Evaluation Of Pain Management And Its Implications For Patient Care Among Nurses At The Lautech Teaching Hospital Ogbomosho Oyo State

Project and Seminar Material for Nursing (Science)

Evaluation Of Pain Management And Its Implications For Patient Care Among Nurses At The Lautech Teaching Hospital Ogbomosho Oyo State


Abstract


Background: Pain is the most devastating symptoms in cancer and may occur right from time of diagnosis to the end of life. It adversely affects the quality of life especially the physical component leading to disability. Pain remains a major challenge in cancer management despite the great efforts by World Health Organization (W.H.O.) which led to development of guidelines in pain management, the W.H.O. analgesic ladder (W.H.O. 1996). Pain is subjective and its relief mainly depends on the pain treatment employed. There are several patient’s attributes that influence the effect of pain management. These include; age, culture, gender, type of cancer, stage of the disease, among others. The pain management practice is mainly the selection of the most effective pain relief modality/treatment such as analgesics e.g. opioids; palliative surgery, radiation and chemotherapy; physiotherapy; and psychotherapy. The outcome of the treatment is indicated by ability to perform activities of living.

Objective: To assess the pain management and its implications for patient care of living among patients at Lautech Teaching Hospital Ogbomosho (LTH), Nigeria. Methods: This was descriptive cross-sectional study. The study chose cancer patients as a case study for pain management because of their high relativity to pain and a total of 188 patients on cancer treatment were recruited to the study after signing an informed consent. Convenient sampling method was used to obtain the sample. The study was conducted at Lautech Teaching Hospital Ogbomosho (LTH) Cancer Treatment Centre (CTC) i.e. Oncology ward Ground Floor D (GFD), oncology clinic Ground Floor C (GFC)and radiotherapy for a duration of three months. A structured questionnaire and BPI were used to collect the data. Data was entered and analysed using SPSS version 21.0. The data was described using descriptive statistics and analysed using Regression and Pearson correlation to test relationship between independent variables and dependent variable. The pain management practices were identified and pain interference with; performance of ALs, mood, walking, normal work, sleep, relation with others and enjoyment with life was examined. The significant levels were set at P<0.05 for all tests.

Results: A significant relationship between pain relief, pain intensity and interference with performance of living was found. However, none of the social demographics variables (age, education level, marital status, income) were significantly related to pain relief. Chemotherapy and surgery had a significant relationship with the pain relief (P=0.054,) though the painkillers (NSAIDs)(n=172) were the most used for cancer pain control. Conclusion: Pain management practices determine pain relief which has a reciprocal relationship with performance of ALs. Chemotherapy and surgery may be the suitable therapy which may enhance QoL of cancer patient.


Table of Content


Chapter One:

Introduction

  • 1.1 Background of the Study
  • 1.2 Statement of the Problem
  • 1.1 Purpose of the Study
  • 1.2 Objective of the Study
  • 1.3 Research Questions
  • 1.4 Hypothesis
  • 1.5 Justification of Study
  • 1.6 Study benefit
  • 1.9 Definition of Terms
  • 1.10 Study Limitation
  • 1.11 Organization of the Study

Chapter Two:

Review of Related Literature

  • 2.1 Conceptual Review
  • 2.2 Theoretical Review
  • 2.3 Empirical Review

Chapter Three:

Materials and Methods

  • 3.1 Study design
  • 3.2 Study area
  • 3.3 Study Population
  • 3.4 Sample size determination
  • 3.5 Sampling technique
  • 3.6 Inclusion and exclusion criteria
  • 3.6.1 Inclusion criteria
  • 3.6.2 Exclusion criteria
  • 3.7 Data collection
  • 3.7.1 Study instrument
  • 3.7.2 Recruiting and training of research assistants/enumerators
  • 3.7.3 Pretesting of research tool
  • 3.8 Data analysis and presentation
  • 3.9 Ethical consideration
  • 3.10 Dissemination

Chapter Four:

Results and Data Presentation


Chapter Five:

Discussion, Conclusion and Recommendation

  • 5.1 Discussion
  • 5.2 Conclusion
  • 5.3 Recommendations
  • 5.4 Further research
  • REFERENCES
  • APPENDIX

Chapter One


Introduction

1.1 Background of the Study

Pain is unpleasant sensory and emotional experience associated with actual or potential tissue damage, or describe in terms of such damage (International Association for the Study of Pain (ISPA), 1994). Pain is the most terrifying symptom in cancer and affects largely quality of life.

