Virginia T. LeBaron

An Ethnographic Study of Barriers to Cancer Pain Management and Opioid Availability in India

The worlds global cancer burden disproportionally affects lower income countries, where 80% of patients present with late-stage disease and have limited access to palliative care and effective pain-relieving medications, such as morphine. Consequently, millions die each year with unrelieved pain. Objective. The objective of this study was to examine barriers to opioid availability and cancer pain management in India, with an emphasis on the experiences of nurses, who are often the front-line providers of palliative care. Methods. Fifty-nine participants were recruited using a purposive, snowball sampling strategy. Ethnographic data collection included in-depth, semistructured interviews (n = 54), 400+ hours of participant observation, and review of documents over 9 months at a government cancer hospital in South India. Systematic qualitative analysis led to identification of key barriers that are exemplified by representative quotes. Results. Morphine is more available at this study site than in most of India, but access is limited to patients seen by the palliative care service, and significant gaps in supply still occur. Systems to measure and improve pain outcomes are largely absent. Key barriers related to pain management include the role of nursing, opioid misperceptions, bureaucratic hurdles, and sociocultural/infrastructure challenges. Implications. Interventions must streamline process details of morphine procurement, work within the existing sociocultural infrastructure to ensure opioids reach patients most in need, target unexpected audiences for symptom management education, and account for role expectations of health care providers. Conclusion. Macro- and micro-level policy and practice changes are needed to improve opioid availability and cancer pain management in India.

Increasing Role of Nurse Practitioners in House Call Programs

Residence‐based primary care provides homebound frail patients with a care plan that is individually tailored to manage multiple chronic conditions and functional limitations using a variety of resources. We (1) examine the visit volume and Medicare payments for residence‐based health care provided by nurse practitioners (NPs) in the Medicare fee‐for‐service environment; (2) compare NPs residential visits to those of internists and family physicians; and (3) compare the geographical service area of full‐time house call NPs versus NPs who make nursing facility visits a major portion of their work.

Nurse moral distress and cancer pain management: an ethnography of oncology nurses in India.

Background: The majority of cancer patients in low- and middle-income countries (LMICs) present with late-stage, incurable disease, and basic tools to alleviate patient suffering—such as morphine—are often absent. Oncology nurses must cope with many challenges and may experience moral distress (MD), yet little research has examined this experience in LMICs. Objective: This ethnographic study explored the experience of MD with oncology nurses (n = 37) and other providers (n = 22) in India and its potential relationship to opioid availability. Methods: Data (semistructured interviews and field observations) were collected at a 300-bed government cancer hospital in urban South India over 9 months. Dedoose v.4.5.91 supported analysis of transcripts using a coding schema that mapped to an Integrated Model of Nurse Moral Distress and concepts that emerged from field notes. Results: Primary themes included “We feel bad,” “We are alone and afraid,” “We are helpless,” and “We leave it.” A weak link between MD and opioid availability was found. Conclusions: Participants described significant work-related distress, but the moral dimension to this distress was less clear as some key aspects of the Integrated Model of Nurse Moral Distress were not supported. The concept of MD may have limited applicability in settings where alternative courses of action are unknown, or not feasible, and where differing social and cultural norms influence moral sensitivity. Implications for Practice: Improving job-related conditions is prerequisite to creating an environment where MD can manifest. Educational initiatives in LMICs must account for the role of the oncology nurse and their contextual moral and professional obligations.

