereby increasing service quality and controls the output of front line workers.
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The Need To Improve Nursing Practice
Development in medical research and treatments has enhanced the survival rate of cancer patient by at least five years in a number of cancer type. Conversely, pain syndromes from chemotherapy, radiotherapy, surgery or interventional procedures persist to have a large effect on cancer patients’ survivors’ quality of life. This makes it obvious that nurses are uniquely placed in healthcare and have a duty of care in pain assessment for cancer patients and to make sure that pain management strategies are initiated to improve patient’s life, Chapman (2011).
The need to change clinical practice demands healthcare practitioners to regularly develop and enhance their knowledge and skills to make sure they are abreast with best practices. Nursing research consequently focuses on knowledge that is useful in the practice by creating knowledge that influence best clinical practice Burns & Grove (2006). Nurses need to continually look for solutions, choices and outcomes for patients that represent the best available knowledge to constantly improve and validate nursing care, Polit and Beck (2009) .The emergence of evidence-based practice and the development of an evidence base for nursing, the pressure to introduce mechanisms for continuous quality improvement and its associated emphasis on outcome measures, together with the development of practice review techniques, are not accidents of fate. They all reflect a desire to deliver the best nursing care as possible. Pearson, Field and Jordan (2007)
1.1 The Rational for the Topic
The purpose of this dissertation is to explore recent literature reviews which focuses on nursing practice aimed at identifying gaps in cancer pain assessments and management. To be able to achieve this, I will be demonstrating personal competency in analysing and critiquing available literatures and evaluate their impact on healthcare practice.
The chosen topic for this dissertation is cancer pain assessments and management. This is a very interesting topic as there is still more knowledge to be explored. The rationale for this selection is in twofold: first and foremost, this is a topic of personal interest. Having cared for a family member experienced pain during cancer ill health and again coming into contact with patients suffering from aggressive cancer pain as a student nurse in placements have further promoted my passion and interest around the topic. Lastly, by writing this thesis it is hoped to further enhance personal knowledge and skills in the nursing profession required to understand, manage and assess oncology pain effectively in preparation to becoming a qualified nurse.
My primary goal is to discuss and analyse the role of the nurse and other multidisciplinary team involved in delivery an evidenced based care in meeting the holistic assessment of pain for the adult cancer patients. I will also look at barriers that prevent effective pain assessment and finally research for literature reviews from World Health Organisation and the national guidelines, policies and recommendation that underpins the assessment and management of oncology pain. To achieve these objectives, a literature search was conducted.
1.2 Search Strategy
Polit et al (2006) argued that the aim of carrying out a literature search differs from one researcher to the other. However the Nursing Times (2007) identified another rationale for conducting a literature search by stating that literature search a well thought and organized search for all of the obtainable literatures available on a chosen topic. They further went on to say that a thought through literature search is the most valuable and well-organized way to search for sound evidence on the topic in question. These evidence based literatures were researched in books, journals, government documents and the electronic data base. The purpose for conducting literature search for this project is to enable me to obtain articles needed for this piece of work and finally to draw together more information on the chosen subject in order to make an informed discussion in building up knowledge for transition into my future practice. There following inclusion criteria were deployed in assisting to get the most of up to date related literature.
Secondary research articles
Literatures from 2005 – 2012
Literatures relevant to the chosen topic
In setting these inclusion criteria under consideration the literature searching started from the OVID database, searching through CINDHL (Cumulative Index to the Nursing and Allied Health Literature), MEDLINE and the BNI (British Nursing Index).
The literature searching commence with the electronic search on data bases such as psyINFO, Medline and CINAHL as these databases contain a rich and resourceful information on health and the social sciences as indicated by Gerrish and Lacey (2006). Boolean Operators was used to give the search engine the key words to either include or exclude Ely and Scott (2007). These are AND, OR and NOT. AND or NOT which turn to narrow the search whiles OR broadens it. This Boolean Operating system was employed in combining the appropriate keywords to aid in looking up for literature review.
The Key words are as follows:
Cancer pain experience,
suffering in cancer.
Terminal cancer care,
Chronic cancer care
Nursing role and interventions in cancer pain.
The results were then combined and narrowed down to meet the research subject. This search focused on the identification of qualitative literatures relevant to the experience of cancer pain. The research period is from 2005-2012 in order to obtain an up- to -date literature to improve practice.
