Cancer Pain Assessment And Management Nursing Essay

Published Date: 23 Mar 2015

The aim of this project is to a literature review to emphasize the occurrence of inadequate assessment of pain in cancer patients and to identify the significant role of the nurse in the modern multi-professional team in delivering pain treatments for cancer patients. Pain is one of the most prevalent and distressing symptoms in patients with advanced cancer. Almost 70% of patients with cancer experiences pain at a point through the progression of their diseases. Even though most patients achieve adequate pain control,  patients with more complex pain syndromes continues to fail to obtain adequate pain management, Fainsinger et al (2010)

Design

The Literatures searches was carried out on a major data base through journal and researched publications relating to the subject the role of the nurse in effective cancer pain assessment. However, 5 main articles were critically analysed using the Critical Analysis Framework.

Findings

176 of papers of potential interest were identified through database searching and 4 additional records identified from other books and publications. Out of these 180 literatures, 79 were found to be duplication. The quality of these literatures were each critically analysed and evaluated using the framework for critical Appraisal research tool. Using these criteria, I identify 25 literatures search as not directly appropriately related to the topic cancer pain but rather authors writing about various issues on cancer diseases. 20 results were eliminated as they were also directly linked with children or the palliative care.

Finally, 8 core articles were carefully selected as the core articles for this project as they provide recommendations through consensus to provide a useful cancer-related evidenced base pain guide for practice.

Conclusion

Further research and education need to be carried out in supporting clinicians particularly, the nurses who are in constant contact with cancer patients. These training and support will enhance the effectiveness of implementing cancer pain assessments and treatments to patients thereby increasing service quality and controls the output of front line workers.

CHAPTER ONE

The Need To Improve Nursing Practice

Development in medical research and treatments has enhanced the survival rate of cancer patient by at least five years in a number of cancer type. Conversely, pain syndromes from chemotherapy, radiotherapy, surgery or interventional procedures persist to have a large effect on cancer patients' survivors' quality of life. This makes it obvious that nurses are uniquely placed in healthcare and have a duty of care in pain assessment for cancer patients and to make sure that pain management strategies are initiated to improve patient's life, Chapman (2011).

The need to change clinical practice demands healthcare practitioners to regularly develop and enhance their knowledge and skills to make sure they are abreast with best practices. Nursing research consequently focuses on knowledge that is useful in the practice by creating knowledge that influence best clinical practice Burns & Grove (2006). Nurses need to continually look for solutions, choices and outcomes for patients that represent the best available knowledge to constantly improve and validate nursing care, Polit and Beck (2009) .The emergence of evidence-based practice and the development of an evidence base for nursing, the pressure to introduce mechanisms for continuous quality improvement and its associated emphasis on outcome measures, together with the development of practice review techniques, are not accidents of fate. They all reflect a desire to deliver the best nursing care as possible. Pearson, Field and Jordan (2007)

1.1 The Rational for the Topic

The purpose of this dissertation is to explore recent literature reviews which focuses on nursing practice aimed at identifying gaps in cancer pain assessments and management. To be able to achieve this, I will be demonstrating personal competency in analysing and critiquing available literatures and evaluate their impact on healthcare practice.

The chosen topic for this dissertation is cancer pain assessments and management. This is a very interesting topic as there is still more knowledge to be explored. The rationale for this selection is in twofold: first and foremost, this is a topic of personal interest. Having cared for a family member experienced pain during cancer ill health and again coming into contact with patients suffering from aggressive cancer pain as a student nurse in placements have further promoted my passion and interest around the topic. Lastly, by writing this thesis it is hoped to further enhance personal knowledge and skills in the nursing profession required to understand, manage and assess oncology pain effectively in preparation to becoming a qualified nurse.

My primary goal is to discuss and analyse the role of the nurse and other multidisciplinary team involved in delivery an evidenced based care in meeting the holistic assessment of pain for the adult cancer patients. I will also look at barriers that prevent effective pain assessment and finally research for literature reviews from World Health Organisation and the national guidelines, policies and recommendation that underpins the assessment and management of oncology pain. To achieve these objectives, a literature search was conducted.

1.2 Search Strategy

Polit et al (2006) argued that the aim of carrying out a literature search differs from one researcher to the other. However the Nursing Times (2007) identified another rationale for conducting a literature search by stating that literature search a well thought and organized search for all of the obtainable literatures available on a chosen topic. They further went on to say that a thought through literature search is the most valuable and well-organized way to search for sound evidence on the topic in question. These evidence based literatures were researched in books, journals, government documents and the electronic data base. The purpose for conducting literature search for this project is to enable me to obtain articles needed for this piece of work and finally to draw together more information on the chosen subject in order to make an informed discussion in building up knowledge for transition into my future practice. There following inclusion criteria were deployed in assisting to get the most of up to date related literature.

Secondary research articles

English Language

Literatures from 2005 - 2012

Literatures relevant to the chosen topic

In setting these inclusion criteria under consideration the literature searching started from the OVID database, searching through CINDHL (Cumulative Index to the Nursing and Allied Health Literature), MEDLINE and the BNI (British Nursing Index).

The literature searching commence with the electronic search on data bases such as psyINFO, Medline and CINAHL as these databases contain a rich and resourceful information on health and the social sciences as indicated by Gerrish and Lacey (2006). Boolean Operators was used to give the search engine the key words to either include or exclude Ely and Scott (2007). These are AND, OR and NOT. AND or NOT which turn to narrow the search whiles OR broadens it. This Boolean Operating system was employed in combining the appropriate keywords to aid in looking up for literature review.

The Key words are as follows:

Cancer pain experience,

Pain management,

Terminal pain

suffering in cancer.

Terminal cancer care,

Chronic cancer care

Nursing role and interventions in cancer pain.

The results were then combined and narrowed down to meet the research subject. This search focused on the identification of qualitative literatures relevant to the experience of cancer pain. The research period is from 2005-2012 in order to obtain an up- to -date literature to improve practice.

