Can a Complex Online Intervention Improve Cancer Nurses' Pain Screening and Assessment Practices?

Results From a Multicenter, Pre-Post Test Pilot Study

Jane L. Phillips, PhD; Nicole Heneka; MHumNutr; Louise Hickman, PhD; Lawrence Lam, PhD; Tim Shaw, PhD


Pain Manag Nurs. 2017;18(2):75-89. 

In This Article

Abstract and Introduction


Unrelieved cancer pain has an adverse impact on quality of life. While routine screening and assessment forms the basis of effective cancer pain management, it is often poorly done, thus contributing to the burden of unrelieved cancer pain. The aim of this study was to test the impact of an online, complex, evidence-based educational intervention on cancer nurses' pain assessment capabilities and adherence to cancer pain screening and assessment guidelines. Specialist inpatient cancer nurses in five Australian acute care settings participated in an intervention combining an online spaced learning cancer pain assessment module with audit and feedback of pain assessment practices. Participants' self-perceived pain assessment competencies were measured at three time points. Prospective, consecutive chart audits were undertaken to appraise nurses' adherence with pain screening and assessment guidelines. The differences in documented pre-post pain assessment practices were benchmarked and fed back to all sites post intervention. Data were analyzed using inferential statistics. Participants who completed the intervention (n = 44) increased their pain assessment knowledge, assessment tool knowledge, and confidence undertaking a pain assessment (p < .001). The positive changes in nurses' pain assessment capabilities translated into a significant increasing linear trend in the proportion of documented pain assessments in patients' charts at the three time points (χ2 trend = 18.28, df = 1, p < .001). There is evidence that learning content delivered using a spaced learning format, augmented with pain assessment audit and feedback data, improves inpatient cancer nurses' self-perceived pain screening and assessment capabilities and strengthens cancer pain guideline adherence.


Cancer pain is a debilitating symptom experienced by 30% to 75% of cancer patients (van den Beuken-van Everdingen et al., 2007). Nearly half (40–50%) have moderate to severe cancer pain, while more than a quarter (25%-30%) have severe pain (van den Beuken-van Everdingen et al., 2007). Variations in care contribute to cancer pain being under-recognized and undertreated in 50% of patients (van den Beuken-van Everdingen et al., 2007). Many people with cancer experience more than one pain, and some pains are associated with other comorbid conditions.

Cancer pain often persists long after all cancer treatment has ceased (Foley, 2011) and is almost always present during the final months of life (Herr et al., 2010). To address this known clinical practice gap, international and national cancer pain guidelines recommend a range of actions that are achievable with minimal investment but require practice changes (Dy et al., 2008; Foley, 2011). Fully implementing the evidence we have today would significantly reduce the burden of unrelieved cancer pain (Institute of Medicine, 2011).

The subjective nature of pain makes patient-reported outcomes the optimal source of information, and pursuing this information improves nurses' understanding of their patients' pain experience (Gordon et al., 2005). However, instead of seeking a numerically rated pain score (NRS), nurses often adopt informal screening approaches (Kerns, Otis, Rosenberg, & Reid, 2003) and neglect to document the patient's reported pain intensity score. When pain is detected, few nurses proceed to comprehensively assess the patient's pain (Franck & Bruce, 2009; Miaskowski, 2010).

In the United States, pain is considered the fifth vital sign, with the right to appropriate pain assessment and management embedded in hospital accreditation standards (Berry & Dahl, 2000). These standards require clinicians to systematically screen for pain, with the presence of pain prompting a comprehensive pain assessment (Dy et al., 2008; Idell, Grant, & Kirk, 2007), which determines location, temporal pattern(s), identification of treatment and exacerbating and/or relieving factors, and whether the pain is nociceptive or neuropathic in origin (Holen et al., 2006). Notwithstanding this complexity, few nurses have been formally taught how to assess these pain domains, with most learning done "on the run" or by observation of their peers. This knowledge gap has led to calls for the integration of comprehensive interprofessional pain curricula for all undergraduate health students and strengthening of pain education opportunities for existing clinicians (International Association for the Study of Pain, 2012).

Internationally, evidence of screening and assessment practices are increasingly being recognized as quality indicators of optimal cancer pain management (Dy et al., 2008). In Australia, specialist palliative care services are routinely required to capture the daily average pain intensity scores of inpatients and during every home visit for community patients, but there is no such obligation for cancer services (Pidgeon et al., 2015). However, a study conducted within one large Australian specialist palliative care service found little documented evidence of either routine pain screening and/or comprehensive pain assessments being routinely undertaken when pain was identified (Phillips & Piza, 2010).

A consumer survey involving 13 different Australian palliative care services confirms this observation, with 35% of patients reporting having moderate-severe pain that restricted their activity over the preceding three days (Palliative Care Outcomes Collaboration, 2012). Similar results have been reported in the most recent consumer survey (Pidgeon et al., 2015). Thus, even within specialties for which pain management is a core competency, there are opportunities to improve the pain outcomes for patients by strengthening nurses' routine screening and pain assessment capabilities.

Nurses' failure to routinely screen, undertake a comprehensive pain assessment, implement appropriate management, and regularly reassess pain has an adverse impact on cancer patients' and their families' health-related quality of life, sleep, ability to work, and social interactions. As front-line health professionals, nurses play a crucial role in improving patient's cancer pain outcomes. Cancer patients depend on nurses recognizing, assessing, quantifying, and communicating findings to other members of the interdisciplinary team (Fishman et al., 2013).

Changing behavior in dynamic clinical environments is challenging. A range of predisposing, enabling, and reinforcing factors are known to shape nurses' pain assessment practices. Nurses' pain assessment competencies (Herr et al., 2010), their understanding of suitable assessment tools, their commitment and capacity to integrate pain assessment findings into clinical decision-making (Luckett et al., 2014), communication skills, and capacity to address their patients' care needs within the context of multiprofessional practice (Carr, Brockbank, & Barrett, 2003; Fishman et al., 2013) all have an impact on patient-reported pain outcomes.

Interventions targeting nurses' cancer pain management practices have had varying degrees of success (Cummings et al., 2011; de Rond, de Wit, van Dam, & Muller, 2000; Ger et al., 2004; McDonald, Pezzin, Feldman, Murtaugh, & Peng, 2005). A review of clinical interventions directed at improving the treatment of cancer pain across units concluded that, although professional knowledge and attitudes about pain and nursing pain assessment rates are improvable, no hospital-wide intervention has been effective in reducing pain severity (Goldberg & Morrison, 2007).

Although numerous cancer pain education interventions have been implemented for nurses (de Rond et al., 2000; Ger et al., 2004; McDonald et al., 2005), none have targeted cancer pain assessment as a distinct and separate learning component. Most education interventions have embedded cancer pain screening and assessment into a broader pain management learning package (Franck & Bruce, 2009). Improvement interventions are largely shaped by intuition derived from experience, which in part explains their ad hoc success and limited transferability (Davidoff, Dixon-Woods, Leviton, & Michie, 2015). These results suggest that there are opportunities to maximize the impact of the behavioral change intervention by including evidence-based strategies.