W.H.O. defined QoL as individual’s perception of their position in the context of culture and value system where they live, and in relation to their goals, expectations, standard and concerns. W.H.O. furthers identifies six components of QoL i.e. person’s physical health, psychological state, level of independence, social relationships, personal beliefs/spirituality and relationships to relevant features of environment. (W.H.O. health promotion glossary (HPG) 1998)

The incidence of cancer was 12,667,470 in 2008 and is projected by W.H.O. to increase to over fifteen millions by year 2020 thus suggesting that cancer-related pain may be a major issue of health care systems, throughout the world (Ripamonti C.I. 2012). The number of patients is increasing with estimated nine millions new cases per year half of which are in developing countries. (W.H.O. 1996). According to Nigeria national cancer control strategy 2011-2016, Nigeria’s annual incidence of cancer is estimated at about 28,000 cases. This implies that about 9000 patients suffer from cancer pain.

Cancer pain can be classified as periodic, long term or sudden and based on pathophysiology can as well be classified as nociceptive, neuropathic, idiopathic or psychogenic. Patients may suffer from variety of pains i.e. total pain which include physical, social- cultural, psychological and spiritual pain. This pain mostly starts right from diagnoses and persists throughout the disease process. Although pain is subjective, physical pain remains the main cause of suffering and can easily be assessed using the validated tools.

Cancer pain among patients have prevalence of 64% in patients with metastasis, advanced or terminal phase disease, 59% in patients on anticancer treatment and 33% in patients after curative treatment i.e. cancer survivors, however there was no difference in pain prevalence between the patients during anticancer treatment among those in advanced or terminal phase of the disease. (Sichetti, Bandieri, Romero, Biagio, Luppi, Belfiglio, Tognoni and Ripamonti, 2010).

Pain threshold varies in each patient differs. It may be raised by empathy, distraction, sense of humour, sufficient sleep and understanding or lowered by fear, anger, loneliness, depression and fatigue. (Ripamonti C I, 2012).
In almost all patients, the quality of life is largely affected by pain with physical activity affected most especially sleeping, appetite, personal relationship, emotion, and visual activity (Bhuvan K.C. et al, 2022), patients with mild cancer pain are oftenly undertreated despite the clear guidelines by W.H.O. 3 steps analgesic ladder. Cancer pain despite causing great suffering to the patient also takes along a heavy burden on the family and society at large. (Ping, Sunz, Lu, Pang, and Ding, 2012).

The main goals of pain management are to achieve pain control and relief, reduce adverse effects and cost, enhance autonomy and performance of activities of daily living including psychological aspect, and improve quality of life. (American Society of Anaesthesiologists (ASA) Task Force, 1996.) Successful pain management require multidisciplinary approach failure to which result to under-treatment (APCA, 2012). In 1986 W.H.O. came up with cancer management guidelines to ensure optimal cancer pain assessment and treatment.

European Society for Medical Oncology (ESMO) clinical practice guidelines 2011 recommended that assessment and management of pain in patients is of great importance in all stages of the disease. Correct and consistent assessment of pain by using validated assessment tools is the initial step for an effective and individualized treatment. Three tools have been suggested for use in assessment of pain intensity i.e. visual analog scales, verbal rating scale, and numerical rating scale. However, when cognitive functions are severely affected e.g. in old age and in presence of inadequate communication skills or end of life stage, self-reporting of pain becomes difficult. In this case observation of pain related behaviours and discomfort may be used as an alternative assessment tool for pain though not validated. (Ripamonti Bandieri, and Roila, 2011).


1.2 Statement of Problem

Pain is the most terrifying symptom in patients. It is defined as unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for Study of Pain (IASP), 1994). Nevertheless, it is essential for survival as an important physiologic response to stimuli.

Patients generally suffers from various types of pain such as acute pain, chronic pain, incidental pain, breakthrough pain, procedural pain, neuropathic, and nociceptive pain. These pains are influenced by psychological factors, spiritual factors, and social factors. Pain management practices require holistically integrated multi-disciplinary approach and are the main determinant of pain relief.

Cancer pain when is inadequately controlled can affect patient‟s physiological, psychological, social and mental functions causing great suffering and also brings a heavy burden on the family and society. It interferes with the performance of ALs, mood, mobility and independence which occurs despite the underlying disease stability. Cancer patient in pain may become hopeless and may believe that pain indicates complication and worsening of the deadly ailment. Further it can result to poor compliance to cancer treatment, despair and feeling of worthlessness.