Recommendations to support nurses and improve the delivery of oncology and palliative care in India

Context: Nurses in India often practice in resource-constrained settings and care for cancer patients with high symptom burden yet receive little oncology or palliative care training. Aim: The aim of this study is to explore challenges encountered by nurses in India and offer recommendations to improve the delivery of oncology and palliative care. Methods: Qualitative ethnography. Setting: The study was conducted at a government cancer hospital in urban South India. Sample: Thirty-seven oncology/palliative care nurses and 22 others (physicians, social workers, pharmacists, patients/family members) who interact closely with nurses were included in the study. Data Collection: Data were collected over 9 months (September 2011– June 2012). Key data sources included over 400 hours of participant observation and 54 audio-recorded semi-structured interviews. Analysis: Systematic qualitative analysis of field notes and interview transcripts identified key themes and patterns. Results: Key concerns of nurses included safety related to chemotherapy administration, workload and clerical responsibilities, patients who died on the wards, monitoring family attendants, and lack of supplies. Many participants verbalized distress that they received no formal oncology training. Conclusions: Recommendations to support nurses in India include: prioritize safety, optimize role of the nurse and explore innovative models of care delivery, empower staff nurses, strengthen nurse leadership, offer relevant educational programs, enhance teamwork, improve cancer pain management, and engage in research and quality improvement projects. Strong institutional commitment and leadership are required to implement interventions to support nurses. Successful interventions must account for existing cultural and professional norms and first address safety needs of nurses. Positive aspects from existing models of care delivery can be adapted and integrated into general nursing practice.

The use of cannabis in response to the opioid crisis: A review of the literature

BACKGROUND A staggering number of Americans are dying from overdoses attributed to prescription opioid medications (POMs). In response, states are creating policies related to POM harm reduction strategies, overdose prevention, and alternative therapies for pain management, such as cannabis (medical marijuana). However, little is known about how the use of cannabis for pain management may be associated with POM use. PURPOSE The purpose of this article is to examine state medical cannabis (MC) use laws and policies and their potential association with POM use and related harms. METHODS A systematic literature review was conducted to explore United States policies related to MC use and the association with POM use and related harms. Medline, PubMed, CINAHL, and Cochrane databases were searched to identify peer-reviewed articles published between 2010 and 2017. Using the search criteria, 11,513 records were identified, with 789 abstracts reviewed, and then 134 full-text articles screened for eligibility. FINDINGS Of 134 articles, 10 articles met inclusion criteria. Four articles were cross-sectional online survey studies of MC substitution for POM, six were secondary data analyses exploring state-level POM overdose fatalities, hospitalizations related to MC or POM harms, opioid use disorder admissions, motor vehicle fatalities, and Medicare and Medicaid prescription cost analyses. The literature suggests MC laws could be associated with decreased POM use, fewer POM-related hospitalizations, lower rates of opioid overdose, and reduced national health care expenditures related to POM overdose and misuse. However, available literature on the topic is sparse and has notable limitations. CONCLUSIONS Review of the current literature suggests states that implement MC policies could reduce POM-associated mortality, improve pain management, and significantly reduce health care costs. However, MC research is constrained by federal policy restrictions, and more research related to MC as a potential alternative to POM for pain management, MC harms, and its impact on POM-related harms and health care costs should be a priority of public health, medical, and nursing research.

What Is the Rural Cultural Perspective

An article by Lally et al. (2018) in the current issue describes the process of collecting end-user feedback from a sample of rural Nebraskan women with breast cancer regarding a web-based, psychosocial distress management program, CaringGuidance™. The current article uses that study to inform discussion on future work in the realm of interventions for rural cancer survivors.

Burden of palliative care issues encountered by radiation oncologists caring for patients with advanced cancer

