Pain Assessment Among Chinese Patients With Haematologic Malignancy

Introduction

Pain management is an important consideration in the promotion of patients’ comfort. However, research continues to indicate that patients’ pain management is poor in the overall healthcare provision in Hong Kong, especially among the Chinese patients with haematologic malignancy (Lamia, Hellot & Girault 2006, p.1561). The nursing literature cites nurses’ lack of knowledge as a significant determinant of poor pain management practices (p.1562).

The impetus for this study arose from poor attendance by nurses at in-service sessions discussing pain assessment and management. Knowledge of existing nursing practices and accompanying beliefs and attitudes in relation to pain assessment is paramount in the development of relevant continuing education for registered nurses. The study aims at investigating the nurses’ pain assessment practices as an integral part of pain management in patients with haematologic malignancies. A descriptive research method will be used where a 10-page questionnaire with eight different patient scenarios will be distributed to selected nurses across all clinical divisions of an acute tertiary facility.

Statement of the Problem

While pain assessment is an integral part of healthcare provision for the promotion of the patient’s comfort, it is evident that the nurses’ ability to assess pain among the Chinese with haematologic malignancy is in doubt, judging from the poor pain management practices in Hong Kong hospitals.

Significance of the problem

Proper pain assessment is essential in the overall pain management (Kozier & Erb 2004, p.53). That is to say poor assessment criteria means poor management practices and vice versa. This is because assessment provides the nurse with knowledge of beliefs and attitudes among the patients in relation to pain management as well as assisting in the development of relevant continuing education process for registered nurses (Bryan-Brown 2006, 172; Bickley & Szilagyi 2003, p.121).

Without assessment, the nurse is likely to generate wrong judgment, thus prompting poor management procedures (Szilagyi 2003, p.122). The findings are expected to be essential in establishing proper baseline knowledge for adequate pain management procedures for the haematology malignancy patients in Hong Kong, with the possibility of adoption by other healthcare units.

The number of patients suffering from cancer worldwide has steadily increased in recent years despite extensive efforts to prevent it mainly due to an ageing population (Ganong 2001, p.4). Each year, cancer causes hundreds of thousands of men and women to suffer from unending pain in the process of treatment. A total of 12, 206 men and 10,317 women worldwide were diagnosed with cancer in 2004, and in the same period, 7,183 men and 4,608 women died of the disease (Paz, Crilley, Weinar, Brodsky 2006, p.529).

In Hong Kong, cancer prevalence has been on a steady rise (2% per year) and the cumulative rates up to age 75 were 28.4% for males and 20.3% for females (p.530). That is to say that one person in every four men and 1 person in every five women will develop by age 75 (p.531). Add to an increasing number of chemotherapeutic agents (Murray, et al, 2000, p.66) and a multitude of regimes, it is thus logical to conclude that number of cancer patients undergoing adverse amount of pain has increased concurrently, largely due to knowledge deficit. Furthermore, recent research findings reveal that the longer the patient receives opioids the more concerned nurses become about causing addiction (Shorr et al. 1999, p.85).

Nevertheless, results of current knowledge surveys of nurses suggest that educational efforts probably have been beneficial and hence should continue (Soubani et al. 2007, 1606). It is subsequently imperative to find the best way to pain assessment in order to educate the nurses on the best way to care for patients undergoing such long term pain, like the haematology malignancy patients.

This information is useful in several ways such as exposing areas that have gaps in research literature as well as identifying areas for further study, or serving as a guide for the development of evidence-based practice (Knaus, Draper, Wagner & Zimmerman 1985, p.819). It is therefore justifiable to undertake a study about the pain assessment practices in Hong Kong.

Expected Result

The research is expected to generate some concrete results to help in the compilation of appropriate criteria for the assessment of pain among the haematology patients in Hong Kong. The evaluation criteria for the effectiveness of different treatment method are expected to be valid to warrant adoption in the future. The resultant compilation of the best practices will be essential for any healthcare providers who have the intention of adopting any of the appropriate methodology, depending on the inherent factors such as age, gender, and culture.

The intended evaluation of patients undergoing severe pain as a result of haematologic infections will offer a comparative benchmark for evaluation of other patients going through other kinds of pain. These results are crucial for the success of overall pain assessment.

