Sample Research Proposal on Pain Assessment and Management among Chinese Patient with Malignancy

Pain management is an important consideration in the promotion of patients' comfort. However, research continues to indicate patients' pain management is poor. The nursing literature cites nurses' lack of knowledge as a significant determinant of poor pain management practices. The impetus for this study arose from poor attendance by nurses at inservice sessions discussing pain assessment and management. Knowledge of existing nursing practice and accompanying beliefs and attitudes in relation to pain management is paramount in the development of relevant continuing education for registered nurses. The aim of this investigation was to study nurses' assessment and management in treating pain in patients with haematologic malignancies. A 10-page questionnaire with eight different patient scenarios will be distributed to selected nurses across all clinical divisions of an acute tertiary facility.  Additionally, semi-structured follow up interviews will also be conducted.           Statement of the Problem   The purpose of the study was to investigate nurses' pain assessment and pain management practices of Chinese patients with haematology malignancy requiring an acute hospital admission to a Haematology unit within Hong Kong.   Significance of problem   Protect patients from developing pressure ulcer, it is important to improve pressure ulcer risk assessment and prevention through the implementation of guideline recommendations. Therefore, an intervention program will be prepared and implemented based on the results of the project. The program will be prepared as an addition to the basic health care practice that is common for bedridden patients and other patients at risk for pressure ulcer development. In all these events in a cancer patient, the senior oncology specialist nurses are responsible for co-ordinating care following any operations and/or treatment for cancer. A senior oncology nurse is highly qualified, having specialized training in caring for patients who have cancer, and has many years of experience in this field. As well as supporting a patient and his or her family through operation and treatment, the senior oncology nurse provides the patient and his or her caregivers with clear written and verbal information; and can also examine and arrange any tests the patient might need. The number of patients suffering from cancer worldwide has steadily increased in recent years mainly due to an ageing population (Ernst, 2006). Add to this, an increasing number of chemotherapeutic agents (Murray, et al, 2000) and a multitude of regimes, it therefore becomes very important to the point that it should be imperative to educate the nurse on the care of the patient who has cancer.                                 Background of the problem   Haematologic malignancy is one of the most common cancers occurring in Hong Kong. Pain is reported to be a major symptom for many patients with haematologic cancer. For many haematological patients, the prospect of pain is more frightening than any other potential complications which including death. Pain is often poorly assessed, and many caregivers lack sufficient knowledge to optimize treatment. However, little is known about this symptom among Chinese people who have cancer. Most research on this topic has dealt with adult patients and their nurses. In studying nurses' knowledge and attitudes about pain relief, knowledge deficits about adequate pain relief have been identified as: (1) dosing, safety, and scheduling; (2) how to achieve therapeutic levels; and (3) likelihood of addiction and respiratory depression. In addition, studies have shown that while many nurses viewed patients' self-reports of pain to be reliable, others believed patients often overreported or underreported pain (Manworren, 2000). Additional research has examined issues other than knowledge and attitudes to pain relief. Some barriers nurses have expressed that prevent them from administering optimal pain management are: (1) physician reluctance to prescribe adequate analgesics; (2) nurses' lack of time; (3) patient reluctance to report pain or take opioids; (4) inadequate pain assessment; and (5) fear of addiction (Gunnarsdottir et al, 2003). Pain assessment and management among cancer patients has been studied in non-Chinese populations. However, research concerning the impact of pain assessment and management in the Chinese population has been very limited. The purpose of this study, therefore, was to extend knowledge about pain assessment and management specifically in Chinese patients with haematologic malignancies by examining these important variables: (1) nurses' knowledge and attitudes about relieving patient's pain; (2) nurses' perceived barriers to optimal pain management for the patient; (3) amounts of available analgesics administered by nurses in relation to levels of patient's pain; and (4) the patient's perceptions of their pain. I hope the results may help nurses working with Chinese populations in identifying patients at risk for increased pain and in planning pain-relieving strategies.                 Objectives   The purpose of the study was to investigate nurses' pain assessment and pain management practices of patients with haematology malignancy requiring an acute hospital admission to a Haematology unit. The specific aims of the first phase of the project were to investigate:   • What are haematology nurses' knowledge and attitudes in relation to pain assessment? • What are haematology nurses' knowledge and attitudes in relation to pain management? • What protocols relating to pain assessment exist in Haematology unit? • What types of pain assessment tools are used by nurses in Haematology unit? • What are the barriers that nurses perceive to exist in assessing and managing pain within Haematology unit?   