Yeur-Hur Lai
Shu-Liu Guo
Francis J. Keefe
Shin-Ling Tsai
Chih-Cheng Chien
Yung-Chuan Sung
Mei-Ling Chen
Effects of brief pain education on hospitalized
cancer patients with moderate to severe pain
Received: 5 November 2003 Accepted: 2 March 2004 Published online: 4 May 2004 Springer-Verlag 2004
This study was supported by a grant from the National Science Council in Taiwan (NSC89-B-038-042T).
Y.-H. Lai (
)
) College of Nursing, Taipei Medical University,250 Wu-Hsing Street, 110 Taipei, Taiwan e-mail: yhlai@tmu.edu.tw
Tel.: +886-2-27389113 Fax: +886-2-27389780 S.-L. Guo
Department of Nursing, Cathay General Hospital,
280, Sec. 4, Jen-Ai Rd., 106 Taipei, Taiwan F. J. Keefe
Pain Prevention and Treatment Research Program,
Duke University Medical Center, P.O. Box 3159, Durham, NC 27710, USA S.-L. Tsai
Department of Nursing,
Taipei Veterans General Hospital, 201, Sec. 2, Shih-Pai Rd., 112 Taipei, Taiwan
C.-C. Chien
Department of Anesthesiology, Cathay General Hospital,
280, Sec. 4, Jen-Ai Rd., 106 Taipei, Taiwan
Y.-C. Sung
Department of Internal Medicine, Cathay General Hospital,
280, Sec. 4, Jen-Ai Rd., 106 Taipei, Taiwan M.-L. Chen
School of Nursing, Chang Gung University, Tao-Yuan, Taiwan
Abstract
The purpose of this
ran-domized controlled study was to
as-sess the effects of a structured pain
education program on the pain
expe-rience of hospitalized cancer patients.
Eligible cancer pain patients were
randomly assigned to either an
ex-perimental group (receiving pain
ed-ucation 10–15 min per day for 5 days,
n=15) or a standard care control
group (n=15). The effects of the
in-tervention on six pain-related
vari-ables were evaluated using three
in-struments. Pain intensity, pain
inter-ference with daily life, negative
be-liefs about opioids, bebe-liefs about
en-durance of pain, pain catastrophizing
(an individual’s tendency to focus on
and exaggerate the threat value of
painful stimuli and negatively
evalu-ate his or her own ability to deal with
pain), and sense of control over pain
were evaluated by the Brief Pain
In-ventory—Short Form Taiwanese
version (BPI-T), Pain and Opioid
Analgesic Beliefs Scale—Cancer
(POABS-CA), and the
Catastrophiz-ing subscale and the sense of control
over pain measure from the Coping
Strategies Questionnaire (CSQ). The
results indicated that, after
complet-ing treatment, patients who had
re-ceived structured pain education had
significantly less pain intensity on
average, negative pain beliefs
re-garding opioids, pain endurance
be-liefs, and pain catastrophizing than
patients in the control group. In
ad-dition, patients in the pain education
group showed a significant increase
in their sense of control over pain.
These preliminary results strongly
suggest that structured pain education
can effectively improve the pain
ex-perience of hospitalized cancer
pa-tients and should be further
imple-mented clinically.
Keywords
Cancer pain · Pain
education · Pain beliefs · Pain
interference · Catastrophizing
Introduction
Pain is one of the most difficult problems faced by cancer
patients in Taiwan. Previous research has shown that
30.7% of newly diagnosed cancer patients in Taiwan
ex-perience pain [13], and up to 85% of terminally ill cancer
patients experience significant levels of pain [4]. These
findings suggest that cancer pain has not yet been
con-trolled in Taiwan, and needs to be alleviated.
One major barrier to effective cancer pain control has
been identified as patients’ lack of adequate knowledge
about cancer pain management [7, 16, 31, 38, 42].
Pa-tients’ negative beliefs or misconceptions about cancer
pain have also been documented in several studies in
Taiwan [23, 24, 25]. These misconceptions include undue
concern about the negative physiological effects of using
opioids [23, 24, 25], worry about becoming addicted and/
or tolerant [23, 24, 25], and difficulties communicating
pain problems to heath-care professionals [25]. Negative
associations with using opioids, such as the connection
between their use and end of life, have also been
identi-fied [23, 24].