Subsequently, further research was carried out through the Internet, accessing the Wiley online library, World Health Organization and The oncology Nursing ISociety ,British pain Society website, and various Nursing Journals online. In addition specialist Journals available in the nursing library and discussions with specialist nurse practitioners and course tutors were used. The university library was used at length and assistance obtained from the librarians with expertise of doing searches some limitations of the electronic searches were encountered.
The importance of using many approaches to identify appropriate literatures was emphasized by Greenhalgh and Peacock (2005) .This process was followed in aiding me to make look up for reference lists in journals which gave me useful insight into the topic. Hand searches were also sorted from related journals and publications from health institutions such as the National Institute for Clinical Excellence, Department of Health on the topic cancer pain, by going through the content pages for relevant articles.
1.3 Inclusion and Exclusion Criteria
I set an appropriate criterion to assists me in focusing on the project topic, as explained in Aveyard (2010). The exclusion and inclusion criterion sets the limits for my review and therefore helped guide me in staying focused within the select subject.
In setting the inclusion criterion, secondary data research was used extensively and publications researched in English focussing on the cancer pain assessment and how the nurse can improve pain assessment for cancer patients.
The literature review aim to stress and identify areas of unending poor practices or gaps in care delivery to aid in discussing knowledge and evidence based practice in managing cancer pain. The Nurses and Midwifery Council (2002) also necessitate a registered nurses to keep up with their professional knowledge and competency on up to date evidence, best practice and if possible bases on applicable available validated research Valente (2003).
This desired practice can be successful when nurses and midwifes build up attitude and an understanding of the need to carry out research process and demonstrate the ability to research and critically question research Ingham-Broomfield (2007)
Many studies of cancer pain occurrence have demonstrated that about 30%-50% of patients in receive of cancer treatment experience pain with advanced disease as indicated by Abernethy, Samsa and Matchar (2003). The World Health Organization (WHO), reported that the gradual increased incidence of cancer in 2008 was 12 667 470 and based on this figures, the incidence of cancer will be >15 million in 2020. Suggesting that the incidence of cancer pain will continue to rise if appropriate measures and interventions are not put in place by then.
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British Pain Society (2010) reported that pain is a major indication of all stages in cancer conditions. This pain experience or symptom can be the first signal to patients with cancer and may be an indication of relapse after curative treatment which many patients with metastatic disease may present due to suboptimal pain treatment. Kassa (2010) indicated that many patients with cancer are continuously complaining that pain is the symptom they mostly fear and that they hypothetically think of seeking for euthanasia in a state of unbearable pain which makes life difficult for them. This report further indicating that pain associated with cancer continues to be a huge health problem for patients and may presents a major health issue to the society and the Nation as a whole.
In UK, it been found that two million people have cancer or have lived with cancer experiencing pain It has been shown by study that this number of pain with cancer continue to rise annually by 3%.
Despite many aware and published guidelines and educational programs on the assessment and treatment of cancer-related pain, pain continues to be a substantial worldwide public health concern in patients with either solid or haematological malignancies British pain Society (2010). Patients with long-term cancer pain have been found to report poorer health, functional or psychological disability as a result of their cancer pain. Macmillan Cancer Support (2008).
==Laird and Colvin (2008) added that cancer-related pain is a huge public health issue and represents a significant challenge to patients and healthcare professionals. Pain in cancer patients may be down to pre-existing pathologies, progression of the disease, tumour growth, bone metastases (cancer-intduced bone pain, CIBP) or the treatment of cancer itself (Strong 2002; Twycross 2008; Urch 2008). These writers concluded that pain due to metastatic cancer is often severe, unrelieved and poorly controlled with patients often having to take high doses of drugs with undesirable side-effects. Gralow andTripathy (2007) further found that up to 70% of patients with cancer-related pain do not receive adequate pain relief and this affects physical and psychological well-being, leading to a lower quality of life for the cancer patients.
A another report indicated that a about33.3% of cancer patient exprience pain. This perecentage rises to 75% in the advanced stages of the disease and further attempt to reduce pain and hence improve the ability to perform basic daily life activities and quality of life have been overshadowed in the attempts to cure the underlying disease, Scottish Intercollegiate Guidelines Network life and functional ability (2008).
Chapman (2012) affirm that cancer pain has many dimensions including psychological, physical, social and spiritual which must be addressed in order to improve their quality of life.
According to a systematic study by Kessels et al (2007) indicated that pain prevalence ranges from 33% in patients after curative treatment to 59% in patients on anticancer treatment and to 64% in patients with metastatic, advanced or terminal phase. Sun, Borneman and Piper (2008) explained the factors that influence the development of chronic pain in cancer survivors who have completed treatment as peripheral neuropathy due to chemotherapy, radiation-induced brachial plexopathy, chronic pelvic pain secondary to radiation and postsurgical pain.