The specific aims of phase two of the project were to investigate: • What are the actual pain assessment practices of nurses in Haematology unit? • What are the actual pain management practices of nurses in Haematology unit? • How do haematology nurses make decisions in relation to their pain assessment practices? • How do haematology nurses make decisions in relation to their pain management practices? Literature Review   The word cancer elicits dread in nearly everyone. Cancer accounts for considerable mortality and morbidity in both men and women (Kozier, 2004). Certain genes controlling growth and interactions with other normal cells are apparently abnormal in structure or regulation in cancer cells. Humans of all ages develop cancer, and a wide variety of organs are affected. The incidence of many cancers increases as the fourth to sixth power of age, so that as people live longer, many more will develop the disease. Apart from individual suffering, the economic burden to society is immense (Murray, et al, 2000). Cancer is caused in all or almost all instances by mutation or by some other abnormal activation of cellular genes that control cell growth and cell mitosis. These abnormal genes are called oncogenes. Also present in all cells are antioncogenes, which suppress the activation of specific oncogenes. Therefore, loss of or inactivation of antioncogenes allows activation of oncogenes that lead to cancer (Guyton & Hall, 2000). Cancer cells are characterized by three properties: (1) diminished or unrestrained control of growth; (2) invasion of local tissues; and (3) spread, or metastasis to other parts of the body. Cells of benign tumors also show diminished control of growth but do not invade local tissue or spread to other parts of the body (Murray, et al, 2000). An abnormal cell mass that develops when controls of the cell cycle and cell division malfunction is called a neoplasm. However, not all neoplasms are cancerous. Benign neoplasms are strictly local affairs. They tend to be surrounded by a capsule, grow slowly, and seldom kill their hosts if they are removed before they compress vital organs. In contrast, malignant (cancerous) neoplasms are nonencapsulated masses that grow more relentlessly and may become killers. Their cells resemble immature cells, and they invade their surroundings rather than pushing them aside, as reflected in the name cancer from the Latin word for "crab." Malignant cells also tend to spread via the blood to distant parts of the body, where they form new masses. This last capability is called metastasis (Marieb 2004). Pain management in cancer patients is therefore of primary importance. For many hospitalized patients, pain is of paramount concern. Pain is considered to impact on the individual's well-being, both physical and psychological, and is a key issue in functional ability. For some groups of patients, it has emerged as a major determinant of quality of life, and is increasingly cited as an outcome to be measured to evaluate effectiveness in health care provision. Education in acute pain management has become more evident in universities and trusts over the past ten years. Many medical schools, however, still teach little about pain at either the preclinical or clinical level and information is poorly integrated despite the emphasis that patients should not be in pain. Nursing has included pain in preregistration programmes since the 1970s following the influence of nursing theories and research. Despite such attention, however, nursing education in pain management was still found to be inadequate (Twycross, 20002). A key component of effective pain management is nurses' possession of adequate knowledge and appropriate attitudes in assessing patients. This necessitates recognition that patients' self-report of pain is the single most reliable indicator of pain and should be recorded in the patient's record as the nursing assessment, regardless of the patient's behavior. Pain has been described as "whatever the experiencing person says it is, existing where ever he says it does" (Potter & Perry, 2004). However, studies reveal that nurses do not always accept the patient's report of pain. For many nurses, there are factors in determining pain, the most influential factor in determining pain intensity is the observation of behaviors. This can be problematic if patients do not vocalize their pain or express it nonverbally. The age of a patient is also influential in nurses' decisions; nurses are more willing to believe pain reports of older patients than younger patients, but less willing to administer opioid analgesics to older patients. Many nurses see objective factors such as clinical observations, type of surgery, and existing drug regimen as more valid indicators of suffering; consistent with this is their decision to provide analgesia. Knowledge and competency are not only influenced by the quality of training and culture of the clinical environment, but also by the practitioner's background and the socialisation process which underpins personal values, beliefs and attitudes towards the meaning and management of pain. Despite knowing what is 'best practice', professionals have been found to give allegiance to their own personal beliefs and work-based attitudes. In other words, while practitioners might claim to respect the definition 'pain is what the patient says it is and exists when they say it does', in reality they continue to make their own judgments of the patient's pain experience (McCaffery & Pasero, 1999). Hawthorne and Redmond (1999) uncovered a plethora of myths and misconceptions about pain management which are based on beliefs, attitudes and traditions rather than proven evidence.                                   Method               The research used a qualitative descriptive research method to provide a 'comprehensive summary' of the data presented in an understandable and usable manner. It was chosen due to the limited research in the area and the possibility of promoting understanding of attitudes and perceptions of nurses' pain assessment and management among Chinese patient with haematologic malignancy.             The target population will be nurses working in a haematologic ward of a rural hospital of approximately 200 beds that provide a wide variety of health services to the community. Hospital ethical approval will be obtained from the hospital, research and ethics committees.             