Social-cultural values also influence patients’ pain
ex-perience. Clinical observation indicates that Taiwanese
patients tend to endure pain, perhaps because expressing
one’s feelings is not encouraged in Chinese culture,
which is influenced by Confucian thought [27]. Studies
have shown that Chinese cancer patients have fatalistic
thoughts about pain [5, 25] and believe that pain should
be endured [23, 24]. These misconceptions may cause
patients to hesitate even more to take pain medicine and
report pain [5, 25], and make them more likely to endure
unnecessary pain.
Since cancer pain is a multidimensional experience
with physical, sensory, affective, cognitive, and
behav-ioral dimensions [1], unrelieved cancer pain may lead to a
more complicated and negative pain experience that
in-terferes with daily life [14, 26] and function [38] of
pa-tients, and be related to patients’ cognition [9, 17, 22].
Patients with uncontrolled pain may think more
neg-atively about pain, such as perceiving that their pain
cannot ever be controlled [9, 22, 23] and catastrophizing
about pain (“an individual’s tendency to focus on and
exaggerate the threat value of painful stimuli and
nega-tively evaluate one’s own ability to deal with pain”) (see
reference 20, p 326; [21]). For example, Tsai [39] has
found that hospitalized patients with pain have moderate
to high levels of pain catastrophizing thoughts. Lai et al.
[22, 23] have found that cancer patients in Taiwan have
very low levels of perceived control over their pain, and
this belief plays a significant role in predicting their
ad-herence to analgesic regimens [23]. Negative cognitions
about pain, such as catastrophizing, have been identified
as one of the most important factors influencing patients’
adjustment to disease [19, 36, 40, 41], and perceiving pain
as threatening or harmful has been found to decrease
patients’ hope [3, 35]. The cognitive dimension of pain
has been recognized as a critical component of the pain
experience of cancer patients, but this dimension has been
explored in very few studies.
Recent pain guidelines and systematic reviews have
recommended pain education as a key strategy for
de-creasing patients’ misconceptions about pain and
en-hancing pain control [11, 16, 28, 37]. Several studies have
shown that pain education reduces the intensity of pain
experienced by cancer patients’ [10, 12, 30, 33], improves
adherence to cancer pain management regimens [2, 8, 10,
33], and decreases misconceptions about pain [2, 8, 10,
12, 33, 43]. However, little is known about whether a
short, brief, structured pain education course can improve
patients’ sense of control over their pain and decrease
their catastrophizing thoughts. Furthermore, most of the
above-mentioned studies were conducted on patients
liv-ing at home. Hospitalized cancer patients in Taiwan are
usually more severely affected physically and are more
distressed (including higher pain levels) than outpatients.
In addition, although health-care professionals may assess
and treat cancer pain in patients under their daily care,
little is known about whether the addition of a systematic
program of structured pain education could enhance the
efficacy of routine daily pain care. The severity of cancer
pain in Taiwan has created an urgent need for evaluating
pain education programs (PEPs) to provide health-care
professionals with more comprehensive evidence for
fu-ture pain control.
The current study was a pilot study for a larger cancer
pain intervention project whose aim is to develop and test
the effects of a brief structured PEP on the pain
experi-ence of hospitalized cancer patients. Pain experiexperi-ence was
evaluated by (1) pain intensity (average, current, least and
worst), (2) pain interference with daily life, (3) negative
beliefs about opioids, (4) beliefs about enduring pain, (5)
pain catastrophizing, and (6) sense of control over pain.
Patients and methods
Patients and setting
Institutional review board (IRB) approval of the study was obtained before recruiting subjects. Patients were recruited from an inpatient medical oncology ward at a medical center in Taipei. Eligible subjects were cancer patients who (1) were adults (>18 years of age) who were aware of their cancer diagnosis, (2) had cancer-related pain during the 2-week study period, (3) could communicate verbally, and (4) agreed to participate in the study and signed a consent form after receiving a detailed explanation of the study. Patients who had surgery during the 2-week study period were excluded from the study because of the different characteristics of surgical and cancer pain.
Design and intervention
This study tested the efficacy of a structured pain education in-tervention using a randomized controlled design with pretest and posttest. Thirty patients were randomly assigned either to an ex-perimental group (pain education, n=15) or to a standard control group (standard care, n=15).
