Berit Taraldsen Valeberg

Self‐reported prevalence, etiology, and characteristics of pain in oncology outpatients

Purpose: To determine the self‐reported prevalence rates for cancer, non‐cancer, and both cancer and non‐cancer pain and to determine if there were differences in demographic, clinical, and pain characteristics among the three pain groups.

Demographic, clinical, and pain characteristics are associated with average pain severity groups in a sample of oncology outpatients.

UNLABELLED Cut-points (CP) for pain severity are useful because they may help clinicians to identify patients with clinically significant pain. However, a need exists to evaluate whether different pain severity groups differ on selected demographic, clinical, and pain characteristics, as well as on factors that may be amenable to psychoeducational interventions such as self-efficacy for pain management, coping strategies, and barriers to pain management. In this cross-sectional study of 210 oncology outpatients with pain, an optimal CP of 4 was found using ratings of average pain intensity. The variables that provided a unique contribution to the prediction of membership in the >4 CP group were gender, presence of breakthrough pain, comorbidities, barriers to pain management, and total self-efficacy for pain management. In addition, patients in the >4 CP group reported lower scores on physical, role, cognitive, and global health function. PERSPECTIVE An average pain CP of >4 could be used to screen oncology outpatients with clinically significant pain. Clinicians must consider a number of demographic, clinical, and pain characteristics as part of their pain assessment procedures. The effectiveness of psychoeducational interventions aimed at barriers and patients self-efficacy for pain management need to be tested.

The PRO-SELF© pain control program improves family caregivers’ knowledge of cancer pain management

Background: The majority of cancer treatment is provided in outpatient settings. Family caregivers’ (FCs’) knowledge and beliefs about pain and its management are critical components of effective care. Objective: This study’s aim was to evaluate the efficacy of a psychoeducational intervention, compared with control, to increase FCs’ knowledge of cancer pain management. Intervention/Methods: Family caregivers of oncology outpatients were randomized together with the patients into the PRO-SELF Pain Control Program (n = 58) or a control group (n = 54). Family caregivers completed a demographic questionnaire and the Family Pain Questionnaire (FPQ) at the beginning and end of the study to assess their knowledge about pain and its management. The intervention consisted of nurse coaching, home visits, and phone calls that occurred over 6 weeks. Results: One hundred twelve FCs (60% female) with a mean age of 63 (SD, 10.7) years participated. Compared with FCs in the control group, FCs in the PRO-SELF group had significantly higher knowledge scores on all of the single items on the FPQ, except for the item “cancer pain can be relieved,” as well as for the total FPQ score. Conclusion: The use of a knowledge and attitude survey like the FPQ, as part of a psychoeducational intervention provides an effective foundation for FC education about cancer pain management. Implications for Practice: Oncology nurses can use FCs’ responses to the FPQ to individualize teaching and spend more time on identified knowledge deficits. This individualized approach to FC education may save staff time and improve patient outcomes.

A randomized clinical trial of the efficacy of a self-care intervention to improve cancer pain management.

Background: The undertreatment of cancer pain remains a significant clinical problem. Objective: The aim of this randomized controlled trial was to evaluate the efficacy of the PRO-SELF Pain Control Program that was modified for Norwegian cancer patients in decreasing pain and increasing opioid intake compared with control care. Interventions/Methods: Oncology outpatients with pain from bone metastasis were randomized into the PRO-SELF (n = 87) or control (n = 92) groups. A nurse visited patients in the PRO-SELF group in their home at weeks 1, 3, and 6 and conducted telephone interviews at weeks 2, 4, and 5. Patients in both groups completed a daily diary of pain intensity ratings and analgesic intake. Results: For both groups, significant decreases in pain intensity scores and in hours per day in pain (both, P < .001) were found over the 6 weeks of the study. However, no significant group × time interactions were found for any of the pain measures. In both groups, total dose of opioid taken increased over time. However, no significant group × time interactions were found for changes over time in the total dose, around-the-clock dose, or as-needed dose of opioid analgesics taken. Conclusions: Possible reasons for the lack of efficacy include an inadequate dose of the psychoeducational intervention, inadequate changes in analgesic prescriptions, and/or the impact of attention provided to the control group. Implications for Practice: Coaching, nursing support, and the use of a pain diary may be important interventions to reduce pain intensity.

Acupuncture versus usual care for postoperative nausea and vomiting in children after tonsillectomy/adenoidectomy: a pragmatic, multicenter, double-blinded, randomized trial

Objectives To investigate the effect of a standardised acupuncture on nausea and vomiting in children after tonsillectomy with or without adenoidectomy when possible placebo effects were precluded. Methods A pragmatic, multicentre, double-blinded, randomised controlled trial. The study was conducted over 10 months in 2012–2013 at three ambulatory clinics. Two hundred and eighty-two children, age 1–11 years, American Society of Anesthesiologists grade ≤II, were included. To equalise expectancy effects, all parents were told that their child would receive acupuncture. However, children were randomly allocated to perioperative bilateral needling acupuncture at PC6, depth 7 mm, mean time 17 min (SD 5–45) during anaesthesia plus usual care, or to usual care only. The regional ethics committee approved this approach. Primary endpoints were nausea and vomiting 24 h postoperatively. Results This study did not demonstrate any effect of acupuncture (95% CI) compared with standard care. The overall vomiting in the acupuncture and usual-care groups was 44.2% and 47.9%, respectively. Nausea was experienced by 31.7% in the acupuncture group and by 32.6% in the usual-care group. The test power was acceptable for comparisons of vomiting. Conclusions The findings suggest that when controlling for possible placebo effects standardised PC6 acupuncture needling during anaesthesia without further stimulation of PC6 is not effective in reducing nausea and vomiting in children after tonsillectomy with or without adenoidectomy. Future studies should investigate acupuncture treatment which balances adequate dose and technique and a feasible, child-friendly acupuncture treatment. Trial Registration Number ClinicalTrials.gov NCT01729052.

