Cancer Pain in an Oncology Unit, Research Paper Example

Introduction

The majority of cancer patients experience pain during hospitalization, according to Kwekkeboom et al. (2008b); while King (2010) reports that this ratio is as high as 79 percent. The innovative methods used to reduce pain and prevent breakthrough pain episodes include muscle relaxation techniques. Clinical nurse leaders need relevant knowledge regarding the method and the efficiency of the technique, in order to make informed decisions about applying them. The below research would review the medical situation, the facilitators and barriers of the implementation, as well as the research literature to gain full insight into the strategies, legal concepts and methodology. The results would then be compared and reviewed, taking into consideration the author’s professional experiences with the clinical situation. The purpose of the research is to create a full analysis of the methods and draw up a framework for the implementation of muscle relaxation and analgesic imagery for use in hospitals treating cancer patients. The framework would include the expectations, benefits, drawbacks, various correlations by estimates and using fractions. Significance levels of various measures would be determined based on the correlations properties.

Research question and thesis

The research question is whether the implementation of muscle relaxation and analgesic imagery would be a cost-effective innovation within the nursing microsystem of cancer patients, and whether it would provide positive patient outcomes. The thesis would be that the number of pain outbreaks and the use of medication would be reduced as a result of implementing the methods detailed above.

The problem

One of the main reasons for hospitalization of cancer patients is the presence of constant pain or the occurrence of returning pain. Advanced cases of cancer are limited regarding analgesic medications, and alternative solutions need to be sought. Relieving pain without medication would also improve patients’ quality of life, their experience and mood. Kwekkeboom et al. (2008a) confirms that the use of alternative pain reducing methods is underutilized in hospitals, and they need to be confirmed as being effective in order to get promoted by health professionals.

Clinical microsystem

The implementation of alternative therapies would bring many improvements to the oncology unit of the urban hospital in question. Patient entry is usually after referral from the oncology specialist following the positive diagnosis of cancer. As cancer patients with constant pain and symptoms of the condition need supervision and a detailed treatment plan, they are hospitalized for at least 4 weeks, to allow the clinical microsystem to set up a treatment plan and find the most effective medication. The most commonly used medications used during the hospitalization are hydromorphone, oxycodone and fentanyl (Reeves, 2008). The number of complaints about the side effects of these drugs has recently increased within the oncology unit, and this is why there is a need for intervention and introduction of alternative pain reduction methods. Demographic data of patients

The unit has the capacity to care for more than 60 patients at the same time. The use of bed capacity is close to 100 percent throughout the year. The tools and systems in place make it possible to care for stage 1 to 3 cancer patients. According to the 2011 statistics, some patterns can be identified, as it is detailed in the table below.

The above statistics show that there is a need for intervention as the number of pain-related complaints recorded has increased by 42 percent. It is also evident that there are significant pain threshold differences between genders, according to Garcia et al. (2007), and the frequency or level of pain should be taken into consideration as well.

Evidence-based intervention

Guided imagery is a relaxation technique that has been researched for many years, and it is providing an alternative pain management method without medication. The mind-body technique does not only support patients in managing pain, but it is also helpful in providing comfort and preventing psychological issues. However, the above detailed demographic data needs to be assessed to create an evidence-based model for intervention.

Literature Review

Several authors have confirmed the effectiveness of cognitive therapies for treating and managing pain in case of advanced cancer patients. (Kwekkeboom et al., 2008a) The treatments have been proven to reduce not only pain, but other, cancer-related symptoms as well. The study completed by Kwekkeboom et al. (2008b) confirms that although there are individual differences in the level of efficiency, short term effects were still present in 3/4^th of the participants, based on the self-report questionnaire.

King (2010) also talked about the implementation of training for muscle relaxation techniques. He confirmed that long term intervention and application by implementing the therapies might have better and more consistent results. Further studies on results and implementation by Gatlin et al. (2007) and Anderson et al. (2006) also talked about the benefits of implementing cognitive complementary therapies.

Ozkan (2010) talks about the different psychological aspects of cancer, and concludes that these can become just as serious as the physical symptoms.

Patient-centered care approach

The most significant characteristics of good patient-centered care are according to Porter-O’Grady et al. (2010) are to provide reassurance and information for relatives and patients, find out more about their expectations of the facility, and implement measures in the change to ensure that these are met by the team.

Baernholdt et al. (2011) determine the six dimensions of health care performance, and the below review would like to review whether the implementation process would improve every aspect of the clinical microsystem service. The six dimensions are drawn from the report created by Baernholdt et al. (2011) regarding the emerging roles of clinical nurse leaders.

• Safety of patients
• Effectiveness and avoiding over- and underuse
• Patient-centered cure
• Timeliness
• Efficiency
• Equity

Plan for implementation and intervention

The study is attempting to predict service outcomes in a cancer patient microsystem of a nursing unit at a hospital. Using the chaos model of nursing, a quantitative seed population would be determined. (Haigh, 2008) The process of implementing major changes in nursing microsystems will be used in order to efficiently and quickly gain consensus and carry out the project. Improving the quality of life of patients would reduce the workflow of all nurses, have a positive implication on the reputation of the hospital, and potentially improve the financial situation as well. Finding resources for research and training would be challenging, however, the authors assume that the cost-saving features of the project would be beneficial for the whole organization long term.

