Commentary
Knowledge, Attitude and Practice of Paramedical Staff and Nursing Assistants towards Cancer Pain Management in a Tertiary Cancer Care Centre
Abhishek Purkayastha1*, Arti Sarin2, Neelam Sharma3, Sankalp Singh1, Niharika Bisht1
1Department of Radiation Oncology, Command Hospital, Pune, India
2Department of Radiation Oncology, INHS Asvini, Mumbai, India
3Department of Radiation Oncology, Army Hospital (Research and Referral), New Delhi, India
*Corresponding author: Abhishek Purkayastha, Department of Radiation Oncology, Command Hospital, India
Published: 20 Mar, 2018
Cite this article as: Purkayastha A, Sarin A, Sharma N,
Singh S, Bisht N. Knowledge, Attitude
and Practice of Paramedical Staff and
Nursing Assistants towards Cancer
Pain Management in a Tertiary Cancer
Care Centre. Clin Oncol. 2018; 3: 1439.
Commentary
Quality of life (QOL) in cancer patients and survivors is most often affected by pain which is
the most distressing symptom influencing almost every aspect of their life [1]. Oncologists face the
challenge of managing cancer pain on a daily basis in developing countries where patients usually
present in more advanced stages of malignancy where the cornerstone of treatment becomes
pain management and palliative care. Surprisingly, majority of cancer patients experience pain in
spite of anti-cancer therapy with a high prevalence of 44% [2] associated with elevated levels of
depression and anxiety [3]. Various factors affecting pain management include the institutional
set-up, awareness and knowledge of patient, nursing staff and treating physicians. The knowledge,
attitude and practice of the paramedical staff (PMS) and nursing assistants (NA) play a crucial role
in pain alleviation apart from the onco-trained nurses and oncologists [4].
Although majority of PMS and NAs in our cancer wards had insufficient theoretical knowledge
about cancer pain management but were very enthusiastic about relieving pain and have a positive
attitude towards pain assessment. The knowledge of pain measurement tools is required for optimal
pain management however, only few NAs were aware of visual analogue scale (VAS), numerical
rating scale (NRS) [5] and facial scale. Earlier studies had assessed the knowledge and attitudes of
physicians on pain management [6], but few have assessed the awareness of PMS and NAs. Majority
of the NAs were not aware of neuropathic pain symptoms to assess neuropathic pain but were aware
of WHO's concept of an 'analgesic step ladder' involving a stepwise approach to the use of analgesics
which is the most widely practiced method in cancer pain management being implemented all over
the world [7].
The PMS’s/ NAs knowledge of opioid administration is an important aspect of pain management
in cancer wards as they work in synergy with the onco-trained nursing staff. Those NAs having
personal experience with opioid administration and with self-educative knowledge tend to have a
better understanding on cancer pain management than their counterparts without any exposure,
though this factor may not hold good by others. Regarding the choice of potent opioids for pain
relief, majority of the PMS preferred fentanyl trans dermal 25 mcg patches over morphine due to
the less harmful effects in long-term use [8]. However few preferred morphine, whereas most of
the nursing staff when taken their opinion considered morphine over fentanyl and pethidine as
the opioid of choice for cancer pain relief. Regarding the dosage and frequency of opioids in case
of chronic persistent pain in admitted ward patients, most NAs were unanimous on increasing the
dosage and frequency which was in agreement with previous surveys [8,9]. Because of the fear of
morphine side effects like respiratory distress [10] many NAs were reluctant to increase the dose
and even considered lowering the dosages of opioids.
The attitude of the PMS is also of utmost importance in pain management in terminal patients
which is actually independent of the theoretical or practical knowledge depending on teaching,
learning and day to day experience. The positive attitude to look after and provide adequate care
in dismal prognosis end stage cancer patients is also important which is expected of the PMS/
NAs. Also majority of the PMS in our set-up attributed insufficient pain management skills to
lack of sufficient knowledge about opioids, their optimal dosage, administration and inadequate
monitoring post opioid administration. Few PMS/ NAs considered inadequate knowledge of
pain management due to inadequate guidance by the on co-trained
nurses and the oncologist himself. They were also of the opinion
that misconceptions and inadequate knowledge of the patients and
their relatives about the disease itself and treatment of pain were a
hindrance to adequate pain management and patient care. Various
pat surveys have time and again demonstrated the fact that cancer
pain management shows marked improvement when patients and
their relatives are aware of the disease and educated about different
protocols of pain management [11]. Apart from knowledge, an
important aspect is experience, with a NA providing cancer care on
a daily basis is likely to have better knowledge and liberal attitude
toward opioid exhibition.
In conclusion, majority of PMS/ NAs showed insufficient
knowledge, inadequate information but a positive attitude toward
optimal cancer pain management and optimal use of opioids
especially morphine and fentanyl. However, an exhaustive joint
multidisciplinary effort involving all three branches of oncology
practice including radiation, medical and surgical oncologist along
with the trained nursing staff and a well formulated pain education
curriculum are needed to improve the knowledge of the NAs about
use of opioids in postoperative as well as cancer pain assessment and
management. We also recommend that appropriate changes in the
PMS training and teaching curriculum should be made focusing
mainly on cancer pain management apart from their routine course.
Therefore humongous efforts are required to improve the present
prevailing situation so as to inculcate awareness, knowledge and
attitudes of PMS/NAs with respect to satisfactory postoperative and
cancer pain management.
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