Nicole Heneka

Impact of a novel online learning module on specialist palliative care nurses’ pain assessment competencies and patients’ reports of pain: Results from a quasi-experimental pilot study

Background: Pain is a complex multidimensional phenomenon moderated by consumer, provider and health system factors. Effective pain management cuts across professional boundaries, with failure to screen and assess contributing to the burden of unrelieved pain. Aim: To test the impact of an online pain assessment learning module on specialist palliative care nurses’ pain assessment competencies, and to determine whether this education impacted positively on palliative care patients’ reported pain ratings. Design: A quasi-experimental pain assessment education pilot study utilising ‘Qstream©’, an online methodology to deliver 11 case-based pain assessment learning scenarios, developed by an interdisciplinary expert panel and delivered to participants’ work emails over a 28-day period in mid-2012. The ‘Self-Perceived Pain Assessment Competencies’ survey and chart audit data, including patient-reported pain intensity ratings, were collected pre-intervention (T1) and post-intervention (T2) and analysed using inferential statistics to determine key outcomes. Setting/participants: Nurses working at two Australian inpatient specialist palliative care services in 2012. Results: The results reported conform to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Guidelines. Participants who completed the education intervention (n = 34) increased their pain assessment knowledge, assessment tool knowledge and confidence to undertake a pain assessment (p < 0.001). Participants were more likely to document pain intensity scores in patients’ medical records than non-participants (95% confidence interval = 7.3%–22.7%, p = 0.021). There was also a significant reduction in the mean patient-reported pain ratings between the admission and audit date at post-test of 1.5 (95% confidence interval = 0.7–2.3) units in pain score. Conclusion: This pilot confers confidence of the education interventions capacity to improve specialist palliative care nurses’ pain assessment practices and to reduce patient-rated pain intensity scores.

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic review

Background: Opioids are the primary pharmacological treatment for cancer pain and, in the palliative care setting, are routinely used to manage symptoms at the end of life. Opioids are one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in oncology and palliative care settings. Aim: To determine the incidence, types and impact of reported opioid medication errors in adult oncology and palliative care patient settings. Design: A systematic review. Data sources: Five electronic databases and the grey literature were searched from 1980 to August 2014. Empirical studies published in English, reporting data on opioid medication error incidence, types or patient impact, within adult oncology and/or palliative care services, were included. Popay’s narrative synthesis approach was used to analyse data. Results: Five empirical studies were included in this review. Opioid error incidence rate was difficult to ascertain as each study focussed on a single narrow area of error. The predominant error type related to deviation from opioid prescribing guidelines, such as incorrect dosing intervals. None of the included studies reported the degree of patient harm resulting from opioid errors. Conclusion: This review has highlighted the paucity of the literature examining opioid error incidence, types and patient impact in adult oncology and palliative care settings. Defining, identifying and quantifying error reporting practices for these populations should be an essential component of future oncology and palliative care quality and safety initiatives.

Clinicians’ perceptions of medication errors with opioids in cancer and palliative care services: a priority setting report

This paper reports the findings of a priority setting process, undertaken with cancer and palliative care clinicians, to better understand the characteristics of medication errors with opioids within their services. Participants representing six public hospitals in one Australian state took part in a series of priority setting workshops and, drawing on actual incidents occurring in their services, sought to identify where in the opioid medication process errors were most frequently occurring. Opioid error types and perceived contributing factors were explored, and strategies to reduce/prevent opioid errors were proposed. The priority setting process provided valuable insights into the types of opioid errors that occur in cancer and palliative care services and the complexity of addressing opioid errors from the clinician’s perspective. The findings from this priority setting process will inform future targeted quality improvement initiatives to support safe opioid medication practices in cancer and palliative care services.

Self-Perceived Pain Assessment Knowledge and Confidence (Self-PAC) Scale for Cancer and Palliative Care Nurses: a Preliminary Validation Study

Background: Pain is highly prevalent in all health care settings, and frequently poorly managed. Effective pain management is predicated on a continuous cycle of screening, assessing, intervening and evaluating. Identifying gaps in nurses’ self‐perceived pain assessment competencies is an essential first step in the design of tailored interventions to embed effective pain assessment into routine clinical practice, and improve patient reported pain outcomes. Yet, few validated instruments focus on the competencies required for undertaking a comprehensive pain assessment, with most focusing on clinician’s pain management competencies. Aim: To examine the validity of the ‘Self‐Perceived Pain Assessment Knowledge and Confidence’ (Self‐PAC) Scale. Design: Preliminary instrument validation. Setting: Two Australian cancer and palliative care services. Participants/Subjects: 186 cancer and palliative care nurses. Methods: The Self‐PAC Scale was administered to participants online. Factor Analyses, including Exploratory and Confirmatory, were applied to examine the structural validity, Cronbach’s alpha was calculated for internal consistency. Criterion validity was investigated by comparing responses from experienced and non‐experienced nurses. Results: Two components resulted with a single factor structure for pain assessment confidence and a two‐factor structure for the knowledge of pain assessment. The factor loading for the subscales ranged from 0.653 to 0.969, with large proportions of the variances explained by the factors. Cronbach’s alpha of the subscales ranged from 0.87–0.92 and significant difference in responses were found between experienced and non‐experienced nurses. Conclusion: Preliminary validation of the Self‐PAC Scale suggests that it is a helpful instrument for assessing cancer and palliative care nurse’ pain assessment competencies.

Opioid errors in inpatient palliative care services: a retrospective review

Opioids are a high-risk medicine frequently used to manage palliative patients’ cancer-related pain and other symptoms. Despite the high volume of opioid use in inpatient palliative care services, and the potential for patient harm, few studies have focused on opioid errors in this population. Objectives To (i) identify the number of opioid errors reported by inpatient palliative care services, (ii) identify reported opioid error characteristics and (iii) determine the impact of opioid errors on palliative patient outcomes. Methods A 24-month retrospective review of opioid errors reported in three inpatient palliative care services in one Australian state. Results Of the 55 opioid errors identified, 84% reached the patient. Most errors involved morphine (35%) or hydromorphone (29%). Opioid administration errors accounted for 76% of reported opioid errors, largely due to omitted dose (33%) or wrong dose (24%) errors. Patients were more likely to receive a lower dose of opioid than ordered as a direct result of an opioid error (57%), with errors adversely impacting pain and/or symptom management in 42% of patients. Half (53%) of the affected patients required additional treatment and/or care as a direct consequence of the opioid error. Conclusion This retrospective review has provided valuable insights into the patterns and impact of opioid errors in inpatient palliative care services. Iatrogenic harm related to opioid underdosing errors contributed to palliative patients’ unrelieved pain. Better understanding the factors that contribute to opioid errors and the role of safety culture in the palliative care service context warrants further investigation.