Management of Cancer Pain Essay Example

hierarchy of grades. Melnyk (2005) offers a levels of evidence framework, which includes strong evidence from systematic reviews and randomised controlled trials, evidence from well-designed non-experimental studies, and expert opinions based on clinical evidence. In addition to research-derived evidence, feedback from patients and professionals is also valued in ensuring best practice. By applying the best available evidence while considering patient circumstances and preferences, clinicians can improve clinical judgments and promote cost-effective healthcare (Sackett, 2000). LoBiondo-Wood (2006) notes that identifying the level of evidence provided by research articles is an important first step when implementing EBP strategies. This essay will investigate the management of pain in cancer, as an example of EBP in practice.

In order to gather supporting evidence for my essay, I conducted a literature review using the Cumulative Index to Nursing ; Allied Health Literature database, which is a primary resource for nursing research. This database offers access to a vast collection of current clinical evidence in the fields of nursing and medicine (Ebesco Publishing, 2010). My search in this database focused on three main concepts: cancer, pain, and management. These terms were combined automatically, resulting in a total of 2,320 search results. To ensure that only the most relevant references were retrieved, I further refined my search parameters.

After searching for "cancer", "pain management", and "research", I received 385 results. I narrowed the results to full-text articles published between 2000 and 2009 that focused on all adult age groups, which yielded 20 results. From these results, I identified two studies, a primary and a secondary source of evidence, that were appropriate for my evidence-based care appraisal. The primary source of evidence, titled "Cancer-related pain

in palliative care: patients' perceptions of pain management" by Bostrom (2004), is a qualitative study. Parahoo (2006) defines original publications as primary sources.

In order to evaluate my main research evidence, I will utilize the LoBiondo-Wood (2006) framework. The author emphasizes that the title of an article is crucial as it serves as the initial point of contact for readers. A well-crafted title should accurately indicate the study's topic and demographic being studied. The title of the qualitative study I have chosen to evaluate adheres to these guidelines, as it explicitly states that it pertains to patient's perspectives on palliative care pain management.

According to Deniz and Lincoln (2000), qualitative research is the investigation of phenomena in their natural environment with the goal of interpreting them based on the meanings attributed by people. This type of research is usually conducted in natural settings where word or text data is gathered to describe the experiences under study. The strategy involves collecting information from a restricted number of subjects, which allows for an extensive analysis of the phenomenon. As stated by LoBiondo-Wood, an abstract is a brief and comprehensive summary positioned at the start of an article that provides a succinct overview of the investigation.

Bostrom (2004) aims to offer a comprehensive review of patients in palliative care with cancer-related pain regarding their perception of pain management. The article includes the presentation of sample and main findings using various methods, leading up to a summary. This research contributes to the current literature on the subject that is commonly referred to for future studies (Parahoo, 2006). Brostrom's qualitative analysis of prior studies on this topic is thorough and well-cited.

Brostrom (2004) notes that despite the abundance of research studies on pain management in cancer patients, none have employed the phenomenological approach to investigate patient perceptions. Streubert (1999) highlights the importance of selecting an appropriate method depending on the research question. To thoroughly comprehend cancer patients' perceptions of pain management, this study utilized the phenomenological approach, a qualitative method that aims to understand individuals' "lived experience" in terms of their emotions and perceptions (Young, 2001). Strategic selection criteria were used for thirty participants based on factors such as gender, age, marital status, diagnosis, duration of care from palliative care team and place of care.

The study shows that the selected sample is encountering the phenomenon being studied. Unlike quantitative research, there is no need for random selection of individuals since the investigation does not intend to control, manipulate or generalize findings. The data was obtained through open and semi-structured interviews which allowed participants to describe their experiences in detail (Streubert, 1999). However, it is difficult to evaluate this aspect of data collection as the article does not disclose how long participant interviews lasted.

The study must continue for a suitable duration to gather enough data for analysis, regardless of the availability of adequate sample data. Approval was granted by the pertinent research committee. The article notes that participants were fully informed and gave prior consent before interviews. Patients were notified of their voluntary participation, answer confidentiality, and right to withdraw from the study at any time without providing a reason. The researcher presented results in an organized and comprehensible manner.