The study specifically focus on Chinese patients with haematologic malignancies by examining these important variables:

1. nurses’ knowledge and attitudes about relieving patient’s pain;
2. nurses’ perceived barriers to optimal pain management for the patient;
3. amounts of available analgesics administered by nurses in relation to levels of patient’s pain; and
4. the patient’s perceptions of their pain.

I believe the findings related to this topic of study will help nurses working with Chinese populations in identifying patients at risk for increased pain and in planning pain-relieving strategies, and at large may be essential to be adapted to other patients from other regions, as long as its viability is assessed.

Background of the problem

Patients who are admitted to the intensive care with haematological malignancy have a higher mortality as compared to other cancer patients (Shorr et al. 1999, p.83; Potter & Perry 2004, p.199). Adverse prognostic factors include the number of organ failures, invasive mechanical ventilation and previous bone marrow transplantation (Potter & Perry 2004, p.199). However, the severity-of-illness scores may underestimate the mortality and more importantly, the severity of the pain of critically ill patients with haematological malignancy (pp.203-204).

Haematologic malignancy is one of the most common cancers occurring in Hong Kong and pain is reported to be a major symptom for many patients with haematologic cancer (Twycross 2002, p.705). For many haematological patients, the prospect of pain is more frightening than any other potential complications which including death (p.707). Pain is often poorly assessed, and many caregivers lack sufficient knowledge to optimize treatment (Gordon et al. 2005, 340). However, little is known about this symptom among Chinese people who have cancer.

Most of the past researches on this area of study have dwelt on the assessment of high mortality rate among patient admitted with this complication, especially with the adult patients. In studying nurses’ knowledge and attitudes about pain relief, Evison, Rickenbacher Ritz & Gratwohl (2001, p.682) identified the knowledge deficits on adequate pain relief to be on areas such as:

1. dosing, safety, and scheduling;
2. how to achieve therapeutic levels; and
3. likelihood of addiction and respiratory depression.

In addition, studies have shown that while many nurses viewed patients’ self-reports of pain to be reliable, others believed patients often over reported or underreported pain (Baker & Fraser 1995, p.370).

Pain assessment and management among cancer patients have been studied in non-Chinese population, with a lot of emphasis on management and little about prior assessment. Furthermore, many of the studies have largely focused on issues other than knowledge and attitudes to pain relief among the Chinese. Some of the barriers nurses have expressed to be preventing them from administering optimal pain assessment and management are:

1. physician reluctance to prescribe adequate analgesics;
2. nurses’ lack of time;
3. patient reluctance to report pain or take opioids;
4. inadequate pain assessment; and
5. fear of addiction (Guyton & Hall 2000, p.321; Harrison et al. 2007, p.1093).

Scope

This study will therefore focus on pain assessment as part of process of proper pain management, with an aim of extending knowledge on this area of practice and study. Specific focus would be on Chinese patients with haematologic malignancies by examining these important variables:

1. nurses’ knowledge and attitudes about relieving patient’s pain;
2. nurses’ perceived barriers to optimal pain management for the patient;
3. amounts of available analgesics administered by nurses in relation to levels of patient’s pain; and
4. the patient’s perceptions of their pain.

Objectives

1. To investigate the nurses’ pain assessment practices on the Chinese acute haematology patients.
2. To investigate the nurses’ knowledge and attitudes in relation to pain assessment.
3. To investigate the existing protocols as well as tools available for pain assessment in the Haematology unit

Research questions

1. What are the common practices nurses apply in assessing pain among the haematology patient?
2. What level of knowledge do nurses have in relation to pain assessment?
3. What protocols and tools exist in pain assessment process in the Haematology Unit?

Literature Review

The word cancer elicits dread in nearly everyone. Cancer has been noted to account for considerable mortality and morbidity in both men and women (Kozier, 2004, p.189). Its cause is related to certain genes controlling growth and interactions with other normal cells that apparently become abnormal in structure or less regulated (Knaus, Draper, Wagner, Zimmerman 1985, pp.818-819). Humans of all ages develop cancer, and a wide variety of organs are affected hence affecting the normal functioning of the body system.

The incidence of many cancers increases as the fourth to sixth power of age, so that as people live longer, many more will develop the disease (Lloyd-Thomas, Wright, Lister & Hinds 1988. p.1026). Its impact has not only been enormous in terms economic costs but also the kind of endless pain the patients undergo during treatments (Murray, et al, 2000, p.201).