Subsequently, further research was carried out through the Internet, accessing the Wiley online library, World Health Organization and The oncology Nursing ISociety ,British pain Society website, and various Nursing Journals online. In addition specialist Journals available in the nursing library and discussions with specialist nurse practitioners and course tutors were used. The university library was used at length and assistance obtained from the librarians with expertise of doing searches some limitations of the electronic searches were encountered.

The importance of using many approaches to identify appropriate literatures was emphasized by Greenhalgh and Peacock (2005) .This process was followed in aiding me to make look up for reference lists in journals which gave me useful insight into the topic. Hand searches were also sorted from related journals and publications from health institutions such as the National Institute for Clinical Excellence, Department of Health on the topic cancer pain, by going through the content pages for relevant articles.

1.3 Inclusion and Exclusion Criteria

I set an appropriate criterion to assists me in focusing on the project topic, as explained in Aveyard (2010). The exclusion and inclusion criterion sets the limits for my review and therefore helped guide me in staying focused within the select subject.

In setting the inclusion criterion, secondary data research was used extensively and publications researched in English focussing on the cancer pain assessment and how the nurse can improve pain assessment for cancer patients.

CHAPTER TWO

LITERATURE REVIEW

The literature review aim to stress and identify areas of unending poor practices or gaps in care delivery to aid in discussing knowledge and evidence based practice in managing cancer pain. The Nurses and Midwifery Council (2002) also necessitate a registered nurses to keep up with their professional knowledge and competency on up to date evidence, best practice and if possible bases on applicable available validated research Valente (2003).

This desired practice can be successful when nurses and midwifes build up attitude and an understanding of the need to carry out research process and demonstrate the ability to research and critically question research Ingham-Broomfield (2007)

Many studies of cancer pain occurrence have demonstrated that about 30%-50% of patients in receive of cancer treatment experience pain with advanced disease as indicated by Abernethy, Samsa and Matchar (2003). The World Health Organization (WHO), reported that the gradual increased incidence of cancer in 2008 was 12 667 470 and based on this figures, the incidence of cancer will be >15 million in 2020. Suggesting that the incidence of cancer pain will continue to rise if appropriate measures and interventions are not put in place by then.

British Pain Society (2010) reported that pain is a major indication of all stages in cancer conditions. This pain experience or symptom can be the first signal to patients with cancer and may be an indication of relapse after curative treatment which many patients with metastatic disease may present due to suboptimal pain treatment. Kassa (2010) indicated that many patients with cancer are continuously complaining that pain is the symptom they mostly fear and that they hypothetically think of seeking for euthanasia in a state of unbearable pain which makes life difficult for them. This report further indicating that pain associated with cancer continues to be a huge health problem for patients and may presents a major health issue to the society and the Nation as a whole.

In UK, it been found that two million people have cancer or have lived with cancer experiencing pain It has been shown by study that this number of pain with cancer continue to rise annually by 3%.

Despite many aware and published guidelines and educational programs on the assessment and treatment of cancer-related pain, pain continues to be a substantial worldwide public health concern in patients with either solid or haematological malignancies British pain Society (2010). Patients with long-term cancer pain have been found to report poorer health, functional or psychological disability as a result of their cancer pain. Macmillan Cancer Support (2008).

==Laird and Colvin (2008) added that cancer-related pain is a huge public health issue and represents a significant challenge to patients and healthcare professionals. Pain in cancer patients may be down to pre-existing pathologies, progression of the disease, tumour growth, bone metastases (cancer-intduced bone pain, CIBP) or the treatment of cancer itself (Strong 2002; Twycross 2008; Urch 2008). These writers concluded that pain due to metastatic cancer is often severe, unrelieved and poorly controlled with patients often having to take high doses of drugs with undesirable side-effects. Gralow andTripathy (2007) further found that up to 70% of patients with cancer-related pain do not receive adequate pain relief and this affects physical and psychological well-being, leading to a lower quality of life for the cancer patients.

A another report indicated that a about33.3% of cancer patient exprience pain. This perecentage rises to 75% in the advanced stages of the disease and further attempt to reduce pain and hence improve the ability to perform basic daily life activities and quality of life have been overshadowed in the attempts to cure the underlying disease, Scottish Intercollegiate Guidelines Network life and functional ability (2008).

Chapman (2012) affirm that cancer pain has many dimensions including psychological, physical, social and spiritual which must be addressed in order to improve their quality of life.

According to a systematic study by Kessels et al (2007) indicated that pain prevalence ranges from 33% in patients after curative treatment to 59% in patients on anticancer treatment and to 64% in patients with metastatic, advanced or terminal phase. Sun, Borneman and Piper (2008) explained the factors that influence the development of chronic pain in cancer survivors who have completed treatment as peripheral neuropathy due to chemotherapy, radiation-induced brachial plexopathy, chronic pelvic pain secondary to radiation and postsurgical pain.

Moreover, another systematic review of literature showed that nearly half of cancer patients were under-treated, with a high variability across study designs and clinical settings. Finally recent studies conducted both in Italy and pan European by Breivik, Cherny and Collett (2009) confirmed and makes it clearly evident that different types of pain or pain syndromes are prevalent in all phases of cancer and are not adequately treated or managed.

2.1 Definition of Pain

Pain is difficult to define due to the complexity of its anatomical and physiological foundations, and the experience and the perceptions of each individual person and the social and cultural meanings of pain Pas and Seymour (2008). In contrast, McCaffery (1972) defined pain as 'whatever the experiencing patient says it is, and exists whenever he says it does 'This old but useful definition of pain is well known and still relevant to practitioners. However, the British pain society (2006) also described pain in a more functional way as an unpleasant sensation that is conveyed to the brain by sensory neurons.