Study done in Beijing on quality of life (QoL) in patients in 2012 concluded that patients with pain have poor QoL which is improved by adequate pain control. QoL is one of the main outcomes which determine the effectiveness of cancer treatment (Ping Y et al, 2012). Study done in Mainland China showed that patient‟s appetite, mood, sleep, daily activity, pain intensity, general appearance and family support is significantly correlated to pain score while social support, attitude to cancer and its treatment is not.(Di Deng et al, 2011)

The number of patients with cancer is on increase with estimated nine million new cases every year, where more than half are from developing countries. (W.H.O.1996). Cancer pain occurs in about one third of the patients on anticancer treatment. Therefore pain management and cancer treatment should go concurrently with an aim of relieving the pain to patients‟ contentment. This ensures effective body functions and painless death. (W.H.O., 1996). In 1986 World Health Organization published guidelines for pain management termed as W.H.O. analgesic ladder‟ which is an organised guide to pain assessment and analgesic choice in cancer pain treatment.

According to Nigeria national cancer control strategy 2011-2016, Nigeria‟s annual incidence of cancer is estimated at about 28,000 cases. The occurrence of cancer pain under-treatment was found to be determined by geographical area (Europe and Asia), low economic level countries and cancer care setting. Wealthier health systems withstand and encourage a better pain management via awareness crusades and full drug covering by health insurances or national health system. (Deandrea et al, 2008). Nigeria is a developing country with poor health financing system, with majority of the citizens unable to join health insurances. The public health insurance scheme available in Nigeria doesn’t cater for the outpatient. Other private health insurance schemes are too expensive for majority of Nigerians. This may result to uninsured and underinsured patients who may not afford to buy the pain medications hence may choose not to purchase them. Pain has been included as the 5th vital sign by JCAHO for institutions in US yet in Nigeria this has not been implemented both in practice and in training. There are no specialised pain clinics and advanced pain management techniques readily available to cancer pain patients and often pain management remain a low priority.

This special group of population. Publicized study findings will create reasons for institutions to improve the public’s opinion on the quality of care received thus improve pain management tactics. Finally the study findings will be compared with those of other similar studies done.


1.3 Purpose of the Study

To evaluate pain management and its implications for patient care among nurses at the Lautech teaching hospital Ogbomosho Oyo State


1.4 Objective of the Study

  1. To identify the most common mode of pain treatment used in cancer patient.
  2. To assess the effect of pain management practices on pain relief
  3. To identify the most effective mode of treatment in pain management.
  4. To assess the effects of pain relief on performance of activities of living.
  5. To identify mitigating factors that influences the pain management practices and pain relief.

1.5 Research Questions

  1. Do cancer patient who are on pain management get adequate pain relief?
  2. How does the cancer pain affect the patient’s performance of activities of living?
  3. What are the most common pain relieving modalities used?
  4. What are the most effective pain relieving modalities available to patients?
  5. Are there mitigating factors that influences the pain management practices and pain relief?

1.6 Hypothesis

Pain management practice at LTH cancer treatment centre leads to cancer pain relief which enhance the performance of activities of living among the patients attending the clinic.


1.7 Justification of Study

According to W.H.O. the number of patients is increasing throughout the world with estimated nine millions new cases per year in which more than a half is in developing countries. (W.H.O. 1996). According to Nigeria national cancer control strategy 2011-2016, Nigeria‟s annual incidence of cancer is estimated at about 28,000 cases. Among patients on active anticancer treatment, cancer pain occurs in about one third and among those with advanced disease, in more than two thirds. (W.H.O. 1996). This implies that about 9000 patients suffer from cancer pain in Nigeria.

Cancer pain affects the QoL adversely and mostly the physical aspect. It is strongly associated with impaired daily functioning, deteriorating depression and anxiety, dissatisfaction with opioid therapy, poor medical outcomes, and socioeconomic burden considering that patients with cancer pain are likely to utilize more healthcare resources than those without. The main aim of the cancer treatment especially in advanced disease state is the pain relief among other management of other cancer symptoms.

LTH is the only government institution which offers a comprehensive cancer care and referral for patients from all over the country including some from the private hospitals. Considering the effects of cancer pain on QoL and economy it is felt worthwhile to explore the pain management practices at LTH as the main cancer treatment centre and its effects on the patient‟s performance of activity of living as domain of quality of life. The study findings will provide reliable information for improving hospice and palliative care for.


1.8 Study Benefit

Since pain is the most devastating cancer symptom to majority of patients, once it is well managed and controlled quality of life of the patient is enhanced. Therefore, the findings of this study will be utilized to improve pain management practices especially in palliative care as part of evidenced based practice. In addition, the findings will be utilized to develop future policies concerned with pain management practices and improvement of quality of life of patients.