PURPOSE Radiation oncologists frequently provide care for patients with advanced cancer who are in their last months or weeks of life. This study examined the previously not well-characterized types and frequencies of palliative care issues encountered in consultations for palliative radiation therapy (PRT). METHODS AND MATERIALS This prospective, survey-based study assessed consecutive consults for PRT from May 19, 2014, to September 26, 2014 at 3 Boston-area community and academic, hospital-based centers. Participating physicians and nurse practitioners completed a survey to identify and rank the relevance (5-point Likert scale, not at all to extremely) of palliative care issues. Eight domains adapted from national palliative care guidelines (physical symptoms, psychosocial issues, cultural considerations, spiritual needs, care coordination, advance care planning, goals of care, and ethical and legal issues) were evaluated. A total of 162 consecutive consultations were surveyed with 140 responses received (86% response rate). RESULTS Most (82%) consults had 2 or more palliative care domains ranked as highly (very or extremely) relevant to care. The domains of physical symptoms (91%), care coordination (70%), goals of care (59%), and psychosocial issues (52%) were the most commonly reported domains as highly relevant to care. Forty-six percent of consults involved a high palliative care burden (4 or more palliative care domains identified as highly relevant to care). Predictors of high palliative care burden in multivariable analysis were Eastern Cooperative Oncology Group performance status >2 (odds ratio, 3.57; P = .047), a plan for no further anticancer therapy after PRT (odds ratio, 3.46; P = .03), and a recommendation against PRT (odds ratio, 4.80; P = .01). CONCLUSIONS Radiation oncology clinicians encounter multiple palliative care issues when consulting on patients for PRT. Clinicians identified physical symptoms, care coordination, and goals of care as the most relevant palliative care domains. These findings can help guide palliative care development within radiation oncology, including education and structures of care delivery.

Global Oncology Volunteering: Making an Effective Contribution

Elements of a good health system are lacking in most low- and middle-income countries (LMICs) and in many high-income countries, including the United States. 
A major problem is financing health care. On average, about 50% of healthcare financing in low-income countries comes from out-of-pocket payments, compared to 30% in middle-income countries and 14% in high-income countries.

Challenges Encountered by Vietnamese Nurses When Caring for Patients With Cancer

&NA; Providing holistic care is acknowledged as central to providing quality care for patients with cancer, but providing competent nursing care consistent with these approaches remains a challenge for nurses in Vietnam. Obstacles for Vietnamese oncology nurses include their low status, the limited scope of nursing practice, work overload in a hierarchical system, and cultural beliefs that view death and dying as taboo. Additional research to support oncology nurses in Vietnam must acknowledge the merits of improving nursing education as an important strategy for enhancing nursing autonomy, quality of care, and outcomes for the increasing number of patients with cancer in low‐ and middle‐income countries.

Screening for Pain in the Ambulatory Cancer Setting: Is 0-10 Enough?

PURPOSE The purpose of this study was to explore concordance between patient self-reports of pain on validated questionnaires and discussions of pain in the ambulatory oncology setting. METHODS Adult, ambulatory patients (N = 452) with all stages of cancer were included. Three pain measures were evaluated: two items from the Symptom Distress Scale (frequency [SDSF] and intensity [SDSI]) and the Pain Intensity Numeric Scale (PINS). Relevant pain was defined as: (1) scores 3 of 5 on SDSF or SDSI or 5 of 10 on the (PINS); or (2) discussion of existing pain in an audio-recorded clinic visit. For each scale, McNemars test assessed concordance of patient self-reports of relevant pain with discussions of relevant pain in the audio-recorded clinic visit. Sensitivity, specificity, and accuracy were calculated and a receiver operating characteristic analysis evaluated thresholds on self-report pain questionnaires to best identify relevant pain discussed in clinic. RESULTS Identification of relevant pain by self-report was discordant (P < .001) with discussed pain coded in audio-recorded visits for all three measures. Specificity was higher for intensity (SDSI, 0.94; PINS, 0.97) than frequency (SDSF, 0.87); sensitivity was higher for frequency (SDSF, 0.35) than intensity (SDSI, 0.24; PINS, 0.12). Accuracy was higher for the SDS pain items (SDSF, 0.57; SDSI, 0.54) than for PINS (0.48). Receiver operating characteristic analysis curves suggest that lower threshold scores may improve the identification of relevant pain. CONCLUSION Self-report pain screening measures favored specificity over sensitivity. Asking about pain frequency (in addition to intensity) and reconsidering threshold scores on pain intensity scales may be practical strategies to more accurately identify patients with cancer who have relevant pain.