Action Plan

The implementation of the changes would require the use of the 4-step process, described by Hix et al. (2009).

Establishing the sense of urgency

Collecting data of the pain-related symptoms, proving that the statistics show an increase in patient complaints would be the first step of the process. The CLN would then collect the data related to side-effects of analgesic medications and share the results with the management. Emphasizing the fact that patient satisfaction would be increased by the therapies and supporting it with relevant research results would create a sense of urgency. The research would take approximately 2 weeks, and written briefs would be provided for the leadership.

Creating the guiding coalition

In order to gain agreement, support needs to be sought from nurses, doctors and support staff, there is a need for seeking agreements and outline the details of implementation together. This process would take two weeks, with two 1-hour meetings held each week.

Developing a vision

The vision associated with the changes would be communicated through various channels within the microsystem, and it would be built around patient-based care, described earlier within the study. The vision would state that patients would be given options to avoid side-effects and a chance to improve their quality of life. It is important to gain consensus from all workers and seek feedback. The feedback would consist of personal work-related experiences and observation, and staff would have 2 weeks to hand these in for review.

Communicating the vision

The vision, backed by supporting literature would be communicated with the nursing team of the oncology unit, and the written communication would be handed out to 24 of the practice nurses and 8 other nursing staff within 4 weeks from the development. The variables determined by the below change theory would be assessed in group settings, to allow feedback and recommendations.

Training

The CNL would research suitable and accredited training programs and enroll 2 nurses for the training from each shift slot. The cost of the training would be funded by the training budget of the oncology unit. Replacement of staff would be guaranteed by overtime and staffing reorganization. The training would take approximately 2 days.

Creating a schedule for implementation

The program would ensure that in every part of the day, there would be at least one trained nurse being able to carry out the treatment. The responsibilities of trained nurses would be reviewed, and their contract would be amended accordingly. Data would be collected from patients regarding their pain relief preferences, and a detailed schedule would be drawn up.

Timeline

Completion schedule

The preparation stage would take a maximum of six weeks, collecting data, research results and drawing up the plan. Supplies, such as guidebooks, sound-proofing equipment and relaxation aids need to be purchased on an organizational level, after approval from the financial planning department. This process would take one month. The preparatory phase, including identification for the most suitable treatment room, timescales and selection criteria of patients would take 2 weeks. After the program is ready to start, the CNL would coordinate the implementation, including planning of training in collaboration with the training and change agents, the staffing changes with the help of the staffing office and change agent.

Responsibilities

The nurse educators would be responsible for arranging and evaluating the training, scheduling assessments. The manager would seek written approval and funding from the organization for the unit-level project. The staffing office would amend the schedules for the period when the training is carried out; also ensure that the service is provided 24 hours a day, 7 days a week, by changing the schedule of selected nurses, who have completed the training. The coordination of tasks, assessment and evaluation would be the responsibility of the CNL, and they would work together with the nurse manager to gain statistical data and assess the situation.

Change theory

The chaos theory assumes that every complex system (in this case, the nursing microsystem of oncology department) has its own rules based on the correlation of randomly assigned and identified variables. The study would focus on one clinical microsystem, as most of the variables of patient satisfaction would be controlled on this level. Different variables can be determined and assigned a significance level while implementing the chaos-theory in the change management project. The below section would determine some of the most significant variables, identified by Kwekkeboom et al. (2008a), and King (2010). To successfully measure the effectiveness of the therapy and the benefits of the program, the following variables would be identified:

Frequency of pain – how often does the patient experience pain; is it outbreaks or a constant presence of discomfort?

Scale of pain based on self-report – By asking relatives and patients about the pain and assigning a number on a 1-10 scale would help the CNL design the right intervention model.

Scale of pain based on observation – using interaction and active observation during the day, nurses would be able to judge the level of pain on a 1-10 scale.

How advanced the patient’s condition is – the clinical reports would be used to determine the significance of the pain in the patient’s life and how long they are likely to have to face the discomfort.

Existence of psychological symptoms; depression, mood changes – these conditions could possibly be improved by the cognitive therapy, however, further studies are needed in order to be able to safely apply the methods without worsening these conditions.

Level of communication with relatives – Baernholdt et al. (2010) and O’Grady et al. (2010) confirmed that the effective communication with patients and relatives improves the perception of the therapy. Therefore, full agreement needs to be sought, and the initial attitudes might be recorded.

Perceptions of patient related to cognitive therapies – this factor is proven to be a determining force for the self-report about the effectiveness of the treatment, according to King (2010).

Previous experience with complementary pain relief methods – Lynette et al. (2007) talks about the “placebo effect” in detail and the importance of these factors in the effectiveness of treatment.

Anticipation of results – finding out more about patients’ and relatives’ preconceptions regarding the treatment would allow the researchers to critically evaluate the results.