Moreover, another systematic review of literature showed that nearly half of cancer patients were under-treated, with a high variability across study designs and clinical settings. Finally recent studies conducted both in Italy and pan European by Breivik, Cherny and Collett (2009) confirmed and makes it clearly evident that different types of pain or pain syndromes are prevalent in all phases of cancer and are not adequately treated or managed.
2.1 Definition of Pain
Pain is difficult to define due to the complexity of its anatomical and physiological foundations, and the experience and the perceptions of each individual person and the social and cultural meanings of pain Pas and Seymour (2008). In contrast, McCaffery (1972) defined pain as ‘whatever the experiencing patient says it is, and exists whenever he says it does ‘This old but useful definition of pain is well known and still relevant to practitioners. However, the British pain society (2006) also described pain in a more functional way as an unpleasant sensation that is conveyed to the brain by sensory neurons.
The Association for the Study of Pain provides also a comprehensive definition of pain as ‘an unpleasant sensory and subjective experience associated with actual or potential tissue damage, or described in terms of such damage. This implies that pain is a more individual experience and a complex phenomenon influenced by biological, psychological and social factors. Wilson (2007) further explained that pain is a multidimensional phenomenon with physical, psychological, social and spiritual components. Suggesting that pain may arise from a number of situations and could be from injury which is a major cause, or may also arise from an illness. Pain has many causes. It may result from a chronic condition such as arthritis or fibromyalgia, it may occur during an intervention (procedural pain), after surgery, in response to an injury or as a symptom of disease British pain Society (2007)
2.2 Pain Theories
Nair and Peate (2009) found that most pain theories recognize that pain experience is both emotional and psychological. The specificity theory hypothesises that pain is experienced when specific nerve endings are stimulated. Information is then carried to a pain centre in the brain. It is the characteristics of the stimulus that determines the intensity of the pain rather than brain. Pattern theory, on the other hand, suggests that no separate system for pain sensation exists. Relatively pain is interpreted by the brain when intense peripheral nerve stimulation occurs Gould and Thomas (1997) Such theories do not explain why pain can occur as a result of gentle stimulus, that is neuralgia, or when no tissue damage exists. Neither do they explain why two people with the same injury may experience different levels of pain. For this reason, Melzack and Wall’s (1988) gate theory is more widely accepted as the most important pain theory Main and Spainswick( 2000)
2.3 The Control Theory of Pain
The gate control theory of pain explains that pain impulses must pass through a theoretical gate at the dorsal horn of the spinal cord before ascending towards the brain. Pain messages from A Î´ and C fibres will push open the gate Nair and Peate (2009) . However, the actions of AB fibres and the descending pain pathway will push the gate closed. The intensity of an individual’s pain, therefore, is determined by a balance between noxious stimuli and the AB fibre or descending brain activity. The wider the gate is open the more intense the pain, however, if the gate closes the pain ceases McCaffery et al (2003)
2.4 Classification of Cancer Pain
Chapman (2012) stated that cancer pain can also be described in terms of broad physiological types of pain such as somatic or visceral and neuropathic pain. Patients with cancer may experience pain that has elements of all these types of physiological pain. Nair and Peate (2009) stated that cancer pain can be classified as being either nociceptive or neuropathic. Briggs (2010) pointed out that understanding the likely cause of pain aids development of an individualised management plan to address all aspects of the patient’s pain. It is therefore imperative that nurses have a sound understanding of cancer pain and knowledge of how to assess and manage it.
There are several ways to categorize the type of pain that occur for instance acute or chronic pain, nociceptive (somatic or visceral) or neuropathic, Macintyre et al (2010).
Godfery (2005) explained that nociceptive pain is the normal pain pathway that occurs in response to rise to tissue injury or damage. It consists of four components: transduction, transduction, transmission, perception and modulation. Nociceptors are free nerve endings found at the end of pain neurons. They are found in skin and subcutaneous tissues, muscle, visceral organs, tendons, fascia, joint capsules and arterial wall.
In contrast, Mann (2008) expressed that neuropathic pain does not originates as part of normal pain pathways. It is described as pain related to abnormal processing within the nervous system. Nerve injury or dysfunction can be caused by condition such as metabolic disorder, chemotherapy, surgery, radiation, neurotoxins, nerve compression, joint degeneration, tumor infiltration and malnutrition.