The findings also will help to identify the gaps for further research and innovative strategies for the management of cancer pain and enhancement of quality of life of patients.


1.9 Definition of Terms

Activities of Living

Activities that a person tend to do every day without needing assistance and are essential for survival

Pain

Pain is unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Palliative Care

Approach that aims at improving the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering.

Quality of Life

Multidimensional construct that includes performance and enjoyment of social roles, physical health, intellectual functioning, emotional state, and life satisfaction or well-being.


1.10 Study Limitation

The study relied on respondents‟ subjective pain perception and was limited to participants who are aged 18 years and above.

The study findings were limited by the cross-section study design that did not allow examination of effects of pain management practices over time.

Only those who could afford the services were available for the study thus those who could not afford were left out.


1.11 Organization of the Study

This study is divided into five chapters.

  • Chapter one is introduction which consists of the background to the study, statement of problem, research questions, research hypotheses, objectives of the study, the significance of the study, the scope and limitations of the study and finally the organization of the study.
  • Chapter two deals with the literature review which consists of the conceptual literature, theoretical literature, empirical literature, theoretical framework.
  • Chapter three gives the research methodology including research design, population of study, sample size, sampling technique, method of data collection, instrument of data analysis, method of data analysis, validity/reliability of instrument.
  • Chapter four is presentation and analysis of data, discussion of findings.
  • Chapter five gives the summary, conclusion and recommendations.

Chapter Five


Discussion, Conclusion and Recommendation

5.1 Discussion

The study objective was to describe the pain management and its implications for patient care attending cancer centre at LTH. All the patients reported having experienced pain at varying degree and the majority had severe pain which impaired normal function despite the pain treatment. In this study the majority 90% (170) had moderate to severe pain based on Numerical Rating Scale. The study showed that the majority 92.6% (174) of these patients were on pain treatment. Overall, the results showed that the cancer patient at LTH experience cancer pain which interferes with the performance of ALs, this cancer pain is relieved to varying degrees and majority reported being satisfied with the pain treatment.

The study showed that the most common mode of cancer pain treatment used by the patient was the NSAID mainly the diclofenac and paracetamol with only a few on opioid. Although specific pain killer was not statistically significant in determining pain relief, radiotherapy seemed to be the most effective with average pain relief of 90% similar to combination of chemotherapy with NSAID (Mean=90% pain relief). In contrast to other studies and W.H.O. recommendations, the patients on morphine though used by few patients had only 68% average pain relief (WHO, 1999). This could be due to the dose used which was not determined in this study and consistence considering the majority of the patients were outpatients residing far from the hospital. In addition the analgesic should as much as possible follow the five principle i.e „by the mouth‟ „by the clock‟ „by the ladder‟ „for the individual‟ and „attention to details‟ which were not determined in this study (W.H.O 1996). The Most clinical setting especially in developed countries prefer opioids sustained release tablets for cancer pain, however such drugs are very expensive adding to the financial burden. In addition, only a small number 1% of the patients was on adjuvants drugs for pain. Pain killers only gave an average of 72% (S.D = 26) pain relief.

The type of cancer therapy determine the degree of pain relief according to this study with those on chemotherapy and surgery giving statistically significant pain relief (p=0.054) which was in line with the study done at Beijing by Ping Y et al, 2012). Immunotherapy was associated with the least pain relief; hormonal therapy and radiotherapy were statistically insignificant in relation to pain relief.

Different primary cancers had different average pain relief although this was statistically insignificant (p=0.840). The patients with cervical cancer and lung cancer had the lowest level of pain relief i.e. less than 70%. Patients with lung cancer experience cancer pain frequently than those with other types of cancer (Ping Y et al, 2012) and therefore they require more attention.

This study demonstrated that the patients who were on stage three of the disease had the highest pain relief compared with stages I, II, and IV. However those who had stage four diseases had the lowest pain relief which could be associated with the metastasis. This was similar to study done by Ping Y et al, 2012 in Beijing which showed a significant relationship between pain relief and cancer stage. The participants those with stage one disease had average pain relief of 73% this could be attributed to the effectiveness of cancer therapy on the localised tumour.

The correlations of the type of cancer therapy and pain relief demonstrated that those patients on chemotherapy and surgery got pain relief (p=0.0054, p=0.054). Ping Y et al, (2012) study demonstrated that chemotherapy is one of the predictor of pain controlled. It is clear from this study that chemotherapy and surgery leads to pain relief thus improves the performance of ALs and generally QoL of patients.