Self-report of results

Correlations

By using the above non-linear dynamics of implementing the plan, a simple correlation rule can be set up between the above variables, to determine the most successful approach to implementation. The suggested correlations are:

Scale of pain based on self-report – How advanced the patient’s condition is

Perceptions of patient related to cognitive therapies – Self-report of results

Anticipation of results – Self-report of results

Level of communication with relatives – Anticipation of results

Existence of psychological symptoms; depression, mood changes – Scale of pain based on self-report.

How advanced the patient’s condition is – Scale of pain based on observation

Frequency of pain – How advanced the patient’s condition is

 The above correlations would allow the CNL to develop structures and methods in order to determine the group of patients that can benefit from the treatment the most, and design the result prediction of the method.

Evaluation plan

The evaluation process of the results would be based on the original correlations drawn up using the chaos theory. The correlations between different variables would be assessed in order to determine the changes. The benefit of the chaos theory would allow the CNL to make the program flexible and apply changes when necessary.

The correlations between the outcomes – pain reducing effects – and the following would be monitored on a weekly basis:

• Frequency of pain
• Anticipation of results
• Communication
• Previous experiences
• Demographic variables of patient
• How advanced the patient’s condition is
• Time when the treatment was applied
• The number of times the treatment was applied.

Changes would be recorded in a project diary, and the evaluation of statistics would be completed in every 4 weeks, with the help of the nurse manager. Recording outcomes would be the assigned responsibility of all nursing staff, and the nurses taking part in the training would collect the data when the treatment is applied. The differences between results when traditional methods are applied and the ones related to complementary therapy would be assessed every 4 weeks, to allow the microsystem management to make necessary changes and improve the program.

The above evaluation plan would allow the CNL to review and change the application; treatment schedules, the group of patients selected for the alternative treatment, and improve the communication with patients and relatives, to promote patient-centered care throughout the organization.

Conclusion

Although the above change development study has reviewed the relevant literature and identified the most significant dynamics of implementation, it has also revealed various research development areas as well. Therefore, before implementing the changes and designing the protocol, there is a need for financial and risk assessment, as well as reviewing new studies and recommendations regarding complementary treatments.

The limitations of the implementation process, as seen in the above overview are negotiable, and there are several benefits of the alternative and complementary pain management program, while the risks still need to be assessed. In order to make the model sustainable, it is also important to make the program budget-neutral, or even cost-saving, however, further research and analysis is needed to develop a framework for assessing the financial implications of training, certification, extra staff and other aspects of the project.

References

Kwekkeboom, K., Wanta, B., Bumpus, M. (2008a) Individual Difference Variables and the Effects of Progressive Muscle Relaxation and Analgesic Imagery Interventions on Cancer Pain. Journal of Pain and Symptom Management. Vol. 36 No. 6 December 2008 pp. 604-615,

King, K. (2010) A Review of the Effects of Guided Imagery on Cancer Patients with Pain. Complementary Health Practice Review 2010 15: 98

Kwekkeboom, K., Hau, H., Wanta, B., Bumpus, M. (2008b) Patients’ Perceptions of the Effectiveness of Guided Imagery and Progressive Muscle Relaxation Interventions Used for Cancer Pain. Complement Ther Clin Pract. 2008 August; 14(3): 185–194.

Lynette, A., Pujol, M., Monti, D. (2007) Managing Cancer Pain With Nonpharmacologic and Complementary Therapies. J Am Osteopath Assoc December 1, 2007 vol. 107 no. suppl 7.

Baernholdt, M. and Cottingham, S. (2010) The Clinical Nurse Leader – new nursing role with global implications. International Nursing Review 58, 74–78

Porter-O’Grady, T., Clark, J., Wiggins, (2010) The Case for Clinical Nurse Leaders: Guiding Nursing Practice into the 21st Century. Nurse Leader. February, 2010.

Özkan, S. (2010) Psychiatric Aspects of Pain in Cancer Patients. Asian Pacific J Cancer Prev, 11, MECC Supplement, 113-116

Anderson K., Cohen MZ, Mendoza TR, et al. Brief cognitive-behavioral audiotape interventions for cancer-related pain: Immediate but not long-term effectiveness. Cancer 2006; 107:207.

 Gatlin C., Schulmeister L. When medication is not enough: nonpharmacologic management of pain. Clin J Oncol Nurs 2007; 11:699.

Haigh, C. (2008) Using simplified chaos theory to manage nursing services. Journal of Nursing Management. 16, 298-304

Stanley, J., Gannon, J., Gabuat, J., Hartranft, S., Adams, N., Mayes, C., Shouse, G. M., Edwards, B. A., & Burch, D. (2008). The clinical nurse leader: A catalyst for improving quality and patient safety. Journal of Nursing Management, 16, 614-622

Hix, C., McKeon, L., Walters, S. (2009) Clinical Nurse Leader Impact on Clinical Microsystems Outcomes. JONA Volume 39, Number 2, pp. 71-76

Garcia, E., Godoy-Izquierdo, D., Godoy, J., Perez, M., Lopez-Chicheri, I. (2007) Gender differences in pressure pain threshold in a repeated measures assessment. Psychology, Health & Medicine, October 2007; 12(5): 567 – 579