According to Higginson and Murtagh (2010) , Portenoy and Koh (2010) most patients with advanced cancer have at least two types of cancer related pain which derives from a variety of etiologies.
2.5 Types of Pain
Pain is commonly divided into three types, acute pain that lasts for less than three months and subsides with healing. Persistent or chronic pain lasts beyond the normal period of healing or has an unidentifiable cause. Lastly cancer pain which is associated with a malignancy, Macintyre and Schug (2007). Chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Statistics on chronic pain conducted by British Pain Society (2010) and the Royal College of General Practitioners (2005) indicated that nearly one in seven people suffer from chronic pain and 20% have suffered for more than 20 years. Two-thirds of chronic pain sufferers surveyed in the UK reports inadequate pain control Mackrodt (2005), Allcock, Elkan and Williams (2007), Chronic Pain Policy Coalition (2007) also stated that pathology of chronic pain is not readily identifiable and may also be unresponsive to a variety of treatments, tensions may result and patients may feel their symptoms are not being acknowledged or taken seriously. Pain can also arise because of changes in the peripheral neurones or nerve compression as a result of a growing tumour; it may also have an inflammatory element Urch and Dickenson (2008).
2.6 Effects of Pain in Cancer Patients
Several studies have examined the effects of pain in patients with cancer and have reported that uncontrolled pain reduces quality of life. The effect of pain on mood and psychological functioning is also well documented, with patients at increased risk of anxiety, depression and suicidal ideation Chapman (2011). The European Pain Cancer survey Breivik et al (2009) found that persistent pain interferes with activities of daily living and social interaction, stop patients from concentrating and made it difficult to perform activities. Raphael, et al (2010) added that pain places increased burden on relatives and patients further reporting that they are unable to care for themselves or others as pain affected their performance at work.
In a qualitative study, conducted byâ€‚Saundersâ€‚andâ€‚Anthonyâ€‚(2007) found that pain ‘robbed them’ patients the ability of performing the simplest tasks and they pleasures. Valerand et al (2007) also reported that patients used the term ‘feeling desperate’ about their situation of living with pain having a lack of control over sleep patterns and felt increased fatigued due to pain. Chapman (2012) also found that pain can lead to lifestyle changes, such as alterations in work practice, an inability to perform many activities independently, and reduced psychological and social functioning.
The experience of pain is a highly complex phenomenon with physical, behavioural, cognitive, emotional, spiritual, and interpersonal aspects. This multidimensional nature of pain must be acknowledged in the assessment and management of patients British Pain Society (2010). The International Association for the Study of Pain (1986) also found that pain may result in psychological features, including complaints of poor or non-refreshing sleep, tiredness, depression and poor concentration. However, Cousins and Gallagher (2012) also reported that psychosocial features may play a significant role in the persistence of symptom. In patients with cancer, acute pain may be caused by recurring and/or progressive tissue injury associated with diagnostic or therapeutic interventions Williams and Dale (2006)
Chapman (2012) reported that cognitive behavioural interventions have been found to minimise the impact of pain on mood and has been shown to be effective in patients with psychological issues resulting from pain . The author added that the meaning of pain may be different for patients with cancer compared to those patients with pain relating to non-life threatening illness and some cancer patients may see increased pain as a sign of disease progression or the failure of strong medication, with possible consequences for mood and adherence to treatment protocols. Miaskowski, et al (2005) suggested that a comprehensive pain assessment should include the personal and social influences that determine how pain is experienced and perceived. The British Pain Society (2010) indicated that Pain Management Programmes (PMPs) based on cognitive and behavioural principals are the treatment of choice for people whose persistent pain adversely affects their quality of life. A PMP aims to improve the physical, psychological, emotional and social dimensions of a person’s quality of life, functioning towards optimal functioning and independence in managing persistent pain.
Methodology and Method
3.1 Research Methodology
A research embodies the systematic study of sources, materials and phenomena in a way as to draw a conclusion on a matter or to establish some facts (Saunders et al., 2007). In order to allow a greater understanding and comparison of the expectations related to two very different types of pain experiences in cancer patients; chronic progressive cancer-related pain and acute pain after surgery for cancer, a holistic approach has been adopted by the researcher. Methodology is basically about the methods involved in testing and examining the philosophical views which are outcomes of scientific investigations (Collis and Hussey, 2003).