The patients who were satisfied with the pain treatment reported lower pain score on Worst pain experienced in 24 hours while those who reported dissatisfied reported high score (6.97 v.s. 5.97, P=0.008, F=7.197). Panteli V et al, (2014), pointed that low pain relief resulted into low levels of satisfaction of pain management. However, according to Ping Y at el, (2012) patients in pain are satisfied with their pain management regardless of the actual pain relief. This could be attributed to adequate perceived pain management practices than by pain relief itself. There was positive correlation between Worst pain reported and the described nature of pain. The study found that higher the Worst pain score the severe the nature of pain was described. (F=7.197, P<0.0001, r =.588). The majority described it as discomfort.

This study like previous studies (Ping Y at el, 2012, Di Deng et al, 2011; Mathews, Tajeda, Johnson, Berbaum, and Manfredi, 2022), demonstrated that the interference with normal function is reciprocal to pain relief i.e. the higher the degree of pain relief the less the interference with ALs. There was a reciprocal relationship between cancer pain and QoL, i.e.

they may aggravate each other resulting into vicious cycle between them. From this study it was clear cancer pain interferes with; the performance of ALs, mood, walking, carrying out normal work, relations and enjoyment in life significantly. However interference with sleep was not significant which could be due to the perception of illness and pain management practices i.e. the feeling of satisfaction reduces emotional stress leading to relaxation of mind. Interference with relation was found to be a predictor of pain relief (p=0.001, t= -3.380).

Mitigating factors (drug of abuse use, marital status, hospital financier, age, gender, type of primary cancer, education level, duration of illness) were tested for their influence relationship between the pain management practices and pain relief. Drugs of abuse use was statistically significant among those who had history of taking Cannabis Sativa (Bhang) prior to disease (p= 0.002) with average of 10% pain relief. This could be attributed to tolerance since cannabinoids are known to relief cancer symptoms such as pain and nausea. Researchers recommend for more research on therapeutic use of cannabis (Susannah K et al, 2014, Bar- Sela G et al, 2014). Those who were former cigarette smokers had highest pain relief average of 76% p=0.387. Study done by Ditre, Gonzalez, Simmons, Faul, Brandson, and Jacobsen, (2012) suggested that continued smoking regardless of cancer diagnosis was associated with rise in pain and amplified interference from pain and further added that pain may be a potent motivator of pain. Tobacco smoke is associated with increase in pain since it (nicotine) reduces blood and oxygen flow to peripheral tissues or through direct influence on the neurological processing of sensory information.

In this study gender, marital status and level of education were not statistically significant in determination of the degree of pain relief one got which is in line with study done by Deandrea et al (2012). This is contrary to findings done by Morgan et al (2011), which demonstrated that partner‟s relationship (marital status) reduced negative effects of pain. However a study done by Heydarnejad, Hassanpour, and Solati, (2011) suggested that none of the demographic variables (age, education, marital status, income) were significantly related to QoL of patients on chemotherapy. As a result pain management in younger or older patient was not different in this study. Similarly, Ping Y et al (2012) did not find gender as a predicator of pain relief in patients.

While other studies did show relationship between pain and financial status (health financier) (Wang et al, 2012, Masika, Wettergren, Kohi, and Essen, 2012, Ping Y et al, 2012) this study did not. This could have been attributed to limitation of study designed i.e. cross-sectional used in this study as opposed to longitudinal study design that used by the other studies. (Masika et al, 2012)

It was observed that most of the patients who returned to the clinic before the appointment date complained mainly of cancer pain. It was also observed that most of the patients who had chronic illness other than cancer especially hypertension had stopped taking the antihypertensive as they concentrated on cancer therapy.


5.1 Conclusion

The findings of this cross-sectional study on pain management practices and its effect on performance of ALs suggest that pain relief is a key determinant of one‟s function i.e. performance of ALs and independency. Also the pain management practice determines the level of pain relief. The most common used mode of pain management is painkillers with the chemotherapy being the most effective mode. Only a few mitigating factors were identified to influence the pain management practices and pain relief e.g. history of bhang use. However in this study, other factors such as age, gender, education level and income were not identified as predictors of pain relief. Interference with relation to others was identified as a predictor of pain relief.


5.2 Recommendations

From the findings of this study the following recommendations were made:

  1. Cancer pain still needs more attention and more structured interventions to improve QoL in patients
  2. All the patients should be assessed thoroughly for pain at all contacts with health care provider and appropriate action taken promptly.
  3. Palliative care should be incorporated in CTC for better pain management other than being a kind of stand-alone department.

5.3 Further research

There is need for further research on other domains of QoL in relation to pain and also on barriers to adequate pain treatment.


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