The Association for the Study of Pain provides also a comprehensive definition of pain as 'an unpleasant sensory and subjective experience associated with actual or potential tissue damage, or described in terms of such damage. This implies that pain is a more individual experience and a complex phenomenon influenced by biological, psychological and social factors. Wilson (2007) further explained that pain is a multidimensional phenomenon with physical, psychological, social and spiritual components. Suggesting that pain may arise from a number of situations and could be from injury which is a major cause, or may also arise from an illness. Pain has many causes. It may result from a chronic condition such as arthritis or fibromyalgia, it may occur during an intervention (procedural pain), after surgery, in response to an injury or as a symptom of disease British pain Society (2007)

2.2 Pain Theories

Nair and Peate (2009) found that most pain theories recognize that pain experience is both emotional and psychological. The specificity theory hypothesises that pain is experienced when specific nerve endings are stimulated. Information is then carried to a pain centre in the brain. It is the characteristics of the stimulus that determines the intensity of the pain rather than brain. Pattern theory, on the other hand, suggests that no separate system for pain sensation exists. Relatively pain is interpreted by the brain when intense peripheral nerve stimulation occurs Gould and Thomas (1997) Such theories do not explain why pain can occur as a result of gentle stimulus, that is neuralgia, or when no tissue damage exists. Neither do they explain why two people with the same injury may experience different levels of pain. For this reason, Melzack and Wall's (1988) gate theory is more widely accepted as the most important pain theory Main and Spainswick( 2000)

2.3 The Control Theory of Pain

The gate control theory of pain explains that pain impulses must pass through a theoretical gate at the dorsal horn of the spinal cord before ascending towards the brain. Pain messages from A δ and C fibres will push open the gate Nair and Peate (2009) . However, the actions of AB fibres and the descending pain pathway will push the gate closed. The intensity of an individual's pain, therefore, is determined by a balance between noxious stimuli and the AB fibre or descending brain activity. The wider the gate is open the more intense the pain, however, if the gate closes the pain ceases McCaffery et al (2003)

2.4 Classification of Cancer Pain

Chapman (2012) stated that cancer pain can also be described in terms of broad physiological types of pain such as somatic or visceral and neuropathic pain. Patients with cancer may experience pain that has elements of all these types of physiological pain. Nair and Peate (2009) stated that cancer pain can be classified as being either nociceptive or neuropathic. Briggs (2010) pointed out that understanding the likely cause of pain aids development of an individualised management plan to address all aspects of the patient's pain. It is therefore imperative that nurses have a sound understanding of cancer pain and knowledge of how to assess and manage it.

There are several ways to categorize the type of pain that occur for instance acute or chronic pain, nociceptive (somatic or visceral) or neuropathic, Macintyre et al (2010).

Godfery (2005) explained that nociceptive pain is the normal pain pathway that occurs in response to rise to tissue injury or damage. It consists of four components: transduction, transduction, transmission, perception and modulation. Nociceptors are free nerve endings found at the end of pain neurons. They are found in skin and subcutaneous tissues, muscle, visceral organs, tendons, fascia, joint capsules and arterial wall.

In contrast, Mann (2008) expressed that neuropathic pain does not originates as part of normal pain pathways. It is described as pain related to abnormal processing within the nervous system. Nerve injury or dysfunction can be caused by condition such as metabolic disorder, chemotherapy, surgery, radiation, neurotoxins, nerve compression, joint degeneration, tumor infiltration and malnutrition.

According to Higginson and Murtagh (2010) , Portenoy and Koh (2010) most patients with advanced cancer have at least two types of cancer related pain which derives from a variety of etiologies.

2.5 Types of Pain

Pain is commonly divided into three types, acute pain that lasts for less than three months and subsides with healing. Persistent or chronic pain lasts beyond the normal period of healing or has an unidentifiable cause. Lastly cancer pain which is associated with a malignancy, Macintyre and Schug (2007). Chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Statistics on chronic pain conducted by British Pain Society (2010) and the Royal College of General Practitioners (2005) indicated that nearly one in seven people suffer from chronic pain and 20% have suffered for more than 20 years. Two-thirds of chronic pain sufferers surveyed in the UK reports inadequate pain control Mackrodt (2005), Allcock, Elkan and Williams (2007), Chronic Pain Policy Coalition (2007) also stated that pathology of chronic pain is not readily identifiable and may also be unresponsive to a variety of treatments, tensions may result and patients may feel their symptoms are not being acknowledged or taken seriously. Pain can also arise because of changes in the peripheral neurones or nerve compression as a result of a growing tumour; it may also have an inflammatory element Urch and Dickenson (2008).

2.6 Effects of Pain in Cancer Patients

Several studies have examined the effects of pain in patients with cancer and have reported that uncontrolled pain reduces quality of life. The effect of pain on mood and psychological functioning is also well documented, with patients at increased risk of anxiety, depression and suicidal ideation Chapman (2011). The European Pain Cancer survey Breivik et al (2009) found that persistent pain interferes with activities of daily living and social interaction, stop patients from concentrating and made it difficult to perform activities. Raphael, et al (2010) added that pain places increased burden on relatives and patients further reporting that they are unable to care for themselves or others as pain affected their performance at work.

In a qualitative study, conducted by Saunders and Anthony (2007) found that pain 'robbed them' patients the ability of performing the simplest tasks and they pleasures. Valerand et al (2007) also reported that patients used the term 'feeling desperate' about their situation of living with pain having a lack of control over sleep patterns and felt increased fatigued due to pain. Chapman (2012) also found that pain can lead to lifestyle changes, such as alterations in work practice, an inability to perform many activities independently, and reduced psychological and social functioning.