Cancer is caused by mutation or by some other abnormal activation of cellular genes that control cell growth and cell mitosis (McCaffery & Pasero 1999, p.133; Marieb 2004, p.412). The abnormal genes called oncogenes, together with present antioncogenes cells, which suppress the activation of specific oncogenes are the primary source of cancer (Marieb 2004, p. 413). It’s the loss of or inactivation of antioncogenes paves way for the activation of oncogenes, which subsequently leads to cancer development (Guyton & Hall 2000, p.266).

Cancer cells are characterized by three properties:

1. diminished or unrestrained control of growth;
2. invasion of local tissues; and
3. spread, or metastasis to other parts of the body (Guyton & Hall 2000, p.281).

Cells of benign tumors also show diminished control of growth but do not invade local tissue or spread to other parts of the body (Murray, et al, 2000, p.141).

Pain assessment in cancer patients is therefore of primary importance in process of pain management. This is because as has been observed, many hospitalized patients consider pain control as part of healthcare provision, and its persistent is of great concern to them (Harrison et al 2007, p.1091). Hawthorne & Redmond (1999, p. 41) observes that pain is considered to impact on the general well being of individual, both physically and psychologically, and most importantly it has emerged to be key issue in functional ability of the patient. Furthermore, certain groups of patients consider it as a major determinant of quality of life and increasingly cite it as an outcome to be measured to evaluate effectiveness in health care provision (Yau, Rohatiner, Lister, & Hinds 1991, p.931; Hawthorne & Redmond 1999, p.99).

Education in acute pain management has been evidently expanded in universities and trusts over the past decade. However, there is equal measure of knowledge gap since these schools major on pain management, without considering pain assessment as part of the management process (Hawthorne & Redmond 1999, p.54). Yau et al. (1991, p.940) observes that one key component of effective pain management is nurses’ possession of adequate knowledge and “appropriate attitudes” in assessing patients during healthcare provision.

This facilitates recognition that patients’ self-report of pain is the single most reliable indicator of pain and thus should be recorded in the patient’s record as the nursing assessment, regardless of the patient’s behavior (p.1941). However, despite the above enormity of the issue, one peculiar scenario was revealed in some a study by Gordon et al. (2005, p.346) who established that majority of the nurses normally fail to acknowledge the patient’s report of pain. These nurses believe that there are factors in determining pain rather than the patient’s own view and assessment such their own observation of patient’s behaviors. This assumption can be disastrous, especially if the patient do not express themselves in a recognized manner to warrant observation (p.347).

The age factor has also been displayed in some of the practicing; some studies revealed that nurses are more willing to believe pain reports from older patients against the younger patients, but less willing to administer opioid analgesics to older patients (Ewig, Torres, Riquelme 1998, p.116). They (nurses) therefore see objective factors like clinical observations, type of surgery, and existing drug regimen as more valid indicators of suffering; consistent with this is their decision to provide analgesia (p.121).

Background and the socialization process of the nurse are also critical in the process of pain assessment. This is because they determine personal values, beliefs and attitudes towards the meaning and management and more specifically, assessment of pain (Ganong 2001, p.131; Gordon et al. 2005, p.341). Gordon et al. (2005, 342) observe that knowing what is ‘best practice’ is not enough for professional nurses, since they (nurses) have been found to give allegiance to their own personal beliefs and work-based attitudes.

Methodology

The research will be descriptive in nature, that is, descriptive research methods will be used to provide a comprehensive summary of the data presented in an understandable and usable manner. I preferred this option due to the limited research in the area and the possibility of promoting understanding of attitudes and perceptions of nurses’ pain assessment among the Chinese patients with haemotologic malignancy (Azoulay, Recher & Alberti1999, p.1395).

To get adequate data, structured questionnaires will be used to ensure the reliable information is given. Structured questionnaires are preferred in this case since I have hypothesized that some nurses may not be ready to identify themselves openly during the interviews, preferring confidentiality when answering the questionnaire. This reasoning informed the idea of not using tape recording, which may drive many potential interviewees away (Gordon et al 2005, p.340). Again, scheduling interviews may not be an easy process as the nurses may be committed; hence the use of structured questionnaires, which are appropriate in reducing the logistics nightmares associated with face-to-face meetings (Yau et al.1991, p21; Kozier & Erb 2004, p.31)

The target population will be nurses working in a haematologic ward of a rural hospital of approximately 200 beds that provide a wide variety of health services. Hospital ethical approval will be obtained from the hospital, research and ethics committees.