3.1.1 Research Method
Method covers the entire scope of data collection techniques and research strategies employed by a researcher. The main two methods of data collection are primary and secondary data collection. In gathering data for the purpose of this study, only secondary data has been used. According to Saunders, Philips, & Thornhill (2007), secondary data can be regarded as primary data, which in the past has been collected, processed and stored, by another researcher, for some other purpose. In comparing the expectations relating to pain experiences in cancer patients, other electronic sources such as online journals, articles and databases have been consulted.
Hopkins (2003) describes quantitative research as centered on quantifying relationships between variables. This can either be experimental or descriptive in nature. Whereas descriptive studies do not aim at changing behavior, experimental studies attempt to alter behavior. Qualitative research on the other hand indulges the use of non-statistical and non-numerical information to decode, define and translate some phenomena. For the purposes of this study, the qualitative method has been used to identify and evaluate the effect of pain on cancer pain. This project also focused on the identification of qualitative literature relevant to the experience of cancer pain.
3.2 Research Ethics
In order to ensure that high ethical standards have been observed in the conduct of this study, emphasis has been greatly laid on confidentiality of information. Moreover, the researcher has maintained independence from subjects. According to Cooper and Schindler (2008) ethics can be explained as “norms or standards of behaviour that guide moral choices about our behaviour and our relationships with others”. The subject of confidentiality of information has not arisen as all data collected and analyzed in the research is already available to the public. The researcher has duly acknowledged all sources of data that were consulted in the conduct of the study. All sources of information are also accordingly referenced.
Secondary data has been criticized as having a major limitation which is its inability to precisely predict the future. As the researcher has not gathered any first-hand information and relied solely on secondary data, this becomes a limitation to the study. Time constraints were also faced as a number of databases were accessed for relevant literatures to be used. The later limitation was however overcome by effective time management and commitment in enhancing knowledge in improving practice of pain assessment in cancer patients.
3.4 Critical Appraisal
Critical appraisal is the process of carefully and systematically examining research to judge its validity, reliability, and generalisation as stated by Hill and Spittlehouse(2003). To facilitate this writers like Parahoo (2006) and Ajetunmobi (2002) recommended using critique framework because critiquing framework add breadth and depth to analysis but Ajetunmobi (2002) argues that this must be used as a tool rather than prescriptive, as a rationale for choice rather than simple convenience. The Critical Appraisal Skills Programme (CASP) introduced by Public Health Resource Unit (2006) will be used for this literature review. This is because it is simple and systematic and can easily identify flaws and bias in the various research articles to be reviewed in this work.
This chapter will talk about the themes identified and give an in-depth critical analysis on the findings of the research articles. Polit and Beck (2008) and Parahoo (2006) describe the title of a research study as a descriptive sentence with specific details of the proposed subject. The title should be concise, informative and clear, stimulating interest in the topic with information encouraging reading of the entire article.Polgar and Thomas (2008) indicated that the approach adopted by the researcher will depend on the nature of the issue being investigated and the type of data required. Furthermore the title shows that the studies were of a qualitative and quantitative research as identified by Creswell (2003) an approach which focuses on the way people interpret their life experience in order to give meaning using words.
According to Thorne (2004) researchers must be qualified to commence a research study. However Parahoo (2006) disagree stating that the credentials of the authors should not be noted whether they are qualified or experience to make recommendations. Due to the articles being published between 2005 and 2012 it is expected that the articles will be relevant to recent practice. Parahoo (2006) described that abstract in a study must outline the research purpose, sampling method, methodology, sample(s), results and their importance. Watson et al (2008) further suggest that the abstract should provide a concise summary of the subject and the merits obtained should be carefully evaluated. Publishers may specify the amount of words the abstract should include Locke, Silverman and Spirduso (2004).
According to Parahoo (2006) and Watson et al (2008) the abstract should give the reader enough information to decide whether to continue reading the research; however the reader should not expect too much from abstract because the article will contain the main details.
Why Pain Assessment ?
Dougherty and Lister (2011) reported that assessment is a key step in the process of managing pain. The aim of assessment is to identify all the factors, physical and non physical that affect the patient’s perception of pain. However, Nair and Peate (2009) suggested that pain assessment allows the practitioners to best select appropriate pharmacological and non-pharmacological interventions. Pain is a complex multifaceted phenomenon and its assessment is very challenging. Mackintosh and Elson (2008) stated that accurate assessment and re-assessment of pain are important to provide a baseline measure of the individual’s pain against which changes can be measured, promote trust within the patient and healthcare professional and encourage better communication between the individual as well as healthcare professional. Briggs (2010) argued that the answer to accurate assessment is to ask appropriate holistic questions which aim at identifying the nature of the pain, for example sharp, sho
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