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.


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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