The experience of pain is a highly complex phenomenon with physical, behavioural, cognitive, emotional, spiritual, and interpersonal aspects. This multidimensional nature of pain must be acknowledged in the assessment and management of patients British Pain Society (2010). The International Association for the Study of Pain (1986) also found that pain may result in psychological features, including complaints of poor or non-refreshing sleep, tiredness, depression and poor concentration. However, Cousins and Gallagher (2012) also reported that psychosocial features may play a significant role in the persistence of symptom. In patients with cancer, acute pain may be caused by recurring and/or progressive tissue injury associated with diagnostic or therapeutic interventions Williams and Dale (2006)

Chapman (2012) reported that cognitive behavioural interventions have been found to minimise the impact of pain on mood and has been shown to be effective in patients with psychological issues resulting from pain . The author added that the meaning of pain may be different for patients with cancer compared to those patients with pain relating to non-life threatening illness and some cancer patients may see increased pain as a sign of disease progression or the failure of strong medication, with possible consequences for mood and adherence to treatment protocols. Miaskowski, et al (2005) suggested that a comprehensive pain assessment should include the personal and social influences that determine how pain is experienced and perceived. The British Pain Society (2010) indicated that Pain Management Programmes (PMPs) based on cognitive and behavioural principals are the treatment of choice for people whose persistent pain adversely affects their quality of life. A PMP aims to improve the physical, psychological, emotional and social dimensions of a person's quality of life, functioning towards optimal functioning and independence in managing persistent pain.

CHAPTER THREE

Methodology and Method

3.1 Research Methodology

A research embodies the systematic study of sources, materials and phenomena in a way as to draw a conclusion on a matter or to establish some facts (Saunders et al., 2007). In order to allow a greater understanding and comparison of the expectations related to two very different types of pain experiences in cancer patients; chronic progressive cancer-related pain and acute pain after surgery for cancer, a holistic approach has been adopted by the researcher. Methodology is basically about the methods involved in testing and examining the philosophical views which are outcomes of scientific investigations (Collis and Hussey, 2003).

3.1.1 Research Method

Method covers the entire scope of data collection techniques and research strategies employed by a researcher. The main two methods of data collection are primary and secondary data collection. In gathering data for the purpose of this study, only secondary data has been used. According to Saunders, Philips, & Thornhill (2007), secondary data can be regarded as primary data, which in the past has been collected, processed and stored, by another researcher, for some other purpose. In comparing the expectations relating to pain experiences in cancer patients, other electronic sources such as online journals, articles and databases have been consulted.

Hopkins (2003) describes quantitative research as centered on quantifying relationships between variables. This can either be experimental or descriptive in nature. Whereas descriptive studies do not aim at changing behavior, experimental studies attempt to alter behavior. Qualitative research on the other hand indulges the use of non-statistical and non-numerical information to decode, define and translate some phenomena. For the purposes of this study, the qualitative method has been used to identify and evaluate the effect of pain on cancer pain. This project also focused on the identification of qualitative literature relevant to the experience of cancer pain.

3.2 Research Ethics

In order to ensure that high ethical standards have been observed in the conduct of this study, emphasis has been greatly laid on confidentiality of information. Moreover, the researcher has maintained independence from subjects. According to Cooper and Schindler (2008) ethics can be explained as "norms or standards of behaviour that guide moral choices about our behaviour and our relationships with others". The subject of confidentiality of information has not arisen as all data collected and analyzed in the research is already available to the public. The researcher has duly acknowledged all sources of data that were consulted in the conduct of the study. All sources of information are also accordingly referenced.

3.3 Limitations

Secondary data has been criticized as having a major limitation which is its inability to precisely predict the future. As the researcher has not gathered any first-hand information and relied solely on secondary data, this becomes a limitation to the study. Time constraints were also faced as a number of databases were accessed for relevant literatures to be used. The later limitation was however overcome by effective time management and commitment in enhancing knowledge in improving practice of pain assessment in cancer patients.

3.4 Critical Appraisal

Critical appraisal is the process of carefully and systematically examining research to judge its validity, reliability, and generalisation as stated by Hill and Spittlehouse(2003). To facilitate this writers like Parahoo (2006) and Ajetunmobi (2002) recommended using critique framework because critiquing framework add breadth and depth to analysis but Ajetunmobi (2002) argues that this must be used as a tool rather than prescriptive, as a rationale for choice rather than simple convenience. The Critical Appraisal Skills Programme (CASP) introduced by Public Health Resource Unit (2006) will be used for this literature review. This is because it is simple and systematic and can easily identify flaws and bias in the various research articles to be reviewed in this work.

This chapter will talk about the themes identified and give an in-depth critical analysis on the findings of the research articles. Polit and Beck (2008) and Parahoo (2006) describe the title of a research study as a descriptive sentence with specific details of the proposed subject. The title should be concise, informative and clear, stimulating interest in the topic with information encouraging reading of the entire article.Polgar and Thomas (2008) indicated that the approach adopted by the researcher will depend on the nature of the issue being investigated and the type of data required. Furthermore the title shows that the studies were of a qualitative and quantitative research as identified by Creswell (2003) an approach which focuses on the way people interpret their life experience in order to give meaning using words.

According to Thorne (2004) researchers must be qualified to commence a research study. However Parahoo (2006) disagree stating that the credentials of the authors should not be noted whether they are qualified or experience to make recommendations. Due to the articles being published between 2005 and 2012 it is expected that the articles will be relevant to recent practice. Parahoo (2006) described that abstract in a study must outline the research purpose, sampling method, methodology, sample(s), results and their importance. Watson et al (2008) further suggest that the abstract should provide a concise summary of the subject and the merits obtained should be carefully evaluated. Publishers may specify the amount of words the abstract should include Locke, Silverman and Spirduso (2004).

According to Parahoo (2006) and Watson et al (2008) the abstract should give the reader enough information to decide whether to continue reading the research; however the reader should not expect too much from abstract because the article will contain the main details.

CHAPTER FOUR

Why Pain Assessment ?

Dougherty and Lister (2011) reported that assessment is a key step in the process of managing pain. The aim of assessment is to identify all the factors, physical and non physical that affect the patient's perception of pain. However, Nair and Peate (2009) suggested that pain assessment allows the practitioners to best select appropriate pharmacological and non-pharmacological interventions. Pain is a complex multifaceted phenomenon and its assessment is very challenging. Mackintosh and Elson (2008) stated that accurate assessment and re-assessment of pain are important to provide a baseline measure of the individual's pain against which changes can be measured, promote trust within the patient and healthcare professional and encourage better communication between the individual as well as healthcare professional. Briggs (2010) argued that the answer to accurate assessment is to ask appropriate holistic questions which aim at identifying the nature of the pain, for example sharp, shooting, dull, ache and duration of how long the individual had the pain.