Pain education experimental group. Patients in this group received 10–15 min maximum of structured pain education for 5 days. A masters-prepared oncology nurse with pain control training deliv-ered the intervention each time, using a 16-page pain education booklet developed by the authors for this study. The first 3 days focused on explaining the contents of the pain booklet (see Content
of pain education program below). The last 2 days focused on reviewing and further discussing the contents. All patients in the experimental group also continued to receive the usual course of pain treatment provided to all patients hospitalized with their condition.
Standard care control group. In order to provide a comparable amount of time to patients in both groups (10–15 min), the research assistant also visited control patients once a day. Patients in the standard care control group, therefore, received the usual course of pain treatment of the hospital and a 10- to 15-min visit from the research assistant every day for 5 days. The research assistant provided noninvasive routine care as needed to these patients, but did not give any information or interventions related to pain or pain-related symptoms. Any cancer treatment-related or pain management-related questions raised by the patients were referred to their primary nurse.
Content of pain education program. A structured PEP and a 16-page booklet regarding pain control were developed with the focus on decreasing misconceptions about cancer pain management. The PEP content was based on findings related to pain control in Tai-wan [23, 24, 25], literature review [11, 12, 29, 44], and clinical guidelines for cancer pain management [16, 45].
The PEP covered 11 aspects of pain education. (1) Cancer pain was introduced by explaining how it interferes with daily life and the benefits of not having cancer pain. (2) Methods and drugs usually used to control cancer pain were presented. (3) Miscon-ceptions about using pain medicine, especially concerns about us-ing opioid-like medicines, were discussed. (4) Common methods to prevent or manage the side effects of pain medicines were ex-plained. (5) Misconceptions about and drawbacks of enduring pain were presented. (6) Non-pharmacological pain interventions were briefly introduced. (7) Ways to assess and monitor pain intensity (using a 0 to 10 numerical scale) were taught, along with (8) ways to communicate pain problems with health-care professionals by using the 0 to 10 numerical rating scale. Finally, patients were told (9) about their rights to discuss pain with health-care professionals and not to suffer from pain, (10) that the patient plays a central and active role in his/her pain control, and (11) that cancer pain can be controlled.
Measures
The variables measured were pain intensity (on average, current, least, and worst), pain interference with daily life, pain beliefs about using opioids, beliefs about enduring pain, and catastro-phizing and beliefs (thoughts) of sense of control over pain and decreasing pain. These variables were measured using the Brief Pain Inventory—Short Form Taiwanese version (BPI-T) [14], the Pain Opioid Analgesics Beliefs Scale—Cancer (POABS-CA) [24], the Coping Strategies Questionnaire—Catastrophizing (CSQ-Cat) [34] and two pain coping effectiveness ratings from the CSQ that assess patients’ perception of their ability to control and decrease pain.
Brief Pain Inventory—Short Form Taiwanese version. The BPI-T is a self-report scale that assesses two major aspects of pain: its in-tensity and interference with daily life [14]. It was validated from the Brief Pain Inventory—Short Form Taiwanese version [6, 14]. Pain intensity is measured by four items that rate worst pain in-tensity, pain intensity on average, least pain inin-tensity, and current pain intensity. Seven items assess the interference of pain with daily life (pain interference). Each item is rated on a numerical scale from 0 (“no pain at all” or “does not interfere”) to 10 (“worst possible pain I can imagine” or “completely interferes”). The BPI-T has shown promising psychometric characteristics [14]. In this
study, one item that measured interference with “normal work (work outside the home and housework)”, was deleted from the BPI-T because it was inappropriate for hospitalized patients. After the work item had been dropped from the original BPI-T, five pain experts (three physician specialists in pain and two doctoral-pre-pared oncology nurses) found its content validity to be satisfactory. Cronbach’s alpha values for the internal consistency reliability of the pain intensity and pain interference subscales in baseline test were 0.90 and 0.77, respectively, in this study. These results sug-gest that the minor revision of the BPI-T used in this study did not lead to a reduction in the validity of its psychometric properties. Pain Opioid Analgesics Beliefs Scale—Cancer. The POABS-CA was developed to assess a person’s beliefs about (1) using opioid analgesics in dealing with cancer pain and (2) enduring pain [24]. The POABS-CA is a ten-item five-point Likert-type instrument. Higher scores indicate more negative beliefs regarding opioids and a greater tendency to endure pain. The instrument shows satisfac-tory validity [24] and has been shown to be a reliable and stable pain belief scale, with Cronbach’s alpha (in baseline test) and test-retest reliability of 0.85 and 0.94, respectively.