A stratified random sample would give all the nurses the same chance of being selected, and would remove the risk of bias from researcher familiarity with participants. Nurses not in direct care with haematologic patients or without experience in that field will be excluded.             The nurses who will give informed consent will participate in questionnaire and semi-structured audio-taped interviews. A structured questionnaire will be designed to identify professional demographics and educational input, barriers to acute pain management, perceived competence in clinical skills and to test knowledge. A pilot questionnaire will be administered as a validity check to colleagues working in acute pain, research and education. The study's objectives will be outlined and deficiencies in the layout and wording will be identified. If some questions will be repetitive or irrelevant; alterations will be made and questions will be refined in response to the feedback gathered. Questions of interviews will focus on perceptions and experiences in caring for people with haematologic conditions. The recordings will be transcribed and analyzed to identify themes and relationships within the data, using a method of qualitative content analysis for interview transcripts.             Trustworthiness will be established through the application of dependability, credibility, confirmability, and transferability. Dependability will be ensured through the maintenance of a clear audit trail, by a thorough check of the work by research supervisors, and actions taken to enhance the credibility of the study. These actions will include prolonged engagement through a working acquaintance; tape recording of interviews for accurate and detailed recording of responses; peer consultation with supervisors and experts in the field; checking identification of key points and interpretations with participants; data triangulation through the use of subjects working in different areas; person triangulation by accessing subjects with different levels of training, experience, and responsibility; and the careful examination of contradictory data to modify interpretation and explain negative cases. Confirmability is assured by a detailed description of the research process with the inclusion of data that support conclusions.             Plan   Consent will be obtained from the participating areas together with ethics approval from the Research Committee at the hospital. Surveys will be sent to the selected nurses with a covering letter to explain the intent of the research and stating that their responses would be anonymous and confidential. Nurses will be asked to complete the questionnaire at their leisure. A return address label will be enclosed with the questionnaire so that on completion of the survey the nurse could easily return it via the hospital's internal mail. A follow up interview will then be done. Data will be analyzed using descriptive statistics. It is an expectation that further analysis could be undertaken between the different groups within the hospital. However, if the response rate would be low, there will not be any significant numbers representative of any specific group to make reliable comparisons.               Ethical application               In all countries, research works that involve human subjects and animals should be carried out in accordance with high ethical standards set by various ethics committee. The privacy and dignity of every individual involved in the research was protected. The participants in this study will be assured confidentiality and anonymity through identification coding and reports of aggregate data. The participants that will be involved will be notified of the aims, methods, expected outcome, benefits and potential hazards of the study conducted. Ethics committee approval is also required. For the process of having consent, it is important that the researcher must provide a formal letter of consent being addressed directly to the respondents and the people responsible for reaching out to those subjects needed for the research completion. The consent letter must contain original signatures and cannot contain any restrictions, conditions, or stipulations. Any restrictions or conditions must be kept separately between the parties involved. The consent letter must simply state that consent is given to a person to use his profile and other relevant information for the purpose of realizing the research purpose it serves.       Example of consent letter (the letter must be signed by the researcher and the involved party):   I, _________________, researcher of the proposed research would ask consent to ________________, respondent to give his/her own views and answers to the research questionnaire as enclosed for this particular research.   Dated: _________ _________________, the researcher   In terms of confidentiality, it is a must for the researcher to assure all the involved people, organizations and parties involved for research that confidentiality of information, research findings and results is deemed very important and be kept confidential from all elements not involved in conducting the research and must ensure the respondents right to change, cancel any information important for research as the researcher adheres to the fact that confidentiality of information is a top priority and that any involved parties should not be forced to give any information for the sake of research validity. The researcher ought to provide a formal confidential letter if needed in the process. For access to the organizations, it is crucial that the researcher will ask for a formal letter of approval deemed towards asking permission to allow the researcher in gathering and acquiring only the relevant information needed for research that the organization can directly or indirectly provide. The approval letter should state what the research is all about and for whom the research is done and all the important details there unto.