Three themes emerged from the study, namely communication, planning, and trust, which shed light on the cancer patient's

viewpoint regarding pain management. The report's conclusion outlined the main findings and emphasised their potential impact on nursing practice. Patients often only discussed pain and treatment options towards the end of their illness, sometimes after palliative care involvement. Successful pain control depended on establishing a trustworthy relationship with healthcare professionals like nurses and physicians according to Bostrom (2004).

LoBiondo-Wood (2004) notes that historically, qualitative studies have fallen lower in the hierarchy of evidence, alongside weaker research designs such as evaluative, descriptive, expert opinions, and case studies. However, qualitative data can provide valuable evidence and insights that may be the first systematic exploration into a phenomenon and its associated settings. Professionals are expanding evidence models beyond narrow hierarchical perspectives, considering how to evaluate and include qualitative evidence in systematic reviews (Pearson, 2002). A systematic review refers to a thorough search, selection, appraisal, synthesis and summary of primary research findings in order to answer a specific question (Parahoo, 2006). In critiquing my secondary source of evidence "A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: A critical appraisal" by Oldenmenger (2009), I will use the frameworks provided by Parahoo (2006) and Gerrish (2006).

Parahoo (2006) emphasizes the necessity of a question, aim or hypothesis for a systematic review to be conducted. Pearson (2004) agrees, emphasizing that a well-defined review question is essential for a comprehensive and systematic review. Oldenmenger's study (2009) focuses on two clear and unambiguous aims: identifying major barriers to adequate pain management and critically assessing interventions to address these barriers. Parahoo (2006) reiterates that the aim of a systematic review is to answer the review question and obtain a

credible answer, requiring diligent efforts to locate all relevant studies.

Accessing databases, grey literature, reference lists, and conducting manual searches are crucial when conducting a systematic review. However, the search of relevant literature in Oldenmenger's (2009) study appears to have been restricted. The study only included English-language publications and relevant materials from the senior author's personal library. Unpublished or non-English language studies were not searched for.

As per Bowling's (2009) study, reviewing published and unpublished literature is a crucial starting point for researching a subject. However, publication bias can occur where authors publish only significant results while leaving out non-significant ones. Moreover, English language publications may have more significant findings while non-significant ones are reported in journals of other languages. To enhance review quality, Moher (2003) advises including literature in multiple languages. Parahoo (2006) highlights the importance of knowing how and where to access relevant sources of information. Oldenmenger's (2009) use of online databases like PubMed and articles from their personal library demonstrates effective search procedures.

The search focused on the terms "pain management" and "barriers" or "concern" among patients and healthcare providers. The researchers identified a total of seventy studies that met the specified inclusion criteria. According to Herbert (2005), a systematic review with clear inclusion and exclusion criteria yields more robust evidence in comparison to those without. To investigate interventions that target obstacles that impede proper pain management, the authors specifically chose randomized clinical trials (RTCs).

The RCTs' methodological quality was evaluated using van Tulder's (2003) criteria, with patient pain intensity, patient or professional barriers, analgesic adherence, and adequacy of pain treatment measured by the pain management index (PMI). The author calculated the difference in pain intensity

reduction between the intervention and control groups based on a clinically significant effect of a 30% or >2-point decrease on a 0-10 scale (Oldenmenger, 2009). Extracted data included study details, methods, participants, interventions, outcomes, participant characteristics, and results. In cases of missing data, authors attempted to contact the original source.

The review extracted all statistical significance data from the original papers (Oldenmenger, 2009) and presented it through narrative commentary and summary tables. Oldenmenger's study shows that there were noteworthy variations in participants, interventions, and settings across the reports that could potentially influence the results. The study presents its findings in three main categories, starting with patient-related barriers where patients hinder their own treatment due to misunderstandings about analgesics, failure to follow treatment regimens, and inadequate communication with healthcare providers.