Chapman( 2012) stated reported that thorough pain assessment is essential in defining pain and deliver direct treatment. The aim of assessment is to diagnose the underlying cause of pain and its effect on the patient. British Pain Society (2010) Pain stressed that pain should be assessed regularly and systematically with a validated pain assessment tool. Assessment is not a one-off process; cancer pain is dynamic and may change in response to treatment or disease progression.

The British Pain Society (2006) added that regular assessment is necessary to evaluate changes in pain and the effectiveness of its management. In this sense healthcare professionals must consider pain as the fifth vital sign. Therefore, the patient's pain should be assessed as often as vital signs are taken. Dougherty and Lister (2011) reported that accuracy in pain assessment is a major factor in measuring the adequacy of pain management and indicated that there are many suggested assessment tools found and scales developed to assist the health professional in assess and determining the severity of pain.

The British pain society (2006) assert that the proper and regular self reporting assessment of pain intensity (PI) with the help of validated assessment tools have been shown to be the first step towards effective and individualized treatment. The most frequently used standardized scales are visual analogue scales (VAS), the verbal rating scale (VRS) and the numerical rating scale (NRS) Briggs (2010).

The British Pain Society (2006) emphasized that the presence of pains vary enormously from individual to individual and also vary in the same individual. Some patients may show subtle changes e.g. becoming withdrawn and others becoming aggressive verbalizing and vocalizing their pain. It should therefore be noted that such behaviors may have causes other than pain and appropriate intervention provided as needed.

4.1 Pain Assessment Tools

The use of assessment tools for pain has been shown to increase the effectiveness of nursing intervention and to improve the management of pain Dougherty and Lister (2011) Briggs (2010) found that a wide variety of pain assessment tools exist to support consistent measurement and documentation of pain and that pain rating scales are important in clinical practice. However, Duke (2006) stressed on the fact that it is vital to acknowledge that a pain assessment tool is only one facet of the overall assessment of the patient's pain in achieving a holistic assessment.

Many patients can use them to identify and express their levels of pain and their responses to prescribed treatments. However, McLafferty and Farley (2008) found that the interpretation of pain scores is not straightforward. The patient's ability to understand and use the assessment tools and the careful interpretation of the scores by healthcare professionals are central to successful pain management. Clear documentation and evaluation of results are vital if pain assessment is to be effective De Rond et al (2001)

Coll et al (2004) suggested that using Fitzpatrick et al (1998) framework for identifying the most appropriate pain assessment tool for patients is very useful to show the right pain assessment tool for patients. This framework aim to help nurses to identify the most suitable pain assessment tools for patients. However, more than one assessment tool may be required to assess patients accurately. Therefore, it is important for nurses to be prepared to use a combination of pain assessment tools to achieve the most thorough and individualised holistic pain assessment tools as possible.

Macintyre et al (2010) found that verbal rating scales (or simple descriptor scales) are one of the easiest tools to use and interpret, using key words such as 'no pain', 'mild pain', 'moderate pain' or 'severe pain' have been reported to be helpful in pain assessment. McLafferty and Farley (2008) reported that the Visual Analogue Scale (VAS) can be used by patients verbally or in a written format and may include descriptors for movement, such as 'no pain at rest, mild on movement McLafferty and Farley (2008) further stated that many acute settings have incorporated verbal rating scales into observation charts using numbers to document pain, such as 1=mild pain, 2=moderate pain and so on. Briggs (2010) argued that it is important that the appropriate tools are used and adjectives given to the patient rather than the numbers which are designed to make documentation easy. However, Bird (2005) emphasized that it is important to note that the VAS is highly sensitive to changes in pain levels experienced by patients, which can make it difficult to use Although this scale is generally quick and easy to use, about 20% of patients are unable to complete the assessment or find it confusing.

Macintyre et al (2010) also found that the numerical pain assessment tools can also help assess intensity of pain allowing the person to rate his or her pain from zero indicating no pain and to ten where worst pain imaginable. However these tools require a greater degree of conceptualisation, concentration and dexterity, and therefore may not be suitable for some adults or young children Wood (2004). The psychometric properties of the Numerical Rating Scale (NRS) are among the best characterized of any pain-screening tool; the NRS is highly valid and reliable for detecting acute and chronic pain in many settings, populations, and time frames Jensen and Karoly (2001)

Multidimensional scales offer a more detailed reflection of the person's pain experience. Tools such as the McGill Pain Questionnaire Melzack( 1975) or the Brief Pain Inventory Cleeland and Ryan (1994) can be used in a wide variety of painful conditions, have been published in short and long form, and have been translated

into several languages. Other scales may focus on particular patient groups or neuropathic pain symptoms, for example Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale Bennett (2001). Selecting the appropriate pain assessment tool depends on the clinical area and the individual patient, including factors such as age, cognitive ability, language and preference. Recommendations about the timing and frequency of pain assessment vary according to individual circumstances, but the guiding principles are to assess pain Briggs (2010).

Gagliese and Melzack (2003) argued that the McGill Pain Questionnaire (MPQ) is a standardised scale for the assessment of pain in cognitively intact adults. It assesses the sensory, and evaluative dimensions of pain. However Gagliese and Katz (2003) found that there is a persist concern about the time required for completion, with regards to application in a busy clinical practice and also, patients' capabilities of using this tool.

A careful assessment of patient with pain is to recognize the pain etiology and to determine the associated medical, social, emotional and psychological factors contributing to pain for appropriate and comprehensive treatment British Pain Society (2006). Assessment of pain can be challenging and it is therefore imperative for nurses to be conscious of the many factors that can influence the patients general pain, Dimond (2002). Lynn, Schuster and Kabcenell (2000) reported that to improve pain screening, the American Pain Society first coined the term "Pain as the 5th Vital Sign" to promote routine pain assessment, along with pulse, temperature, blood pressure, and respirations which is still in use in clinical practice to date.