Coping Strategies Questionnaire—Catastrophizing and CSQ sense of control over pain measure. The CSQ-Cat, from a subscale of the CSQ [34], has six items with a Likert scoring system from 0 to 6. The higher the score, the more the individual tends to catastrophize about pain. The summative score for CSQ-Cat ranges from 0 to 36. The CSQ has been translated into Chinese, has satisfactory psy-chometrics and has been shown to be appropriate for use in Tai-wanese cancer patients with pain [39]. For the purposes of this study, we only used the CSQ-Cat subscale to assess patients’ catastrophizing about pain. Cronbach’s alpha was 0.89 (in baseline test) in the current study. Two pain coping effectiveness ratings from the CSQ were used to assess patients’ sense of control over pain. These items, scored from 0 to 6 were: “Based on all the things you do to cope (with your pain), or deal with your pain, on an average day, how much control do you feel you have over it? (0 no control, 6 complete control)”; and “Based on all the things you do to cope with pain, on an average day, how much are you able to decrease it? (0 can’t decrease it at all, 6 can decrease it com-pletely)”. Our unpublished results indicate that these two items are moderately correlated (r=0.62, P<0.0001) and they were thus summed to produce a measure of sense of control over pain. Higher scores indicate greater control over pain perceived by patients. Background information form. A background information form was used to collect demographic and disease/treatment-related data. Demographic information included gender, age, education level, employment status, religion, and marital status. Disease and treat-ment-related variables included disease status (localized/metasta-sized), cancer stage, pain duration (how many months with pain), current anticancer treatment, and performance status which was measured using the Karnofsky performance status index [18], an 11-point scale with scores ranging from normal function (100%) to dead (0%).
Procedure
IRB approval of the study was obtained before conducting this research. Eligible cancer patients were randomly assigned to either the experimental or control group. A nurse research assistant, an experienced masters-prepared oncology nurse with pain control training, administered the intervention, approached each patient, explained the purposes and procedures of the study, and obtained his/her signed consent. Pretest baseline data were then collected using the instruments described above.
Data analysis
Descriptive statistics were used to analyze the frequencies and means of variables. Pretest baseline data for the control and ex-perimental groups were examined using a t-test and the chi-squared test (Table 1). Paired t-tests were used to examine the differences in mean pretest and posttest scores for each group. Repeated measures analysis of variance (ANOVA) was used to compare differences in
means between the two groups. Tables 1, 2, 3, 4 and 5 show these results. In Tables 2, 3, 4 and 5, tcand teare the within-group paired
t-values for the pretest-posttest comparisons in the control and experimental groups, respectively; tp is the t-value for pretest
comparisons between the control and experimental groups. F values represent the between-group repeated measures ANOVA.
Results
Subject characteristics and baseline pretest data
In total, 36 patients were eligible for participation.
How-ever, two patients refused to participate in the study due to
their physical condition, two dropped out during the data
collection process because of uncomfortable physical
condition, and the other two died during the data
collec-tion following a very severe change in their physical
condition. The final sample included 30 patients, 15 each
in the experimental (pain education) and control (standard
care) groups. All the patients had cancer with metastasis,
and half were undergoing chemotherapy.
