Evaluation Of Pain Management And Its Implications For Patient Care Among Nurses

INTRODUCTION

1.1 Back Ground 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?
6. 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.