4.2 Cancer Pain Management

Chapman (2012) stated that flexibility is the key to managing cancer pain as disease, pain interventions and personal preferences vary between patients. In 1986, the World Health Organization (WHO) proposed pharmacological management of cancer pain which facilitates a systematic a strategy for cancer pain based on a sequential three-step analgesic ladder from non opioids to weak opioids and to strong opioids. Caraceni et al (2012) reported that after twenty years of the use of WHO analgesic ladders for cancer pain many study have demonstrated that the program continues to be the reference point for pain management.

Scottish Intercollegiate

Wiffen (2007) added that the WHO analgesic ladder, has clear principle for regular "by the clock" oral medication and has helped cancer sufferers all round the world. Nair and Peate (2009) also explained the three steps ladder each contains a recommended level of pharmacological treatment, if pain persists treatment should be moved up the next step with the goal to achieve pain free at the lowest point on the ladder. Step one involves the use of non opioid drugs, step two recommends adding a weak opiods where the last advocates for the use of strong opioids.

However McNicol et al (2006) found that there is a criticism of the WHO analgesic ladder . Many studies question the usefulness of weak opioids in the treatment of cancer pain (step 2) even though there is insufficient evidence to either support or refute the WHO recommendation that a weak opioid has superiority over an NSAID, British pain Society (2010). In addition, the treatment of bone pain, by the second step on the WHO analgesic ladder has been commonly found to be unhelpful, with inadequate pain management or the development of undesirable and intolerable side-effects Eisenberg (2005)

Studies have indicated that many patients develop adverse effects such as constipation, nausea, vomiting, urinary retention, pruritus and central nervous system (CNS) after taking opoids for pain management. In some cases a reduction in opioid dose may alleviate these side effects. Strategies to manage these adverse effects may include the continued use of anti emetics for nausea, laxatives for constipation, major tranquillizers for confusion, and psychostimulants for drowsiness Ripamonti, Bandieri and Roila (2012)

European Association of Urology (2010) also added that respiratory depression is another potential and most serious adverse effect of opioid therapy. All phases of respiratory activity including the rate, minute volume and tidal exchange may be impaired by taking opioids. With repeated opioid administration, tolerance appears to develop rapidly to the respiratory depressant effects of the opioid drugs. As a result, opioid analgesics can be used in the management of chronic cancer pain without significant risk of respiratory depression. When respiratory depression occurs in patients on chronic opioid therapy, the administration of the specific opioid antagonist naloxone should be given to reverse side effects and improves ventilation.

Barrie (2004) argued that providing adequate pain relief while monitoring minimal side-effects can be a challenge. However, thorough initial titration using a standard release of opioid every four hours, with the same dose available for breakthrough, the total 24-hour opioid requirement can be established. The subjectivity nature of pain makes it impossible to categorically state a standard starting dose and this must be established on an individual basis.

World Health Organization Analgesic Ladder for the Treatment in Pharmacological Management of Cancer Pain.

Source, British Pin Society (2010)

4.3 Barriers of Effective Pain Management

Hawksley (2008) reported that overcoming barriers to pain management in cancer care is critical to improving quality of life in patients living with cancer.

Herr et al (2004) identified some of the specific barriers to successful pain assessment as knowledge deficit in both the health professional and patients. Literatures have also suggested that barriers that might influence pain is fears of addiction and side effects from pain medication and fears of disease progression.

Coulling (2005) affirm that despite the ideals of professionalism, education and the establishment of acute pain services, many practitioners still lack knowledge of pain management and have misconceptions of pain behaviours and pain relief methods, which are not conducive in the delivery of effective pain assessment and management. In addition, Manias et al (2002) found that many nurses have underestimated patients' pain and have assessed pain levels below patients' own assessments. Another literature also reports that inadequate, haphazard provision of pain management by some practitioners, the blaming of limited knowledge and resources, tradition and misconceptions about pain, insufficient staffing and poor time management have all been recognised as contributing factors in barriers to pain management Schafheutle Cantrill and Noyc (2001)

However, the British pain society (2010) reported that patients with cancer may have a number of fears about their pain and might be reluctant to report pain. Pain control can be enhanced if management strategies include interventions on relieving anxiety and depression Loftus( 2007). Taylor (2010) also stated that many patients will not report their pain to nurses. They are often hesitant to interrupt busy nurses, or are fearful of being regarded as a 'nuisance'. Some patients may avoid reporting pain because of fear of addiction to medications or known side effects. Evidence have also indicated that many patients will not report their pain experience as they wish to 'be brave', to express their culture and their unwillingness to report pain. Ward et al (1993).

Brennan et al (2007) added that the belief that pain is an inevitable part of the human condition is widespread and pain myths shared by health professionals and patients alike causes a challenge for pain assessment and managements.

Research has demonstrated that the most important of these barriers raised above are fear or addiction consequences of medication use, inadequate communication with health care professionals and religious and cultural beliefs which have been shown to impede effective pain control Peacock and Patel (2008). Carr (2007) further added that the fears about opioids addiction and side effects, and the association of opioids with pain management may prevent patients from adhering to the pain management plan resulting in inadequate pain management.

However, Childers and Arnold (2012) stressed that the risk of addiction should not prevent the use of opioids for the management of pain in those who need it, but it is important that patient's risk factors are identified and monitored. The management approach needs to be truly individualized and the use of opioids as part of an emotional coping strategy should be managed appropriately. Furthermore, Chapman (2012) pointed out that barriers to pain management needs to be addressed to promote effective pain relief and stressing that nurses have a pivotal role in the management of cancer pain and should develop therapeutic relationships with patients to optimise care. Bosch and, Baños (2002) reported that attitudes or behaviours that prevent successful pain management can be assessed by health professionals using the Barriers Questionnaire (BQ) a tool used to evaluate barriers and improve cancer pain management.