There were no significant differences with respect to
demographic characteristics and disease and treatment
status (Table 1) between patients in the two groups. More
than half of the patients were female, with a mean age
around 55 years and an average of 6 years of formal
education. Most patients were unemployed and all had
religious beliefs. The baseline characteristics of all
pain-related variables were not significantly different
be-tween the two groups (Table 1). In both groups, patients
had been experiencing pain (pain duration) for around
4 months. For patients in the experimental and control
groups, the pain intensity on average was 5.00 and 4.33,
the worst pain intensity was 6.73 and 6.80, and the overall
pain interference with daily life was 5.35 and 5.05,
re-spectively. No significant differences among these
pain-related variables were found between the two groups
(Tables 2 and 3). In addition, patients’ negative beliefs
about opioids and pain endurance did not differ
signifi-cantly at baseline (Table 4). No differences were found in
patients’ perceived control over pain and catastrophizing
about pain between the two groups (Table 5). However,
patients in the experimental group had higher
catastro-Table 1 Subjects’ demographic and medical characteristics (n=30) (NS not significant) Control group Experimen-tal group P value Gender, n (%) Male 6 (40.0) 7 (46.7) NS Female 9 (60.0) 8 (53.3)
Age (years) (mean€SD) 56.07€14.34 51.67€11.20 NS Age groups (years), n (%)
20–40 1 (6.7) 2 (13.3) NS 41–50 4 (26.7) 6 (40.0) 51–70 9 (60.0) 7 (46.7) >71 1 (6.7) 0 (0.0) Education (years) (mean€SD) 5.13€5.04) 6.00€3.44) NS Religion, n (%) Yes 15 (100) 15 (100) NS No 0 0 Marital status, n (%) Married 15 (100) 14 (93.3) NS Not married 0 1 (6.7) Work status, n (%) Unemployed 13 (86.7) 14 (93.3) NS Employed 2 (13.3) 1 (6.7) Metastasis, n (%) Yes 15 (100) 15 (100) NS No 0 0 Cancer stage, n (%) II 6 (40.0) 4 (26.7) NS III 2 (13.3) 4 (26.7) IV 7 (46.7) 7 (26.7) Performance status, n (%) 60 6 (40.0) 6 (40.0) NS 70 7 (46.7) 7 (46.7) 80 2 (13.3) 2 (13.3)
Chemotherapy during current month, n (%)
Yes 7 (46.7) 8 (53.3) NS
No 8 (53.3) 7 (46.7)
Pain duration (months) (mean€SD)
4.85€3.65 3.99€3.71 NS
Table 2 Pain intensities in the control and experimental groups. Pre- and posttest scores are means€SD (tcpaired t-test comparing
pretest and posttest scores for control group, tepaired t-test
com-paring pretest and posttest scores for experimental group, tpt-test
comparing pain intensity scores between control and experimental groups at baseline, F results for repeated measures ANOVA in control and experimental groups)
Variable Control group (n=15) Experimental group (n=15) Between groups
Pretest Posttest tc Pretest Posttest te tp F
Worst pain intensity 6.80€2.83 5.53€2.88 1.99 6.73€2.22 5.33€2.13 2.40* 0.07 0.07
Least pain intensity 2.87€2.50 2.47€1.68 0.64 2.20€2.04 0.93€1.49 2.52* 0.78 1.17
Pain intensity on average 4.33€2.88 3.73€1.83 0.98 5.00€1.07 2.80€1.61 2.40* 0.94 4.01* Current pain intensity 3.33€2.72 3.47€2.03 0.24 3.80€2.57 1.73€1.87 3.46*** 0.48 7.23* *P<0.05, **P<0.01, ***P<0.005
Table 3 Pain interference with daily life in the control and ex-perimental groups. The BPI scores are means€SD (tcpaired t-test
comparing pretest and posttest scores for control group, tepaired
t-test comparing pret-test and postt-test scores for experimental group, tp
t-test comparing pain intensity scores between control and experi-mental groups at baseline, F results for repeated measures ANOVA in control and experimental groups)
Pain interference Control group (n=15) Experimental group (n=15) Between groups
BPI score tc BPI score te tp F
Pretest Posttest Pretest Posttest
Overall 5.05€2.40 3.70€2.96 2.58* 5.35€2.43 3.24€2.48 2.82* 0.35 0.66
General activity 4.87€2.88 4.27€3.81 0.58 5.93€3.15 2.60€2.80 3.88*** 0.97 4.14*
Mood 6.47€2.64 3.87€3.64 2.86* 6.00€3.09 3.60€3.22 2.23* 0.44 0.02
Walking ability 3.60€3.83 3.40€3.62 0.44 5.27€3.49 4.00€3.72 1.45 1.25 1.16
Relations with other people 4.60€4.01 2.33€3.42 2.15* 3.87€3.66 2.60€2.67 1.17 0.52 0.44
Sleep 5.73€3.31 3.80€3.41 1.94 5.07€4.13 2.47€3.44 2.03 0.49 0.17
