van der Peet, E.H., van den Beuken-van Everdingen, M.H., Patijn, J., Schouten, H.C., van Kleef, M., & Courtens, A.M. (2009). Randomized clinical trial of an intensive nursing-based pain education program for cancer outpatients suffering from pain. Supportive Care in Cancer, 17, 1089–1099.

To investigate the effect of intensive home-based nurse-provided education on pain levels, pain knowledge, quality of life, anxiety, and depression in patients with cancer

Patients with cancer were randomized to receive either a pain education intervention or usual care. Pain, knowledge, quality of life, anxiety, and depression were measured at baseline and after four and eight weeks. In the intervention group, effects on symptom levels were communicated to the treating physician. The program included a brochure about pain management, instructions about how to record pain intensity in a diary, and simulation of help-seeking behavior. In the intervention group, palliative care nurses made three home visits. After these visits, nurses communicated with the physician, by means of a written report of pain control and recommendations regarding dose or medication changes. Home visits were at weeks 1, 3, and 6. Follow-up telephone calls to members of the intervention group occurred at weeks 4 and 8.

• The sample was composed of 20 patients age 18 or older.
• In the intervention group, 52.1% of patients were male and 47.9% were female. In the control group, 38.3% of patients were male and 61.7% were female.
• All patients
  • Had been diagnosed with cancer and informed of their diagnosis.
  • Were able to understand and complete the questionnaire.
  • Had a present pain score of 4 or higher on a 0–10 scale.
  • Agreed to participate in the study.
• Patients were excluded from the study if they had completed their curative anticancer treatment before the year 2000.

• Multisite
• Home
• Limburg, the Netherlands

• Phase of care: not stated
• Clinical applications: elder care, palliative care

Randomized controlled trial

• Brief Pain Inventory (selected questions)
• Translated version of the Family Pain Questionnaire (Ferrell, Rhiner, & Rivera, 1999), to measure patients’ knowledge about pain
• European Organization for Research and Treatment quality of life questionnaire (EORTC QLQ-C30 version 3.0), to measure quality of life and nonpain symptoms
• Dutch version of the Hospital Anxiety and Depression Scale (HADS)

At four weeks, the level of pain had decreased in the intervention group (p = 0.02) but not at eight weeks. Significant decreases in pain only persisted in those patients with a high pain score (7–10) at baseline (p = 0.00). Knowledge of pain was significantly increased in the intervention group at week 8 (p < 0.00). Authors found no correlation between increased pain knowledge and decreased pain levels. In 60% of cases, recommendations in nurses' reports were ignored.

In the short term, the nurse-administered pain-related education program lowered pain intensity in patients with cancer and increased patients' knowledge about pain.

• The study had a risk of bias due to no appropriate attentional control condition.
• The patients in the study knew that they were enrolled in pain research.
• Study design did not account for differing severities of illness and disease progression.
• Written communication with the treating physicians proved inadequate.
• Authors provided no information about any changes made in pain management regimens during the course of the study.

In regard to pain and pain management, additional attention must be paid to patient education and to communication between patients and healthcare professionals. The following components should be characteristic of patient education programs: involvement of the patient and family or caregivers, communication with the patient to reinforce information and monitor the plan, integration of medical care into the nursing education program, clear instructions regarding provider notification, and use of a pain diary. The components have the potential to reduce pain. Study findings showed that communications to physicians, written by palliative care nurses, were ignored 60% of the time, suggesting that this form of communication is ineffective. Educating the patient and helping patients to self-advocate in interactions with physicians are important goals.