A stratified random sample would give all the nurses the same chance of being selected, and would remove the risk of bias from researcher familiarity with participants (Yau et al.1991, p.33). Nurses who are not in direct care with haematologic patients or without experience in that field will be excluded. This is to ensure that only nurses with the latest contacts with the patients are given chance to get the first hand information, as conventional common knowledge inform us that people tend to remember more the most recent incidences rather than the past ones (Azoulay, Recher & Alberti 1999, p.1397).

The nurses who will give informed consent will participate by filling the structured questionnaire. A structured questionnaire will be designed to identify professional demographics and educational input, barriers to acute pain management, perceived competence in clinical skills and to test knowledge. This is meant to conform to my research objectives.

Before the final questionnaire is designed, a pilot questionnaire will be administered as a validity check to colleagues working in acute pain, research and education. The pilot administering of the questionnaires is crucial in that I’ll be able to identify loopholes to the old redesigned questionnaires that have been used before. I have decided to use a sample questionnaire that had been used before to guide my questionnaire structure.

As Azoulay, Recher & Alberti (1999, p.1399) observes, structure of a questionnaire is as important as the questions it contains, since structure determines the response. These loopholes would be sealed by coming up with well structured and relevant questions, hence validity and up-to-date (Shorr et al. 1999, p.1017). The study’s objectives will be outlined and deficiencies in the layout and wording will be identified.

If some questions will be repetitive or irrelevant; alterations will be made and questions will be refined in response to the feedback gathered from the pilot questionnaires. Invalid information can completely distort the whole questionnaire structure, administration and outcome, and unreliable data in the questionnaire will render the whole research useless (Paz, Crilley, Weinar, Brodsky 1993, p.527).

Trustworthiness will be established through the application of dependability, credibility, confirmability, and transferability (Lamia, Hellot, & Girault 2006, p.1566). Dependability will be ensured through the maintenance of a clear audit trail, by a thorough check of the work by research supervisors, and actions taken to enhance the credibility of the study (p.1567). These actions will include prolonged engagement through a working acquaintance; peer consultation with supervisors and experts in the field; checking identification of key points and interpretations with participants; data triangulation through the use of subjects working in different areas; person triangulation by accessing subjects with different levels of training, experience, and responsibility; and the careful examination of contradictory data to modify interpretation and explain negative cases (Lamia, Hellot & Girault 2006, p.1568).

Twycross (2002, p.707) states that untrustworthy and undependable team of researchers will not be concerned with the outcome of the research but what they gain in the process, i.e. financial benefits, a habit that will not only distort the process but will kill the research ethics. Confirmability is assured by a detailed description of the research process with the inclusion of data that support conclusions. Any findings must be confirmed as this process lead to the exactness of the process (Yau et al. 1991, p.939).

Limitations

Data will be analyzed using descriptive statistics. It is expectated that further analysis could be undertaken between different groups within the hospital. However, if the response rate is below, there will not be any significant numbers representative of any specific group to make reliable comparisons.

As stated earlier, the area of study has a relatively limited amount of information, hence the difficulty in collecting adequate literature review. Furthermore, some of the past research works may be stale hence offer invalid information. Again, some peer review journals may be available in the internet but at a cost. Sometimes buying what has just been briefly reviewed online for marketing purposes may be deceptive, hence leading to compilation of irrelevant materials, cutting deep into the limited research budget.

Plan of Work

Consent will be obtained from the participating areas together with ethics approval from the Research Committee at the hospital. Surveys will be sent to the selected nurses with a covering letter to explain the intent of the research and stating that their responses would be anonymous and confidential. Nurses will be asked to complete the questionnaire at their leisure. A return address label will be enclosed with the questionnaire so that on completion of the survey the nurse could easily return it via the hospital’s internal mail. A follow up interview will then be done.

Ethical application

In all countries, research works that involve human subjects and animals should be carried out in accordance with high ethical standards set by various ethics committee (Paz, Crilley, Weinar & Brodsky 1993, p.528). The privacy and dignity of every individual involved in the research will be protected at all levels. The participants in this study will be assured confidentiality and anonymity through identification coding and reports of aggregate data. The participants who will be involved will be notified of the aims, methods, expected outcome, benefits and potential hazards of the study conducted and more importantly, approval from the Ethics committee will be a priority.