4.4 Good Communication In Cancer Pain Management Between Patients/Carers And Healthcare Professionals

Good communication with the patient allows the health professionals including nurses to gain an understanding of the patient's experience and enhances rapport. This in turn may encourage patients to report pain and to do so without fear that they are 'disturbing' staff. Verbal and written communication within the multidisciplinary team is important Oncology Nursing Society (2004). The old adage "not documented, not done", is particularly true in a arguable situation and communication from one healthcare provider to another regarding patient care is mandated by professional and regulatory organizations and agencies including NMC and Oncology Nursing Society NMC( 2008), Oncology Nursing Society (2004)

Mackintosh and, Elson (2008) further reported that good communication between patients and healthcare professionals is essential to ensure realistic treatment plan and outcomes can be negotiated. In addition, Moore (2004) emphasized that communication is enhanced when information is presented in an accessible way and patients experience a sense of confidence, trust, and being listened to. Good encounters with professionals can lead to better patient concordance with therapy and better adjustment to diagnosis. More so carers can play an active role in assessment and management of pain but requires good communication with the health professionals to implement practice.

Kimberlin al et (2004) however reported that health professionals should be aware of the burdens realised on the carers of patients with cancer pain and be prepared to communicate effectively in supporting them to enable patients and carers to voice their fears, wishes and concerns with confidence. British Pain Society (2010) emphasized that patients involvement and input in pain management plays a major part in getting the most out of treatment and nurses should encourage patients to report intensity, quality, location and pattern of pain. A study of the effectiveness of pain management intervention in patients with chronic cancer pain demonstrated that giving cancer patients an active role in their pain management had a beneficial effect on patients' pain experience. Information and an explanation about their medication will form part of this Moore (2006).

4.5 Ethical and Legal Issues in Pain Management

All nurses have an ethical and legal responsibility to initiate immediate pain relieving measures while considering other analgesic options and Involving patients in their treatment to improves pain control Furrow (2002). This implies that proper management of patients with pain is essential for controlling and alleviating patient suffering. It is the nurses' moral, ethical, professional, and legal obligation to assess the patients' pain and to intervene , relieve pain and suffering with appropriate interventions. Pain documentation includes the patient's pain intensity ratings and comfort goal, interventions, and the patient's response to the interventions, according to Cohen, et al.( 2003). In addition, Diamond (2002) stated that it is unacceptable for patients to experience unmanaged pain or for nurses to have inadequate knowledge about pain and a poor understanding of their professional accountability.

Brennan et al (2007) demonstrated through literature that currently strategies having been considered for pain management including ethical issue, promoting pain management as a legal right, providing constitutional guarantees and finally statutory regulations that span negligence to improve and raise the awareness by defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct. Furrow (2002) also added that the failure to manage pain by healthcare providers, either physicians or nurses is considered professional negligence and outline that under-treatment of pain is poor medical practice that results in many adverse effects.

Pain is a prevalent problem for the majority of those hospitalized for cancer and patients' satisfaction with their pain management can improve when patients feel that their pain needs are being addressed (Sternman, Gauker, & Krieger, 2003). The Oncology Nursing Society's (ONS) positions on this issue on cancer pain makes it clear that all patients have the right to optimal pain relief, including culturally relevant and sensitive pain education, assessment, and management of pain Oncology Nursing Society (2004). In addition, The Joint Commission on Accreditation of Healthcare Organizations JCAHO (2000) standard asserts that patients have the right to appropriate assessment and management of pain, and that it is the nurse's core responsibility to respect and support each patient's right to pain management.

4.6 Multi-Professional Approach in Pain Management and the Role of the Nurse

Research has shown that inter-professional working can contribute towards improved pain management by the development of multidisciplinary pain management programmes and acute pain services Schofield (2003). Furthermore, The International Association for the Study of Pain (IASP), the American Academy of Pain Medicine, the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists and the American College of Rheumatology, among many other professional organizations, have long advocated the multidisciplinary approach as the preferred method of restoring health-related quality of life and functionality to patients with pain. Cousins and Gallapher (2011)

Multidisciplinary treatments for pain are cost effective, resulting in increased function and, often, resulting in a decrease in pain and well-being of patients Jensen et al (2009). Multidisciplinary involvement work closely with patients and team that comprises nurses, doctors, psychologists, occupational therapists and physiotherapists who teach a number of different skills. Briggs (2010). Effective pain management involves integrating skills to address the challenge of living with pain. However None of the skills delivered attempt to cure the pain but, together, and over the long term, they aim to improve an individual's quality of life SIGN (2010).

The nurses on the programme educate the patients about pain management and medication

Fahal and Oman (2011) reported that nurses as health professionals spend more time with patients than any other member of the healthcare team. They play a critical, active and very important part in controlling cancer patients' pain and alleviating suffering. In controlling cancer pain the nurse needs to understand the psychological state of the cancer patient, cancer pain treatment, the effects of unrelieved cancer pain and patient's socio cultural background. Fahal and Oman (2011) continued to identify the nurses' role in controlling cancer pain as believing the patient, assessing pain, identifying the root of the problem, planning the care, administering medication, evaluating effectiveness, ensuring good pain control and individualizing treatment However, Cox (2010) emphasized that nurses need to give patients the opportunity to take an active role in managing their pain and also contribute to pain assessment to establish the effectiveness of interventions. It is the role of the nurse to educated patients about pain management strategies.

Graves (2003) stated that there is emerging evidence that education and cognitive behavioural interventions for cancer pain alleviate some of the distress and disability associated with pain, as well as improving adherence to analgesic regimens. In addition Miaskowsk et al ( 2004) explained that educational interventions focus primarily on teaching cancer patients about pain, how to use medications in managing pain, and how to communicate their pain with health care providers to improve pain management. They added that recently, some educational interventions have begun include brief training in one or more pain coping skills as a way of enhancing patients' self-care efforts.

McLafferty and Farley (2008) reported that good communication skills are essential in pain assessment while educating patients to help gain the patient's confidence and help the individual to relax. Briggs (2003) added that there is a need for nurses to use effective and sensitive communication with patients to assist in expressions of pain. This approach should encourage the patient to be open and responsive to questions asked as part of the assessment process.