The investigation centered on tackling obstacles to cancer pain management, involving patients, professionals, and the system. The study conducted 11 randomized controlled trials with a specific aim of assessing the impact of patient education in reducing patient-related barriers. The outcomes demonstrated that patients who received intervention showed significant progress in their adherence to analgesics compared to those who didn't receive any support. As regards professional-related barriers, physicians and nurses identified inadequate assessment of pain and pain management, reluctance of patients to report their pain, and insufficient knowledge about managing pain as common challenges. Although the American Pain Society advocates for a multidisciplinary and multilevel approach for effective cancer pain management; however, this approach was not supported by the reviewed studies.

In 2009, Oldenmenger concluded that the authors were unable to find interventions that provided clinically significant pain relief for patients using the chosen outcome measurement

and criteria in their systematic review. Oldenmenger's review included the search process, study evaluation, and conclusion process, but was perceived as challenging to comprehend and follow despite its transparency and rigor. According to the hierarchy of evidence, RCTs and systematic reviews are deemed the most reliable sources of evidence. Other research designs or methods that do not employ randomization are considered to produce lower forms of evidence (Parahoo, 2006).

While quantitative research is acknowledged for offering a stronger evidence base than qualitative methods, the latter prove more effective in tackling unanswered queries or presenting fresh viewpoints in practical settings. According to LoBiondo-Wood (2006), it's essential to appreciate the entirety of human experience, particularly in natural surroundings. Qualitative researchers uphold that individuals attach private significance to their experiences, and pain is subjective. Since pain management is intricate, it necessitates a multifaceted approach. Cancer patients frequently undergo pain, which happens to be one of the most prevalent and distressing symptoms.

The need for further investigation into the views of cancer patients regarding their preferred methods of pain management is highlighted in my chosen topic. The critique argues that understanding the meaning of cancer-related pain goes beyond medication and rating scales. Utilizing research findings is crucial in nursing as it is a practical discipline. However, many nurses still do not view research activities such as participation and dissemination favorably (Edwards, 2002). According to Edwards (2002), bridging this gap will require a shift in ideology and re-education of beliefs, perceptions, values, and practices.

Nurses, as students, are taught to read and analyze research evidence. However, Edwards (2002) suggests that the workplace culture has a greater impact on values and attitudes than

the official curriculum. This lack of critical thinking may result in accepting existing practices and beliefs without question when entering a new field. Nurse clinicians operate within bureaucratic environments that prioritize consistency, conformity to routine, and task completion over best practices (Robert, 1998). Many obstacles to incorporating research into nursing practice stem from the organizations that train and employ nurses.

According to Polit (2006), organizations resist change more than individuals do. Therefore, strong leadership is crucial to implementing evidence-based practice in healthcare organizations. Additionally, a challenge in bridging the gap between research and practice in nursing is the lack of interaction and collaboration between clinicians and researchers, as they are often in different settings and have different professional priorities.

Seers (2004) outlines four types of evidence relevant to clinical practice. The first is research evidence, which is vital for enhancing patient care, but may not be sufficient in guiding practitioner decision-making. The second type is clinical experience knowledge, which is implicit and intuitive, and integrated into everyday practice.

According to Seers (2004), for a practitioner's experience and knowledge to be considered a credible source of evidence, it must be explicated, analysed, and critiqued. Patient, client, and carer knowledge provide the third source of evidence. The practice of evidence-based healthcare cannot ignore how individuals and their families respond to concepts of health and illness. In the case of cancer-related pain, patients' responses are crucial. Personal experiences and preferences must be central components in good practice. Besides research, clinical and patient experiences, evidence also comes from the context of care.

According to Parahoo (2006), traditional nursing knowledge is primarily acquired through reading books or journals, oral communication, and observation of

others' practices. Many traditional practices are performed as rituals. Biley (1997) believes these rituals have healing properties and hold symbolism, latent functions, and meanings for both the patient and nurse. However, Biley also warns that the use of rituals can become problematic if their underlying purpose is forgotten and goes unquestioned.

The studies discussed in this essay provide valuable insights into pain management for cancer patients. To ensure high-quality patient care and outcomes, it is crucial to take into account research evidence, patient assessments, healthcare resources, clinical expertise, patient preferences and values, and critically evaluate and integrate such information. Care should not be standardized but personalized according to individual patients' needs. It is essential to identify any barriers that may impede optimal patient care through transparent communication.