Cancer patients' barriers to pain management and psychometric properties of the Norwegian version of the Barriers Questionnaire II.

The Barriers Questionnaire II (BQ-II) was developed to assess barriers to effective pain management. The purpose of this study was to evaluate the psychometric properties of the BQ-II in a sample of Norwegian cancer patients. The BQ-II was translated into Norwegian and pilot tested with eight oncology outpatients. Then, a convenience sample of 321 cancer patients from two different sites was recruited to maximize the number of questionnaires available for the psychometric analyses. Patients were included if they: were >18 years of age; had a diagnosis of cancer; and self-reported pain and/or use of analgesics. Construct validity of the Norwegian version of the BQ II (NBQ-II) was evaluated using an exploratory factor analysis. A seven-factor solution was found that was more consistent with the original version of the BQ. Construct validity of the NBQ-II was demonstrated through positive correlations between most of the subscale and total scores on the NBQ-II and pain intensity and pain interference scores. Finally, Cronbachs α coefficients of ≥0.7 for six of the seven subscales and 0.89 for the total scale demonstrated acceptable levels of internal consistency. In conclusion, the NBQ-II demonstrated adequate psychometric properties. However, further revision and testing of the questionnaire should be performed to confirm the factor structure that was identified in this study.

Confirmatory Factor Analysis of the Coping Strategies Questionnaire-Revised in Samples of Oncology Outpatients and Inpatients With Pain

ObjectivesThe aims of this study of oncology outpatients with cancer pain were to perform an exploratory factor analysis (EFA) of the 48-item Coping Strategy Questionnaire (CSQ) and a confirmatory factor analysis of the 6-factor solution of the Coping Strategy Questionnaire-Revised (CSQ-R) suggested by Riley and Robinson in 1997. In addition, differences in latent factor means and in the CSQ-R subscale scores between inpatients and outpatients were evaluated. MethodsData from oncology outpatients (n=217) and inpatients (n=225) with pain were used. The Mplus program was used to perform both the EFA and confirmatory factor analysis treating the items as ordinal, and using robust maximum likelihood estimation. Quartimin oblique rotation was used for the EFA. Model fit was evaluated with the χ2 test, the comparative fit index, the root mean square error of approximation, and the standardized root mean square residual, as well as by substantive evaluation of the solutions. ResultsThe EFA of the original 48-item CSQ did not reproduce the factor structure defined by Rosentiel and Keefe. The 6-factor structure from the 27-item CSQ-R fit both the inpatient and outpatient data well with strong factorial invariance, as well as the combined data, allowing some correlated errors among items. Differences were found between the 2 samples for the ignoring, catastrophizing, and praying latent factor means, and for the catastrophizing and praying subscale means. DiscussionThe 27-item CSQ-R is recommended for use as a clinical instrument. However, further research of the 6-factor structure is recommended to identify reasons for the correlated errors.

Development of a pain management algorithm for intensive care units.

OBJECTIVES To develop a pain management algorithm for intensive care unit (ICU) patients and to evaluate the psychometric properties of the translated tools used in the algorithm. BACKGROUND Many ICU patients experience pain. However, an evidence-based algorithm for pain management does not exist. METHODS Literature review, expert panel, and pilot testing were used to develop the algorithm. The tools were evaluated for inter-rater reliability between two nurses. Discriminant validity was evaluated by comparing pain during turning and rest. RESULTS An algorithm was developed. The Behavioral Pain Scale (BPS) and the Behavioral Pain Scale-Non Intubated (BPS-NI) discriminated between pain scores during turning and rest. Inter-rater reliability for the BPS varied from moderate (0.46) to very good (1.00). Inter-rater reliability for the BPS-NI varied from fair (0.21) to good (0.63). CONCLUSIONS The content of the pain management algorithm is consistent with the latest clinical practice guideline recommendations. It may be a useful tool to improve pain assessment and management in adult ICU patients.

Comparison of Oncology Patients' and Their Family Caregivers' Attitudes and Concerns Toward Pain and Pain Management.

Background: Both cancer patients and their family caregivers (FCs) report concerns about pain and pain management. When dyads share appraisal of the illness context, they may experience better dyadic adjustment. Objective: The aim of this study was to compare oncology outpatients’ and their FCs’ attitudes and concerns toward pain and pain management. Methods: In a cross-sectional study, outpatients with pain (n = 71) and their FCs completed the Barriers Questionnaire II, the Brief Pain Inventory, and information about demographic characteristics. Correlations and paired-samples t tests were calculated to evaluate agreement and differences in barrier scores between the patients and their FCs. Results: Congruence was found in patients’ and FCs’ beliefs about pain and the use of analgesics on 4 of 7 subscales (ie, tolerance, immune system, side effects, distract the medical doctor) and on the Barriers Questionnaire II total score. Both patients and their FCs were most concerned about addiction. Conclusions: The concerns that both patients and their FCs have about pain and the use of analgesics may act as barriers to effective pain management. Fear of addiction may be an important barrier to cancer pain management. Only small differences were found in concerns between the patients and their FCs. Implications for Practice: Patients and FCs need education about perceived barriers to effective pain management. They should be coached together to maintain or increase the congruence between them.

Results of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation.

PURPOSE This study aimed to measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay. MATERIALS AND METHODS The algorithm instructed nurses to assess pain, guided them in pain treatment, and was implemented in 3 units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables: pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events. RESULTS Totally, 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. In addition, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics. CONCLUSION Several outcome variables were significantly improved after implementation of the algorithm compared with the control group.