For the process of having consent, it is important that the researcher must provide a formal letter of consent being addressed directly to the respondents and the people responsible for reaching out to those subjects needed for the research completion (Lloyd-Thomas et al. 1988, p.1026). I will make sure the consent letter contain original signature and without any restrictions, conditions, or stipulations. Any restrictions or conditions must be kept separately between the parties involved.

List of References

Azoulay, E, Recher, C, Alberti, C 1999, “Changing use of intensive care for hematological patients”, Intensive Care Med, 25:1395-1401.

Baker, R, & Fraser, R 1995, “Development of Review Criteria: Linking Guidelines and Assessment of Quality”, British Medical Journal, 311, 7001, 370-373.

Bickley, L, & Szilagyi, P 2003, Bates’ Guide to Physical Examination and History Taking 8^th Edition, Lippincott Williams and Wilkins.

Bryan-Brown, W 2006, “Evidence-Based Practice is Wonderful”, American Journal of Critical Care, 83, 34.

Evison, J, Rickenbacher, P, Ritz, R, & Gratwohl, A 2001, “Intensive care unit admission in patients with haematological disease: incidence, outcome and prognostic factors” Swiss Med Wkly, 131:681-686.

Ewig, S, Torres, A, Riquelme, R 1998, “El-Ebiary Pulmonary complications in patients with haematological malignancies treated at a respiratory ICU”, Eur Respir J, 12:116-122.

Ganong, W 2001, Review of Medical Physiology 20^th Edition, McGraw-Hill.

Gordon, C, Oakervee, E, Kaya, B, Thomas, M, & Barnett, M 2005, “Incidence and outcome of critical illness amongst hospitalised patients with haematological malignancy: a prospective observational study of ward and intensive care unit based care”, Anaesthesia, 60:340-347.

Guyton, A, & Hall, J 2000, Textbook of Medical Physiology 10^th Edition, Harcourt Asia Pte Ltd.

Harrison, A, Parry, J, Carpenter, R, Short, A, & Rowan, K 2007, “A new risk prediction model for critical care: the Intensive Care National Audit & Research Centre (ICNARC) model”. Crit Care Med, 35:1091-1098.

Hawthorne,J, & Redmond, K 1999, Pain: Causes and Management, London, Blackwell Science.

Knaus, A, Draper, A, Wagner, P, Zimmerman, E 1985, “APACHE II: a severity of disease classification system”, Crit Care Med, 13:818-829.

Kozier, B, & Erb, G 2004, Fundamentals of Nursing: Concepts, Process, and Practice 7^th Edition, Pearson Education Inc.

Lamia, B, Hellot, M, & Girault, C 2006, “Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU”, Intensive Care Med, 32:1560-1568.

Lloyd-Thomas, R, Wright, I, Lister, T, & Hinds, C 1988, “Prognosis of patients receiving intensive care for life-threatening medical complications of haematological malignancy”, BMJ, 296:1025-1029.

Marieb, E 2004, Essentials of Human Anatomy and Physiology 7^th Edition, Pearson Education Inc.

McCaffery, M, & Pasero, C 1999, Pain: Clinical Manual, Mosby, New York NY.

Murray, K, Granner, K, Mayes, A, & Rodwell, V 2000, Harper’s Biochemistry, London, McGraw-Hill.

Paz, H, Crilley, P, Weinar, M, Brodsky, I 1993, “Outcome of patients requiring medical ICU admission following bone marrow transplantation”, Chest, 104:527-531.

Potter, P, & Perry, A 2004, Fundamentals of Nursing, New York, Mosby.

Shorr, F, Moores, K, Edenfield, J, Christie, J, & Fitzpatrick, M 1999, “Mechanical ventilation in hematopoietic stem cell transplantation: can we effectively predict outcomes?” Chest, 116:1012-1018.

Soubani A, Kseibi E, Bander J, Klein J, Khanchandani G & Ahmed H 2004, Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest, 126:1604-1611.

Twycross, A 2002, “Educating nurses about pain management: the way forward”, Journal of Clinical Nursing. 11, 6, 705-714.

Yau, E, Rohatiner, Z, Lister, T, Hinds J 1991, “Long term prognosis and quality of life following intensive care for life-threatening complications of haematological malignancy”, Br J Cancer, 64:938-942.