Dopson (2010) argued that specialists nurses like the oncology nurse and the pain nurse working on pain management programme can easily support patients and teach them techniques on pain management procedures, however it is important to remember that a non-specialist nurse with a good evidenced based knowledge in pain management and long relationship with patients with pain can begin to address the same issues. In contrast, Shugarman (2012) found that nursing staff with more work experience are more likely to underestimate pain, whereas nursing staff with less work experience overestimate pain. In respect of this, Mackintosh and Elson (2008) pointed out that accurate assessment is the key while using the standardise and appropriate tools to manage cancer pain and further stated that nurses should play a fundamental role in ensuring patients with pain receive the most appropriate care with good communication relationship to enable them express their concerns and fears.

4.7 Implications To Practice And The Nursing Role In Pain Assessment

Accurate pain assessment is a prerequisite of effective control and an indispensable element of nursing care Dougherty and Lister (2011)

Failure to conduct an adequate assessment of pain and documentation of pain management may be interpreted as under-treatment of pain that could result in allegations of serious professional misconduct or litigation. As nurses, we should be mindful of our legal responsibilities to ensure accurate management of pain in documentation NMC (2002).

Fahal, and Oman (2011) stated that the role of the nurse is to anticipate the patient's pain needs, advocate for the patient for what feels appropriate for him within his cultural context and incorporate the patient's belief. The nurse can physically relieve pain by promoting comfort, support painful area, gentleness in handling the patient and use nursing treatments. McLafferty and Farley (2008) emphasised that it is important that nursing staff educate and introduce assessments tool to be used and explain the reasons for its function. Krohn (2002) stressed on the importance of listening to the patient's subjective descriptions of pain and documenting consistently throughout the pain assessment.

The nursing assessment process should not be hurried and the patient should not be made to feel rushed. Patients should be given time to think and to respond to the questions being asked. The British Pain Society (2006) emphasized that careful observation enhances the detection of pains. Briggs (2003) highlighted the importance of setting aside adequate time to carry out a thorough assessment. However, this may not always be possible an initial brief assessment and the nurse need to plan and curry out a thorough assessment later to achieve individualise pain to allow for the best available treatment. Pain assessment should be ongoing and regular. The effects of analgesia

should be monitored closely and recorded in nursing notes to maintain continuity of patient care. Regular assessment of pain, and appropriate administration of analgesia, will help to ensure the patient's pain is managed timely, McLafferty and Farley (2008). Assessments and responses to pain treatments must also be accurately documented by nurses and an adequate handover provided to ensure continuity of care within the multidisciplinary and advocacy, Taylor (2010).

4.8 Recommendations

Having carried out a research on the management and assessment of cancer pain there are some problems ascertained in course of providing answers to the research questions. It could be acknowledged that there is need for nurses in UK to be well equipped on the management and assessment of cancer pain to deliver quality care in cancer patients. Poor assessment of pain and inadequate knowledge on the part of nurses have been identified as major barriers in providing effective pain management and holistic care. Swift (2012) argued that providing holistic care to patients includes ensuring they are comfortable and as free from pain as possible. In order to do this nurses need to understand pain physiology, pain assessment and the wide variety of pain-management strategies available

Extensive measure to improve cancer pain management have been identified in this research. The world Health organisation and other regulatory agencies have advocated for better improvement in the delivery of cancer pain managements by providing recommendations and guidelines for nurses and other multidisciplinary team involve in the service of pain management.

SIGN (2008) recommended that the care of a patient suffering from cancer pain requires a holistic approach combining psychological support, social support, rehabilitation and pain management in order to provide the best possible quality of life. The analgesic treatment should start with drugs indicated by the WHO analgesic ladder appropriate for the severity of pain.

The British Pain Society (2010) recommends that clinician should tailor the dosage, type and route of drugs according to each patient's needs. This is because the type and dose of analgesic drugs are influenced by the intensity of pain and have to be promptly adjusted to reach a balance between pain relief and side effects to achieve good pain management.

The Association of Palliative Medicine and the Royal College of General Practitioners (2010) recommended that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects.

Pain management should not only be considered after all oncological treatments have been exhausted, but should begin much earlier at pre-diagnosis when pain is often a patient's presenting symptom NICE (2004).

The British Pain Society (2010) further recommended that analgesic treatment should start with drugs indicated by the WHO analgesic ladder appropriate for the severity of pain and pain should be managed during the diagnostic evaluation. Most importantly the intensity of pain and the treatment outcomes should be regularly assessed using a validated assessment tools that is (i) VAS, or (ii) VRS or (iii) the NRS.

Finally, it is suggested that optimum management of pain in patients with cancer requires a multidisciplinary approach. Healthcare professionals should be educated about the psychological and social dimensions of the cancer experience. Increased education for physicians, nurses, professional groups, patients, and family caregivers also has been recommended to improve care, It is imperative that nurses, physiotherapists, pharmacists and other healthcare professionals also introduce the principles of multimodal pain management into their curricula SIGN (2008).

4.9 Conclusion

Cancer pain management has been found to be challenging and complicated and therefore requires accurate assessment, reassessment, and constant vigilance by health care providers particularly nurses. Similarly, many barriers to successful pain management have been identified in both the patients and the healthcare professionals. Some identified health care barriers include: inadequate pain assessment by nurses, under-treatment of pain with analgesics, inadequate knowledge regarding pain management, nurses' fear over sedating patients and not believing the patient 's experience of pain which have all been found to collectively to result in the inadequate delivery of effective cancer pain management .

Coulling (2005) emphasized that to improve knowledge in cancer pain management it is essential that the nurses at the centre of care in the delivery of pain management question their own beliefs and attitudes, accept their responsibilities for evidence-based pain management practice and be empowered to do so. The right sort of education can prepare them to execute tasks effectively however most of this depends on clinical practice settings or trusts developing positive cultures that promote common professional values to provide supports in pain management education for its staff.

Finally this research has highlighted the significance of systematic pain assessment process with appropria