Enjoyment of life 5.00€4.02 4.53€3.62 0.55 6.00€3.57 4.79€3.00 1.57 0.72 0.87
*P<0.05, **P<0.01, ***P<0.005
Table 4 Pain-related beliefs in the control and experimental groups. The POABS-CA scores are means€SD (tc paired t-test
comparing pretest and posttest scores for control group, tepaired
t-test comparing pret-test and postt-test scores for experimental group, tp
t-test comparing pain intensity scores between control and experi-mental groups at baseline, F results for repeated measures ANOVA in control and experimental groups)
Control group (n=15) Experimental group (n=15) Between groups
POABS-CA score tc POABS-CA score te tp F
Pretest Posttest Pretest Posttest
Overall 2.91€0.67 2.80€0.51 0.54 2.92€0.63 1.72€0.80 5.9*** 0.02 14.65***
Negative effect beliefs 2.96€0.76 2.77€0.63 0.92 2.92€0.77 1.67€0.94 5.21*** 0.14 11.13*** Pain endurance beliefs 2.95€0.95 2.84€0.86 0.42 3.20€0.81 1.67€0.22 5.64*** 0.76 13.91*** *P<0.05, **P<0.01, ***P<0.005
Table 5 Pain catastrophizing and sense of pain control in the control and experimental groups. The pre- and posttest scores are means€SD (tcpaired t-test comparing pretest and posttest scores for
control group, tepaired t-test comparing pretest and posttest scores
for experimental group, tp t-test comparing pain intensity scores
between control and experimental groups at baseline, F results for repeated measures ANOVA in control and experimental groups)
Control group (n=15) Experimental group (n=15) Between groups
Pretest Posttest tc Pretest Posttest te tp F
Catastrophizing
Overall 14.64€9.54 16.20€12.18 0.50 21.47€8.88 11.94€8.76 4.65*** 2.02 9.07**
It (the pain) is never going to get any better
2.47€1.77 2.67€2.38 0.29 4.27€1.33 2.33€1.84 3.71*** 3.15* 6.15* It (the pain) overwhelms
me
2.87€2.10 2.73€2.19 0.17 3.20€1.90 2.07€2.02 2.83* 0.46 1.29
My life isn’t worth living 2.00€1.96 2.07€2.12 0.13 2.60€2.06 1.67€1.99 2.11* 0.82 2.19 I worry all the time
whe-ther it (the pain) will end
2.33€1.63 3.60€2.32 2.40* 3.80€1.86 2.33€1.63 3.77*** 2.30 17.30*** I can’t stand it anymore 2.60€2.20 2.47€2.33 0.17 4.00€1.77 1.80€1.52 3.75*** 1.92 4.39* I feel like I can’t go on 2.40€2.16 2.67€2.47 0.58 3.60€1.99 1.73€1.53 3.34*** 1.58 8.65** Sense of control over pain
Overall 2.53€0.87 1.63€1.20 2.42* 1.90€1.58 2.63€1.30 1.86* 1.36 8.12**
Ability to control pain 2.73€0.88 1.67€1.18 2.87* 1.80€1.70 2.60€1.12 1.98* 1.89 11.55*** Ability to decrease pain 2.33€1.05 1.60€1.30 1.79 2.00€1.56 2.67€1.72 1.23 0.69 4.28* *P<0.05, **P<0.01, ***P<0.005
phizing scores (mean€SD 21.47€9.54) than in the control
group (14.64€9.54) at baseline, although the difference
was not significant (P=0.07).
Effects of the pain education program
We examined the effects of the PEP on pain intensity,
pain interference, beliefs about using opioids and
endur-ing pain, catastrophizendur-ing, and sense of control over pain
within each group by comparing mean pretest and posttest
scores. Repeated measures ANOVA was applied to
ex-amine the effects of the PEP between the two groups.
The between-groups comparisons showed that,
com-pared to the control group, patients receiving pain
edu-cation showed significant decreases in the following
pain-related variables: pain intensity on average, current pain
intensity, negative beliefs about opioids, pain endurance
beliefs, and pain catastrophizing. Over the course of
treatment, sense of control over pain was also
signifi-cantly increased in the experimental group compared to
the control group.
Within-group pre- and posttest comparisons revealed
that patients in the experimental group had significant
decreases in four types of pain intensity (worst, average,
least, current; Table 2), overall pain interference with
daily life (Table 3), beliefs about the negative effects of
opioids and pain endurance (Table 4), and pain
catastro-phizing. These pre- and posttest comparisons also showed
a significant increase in sense of control over pain in the
experimental group (Table 5). However, pre- and posttest
comparisons for the control group revealed that only
overall pain interference decreased significantly
(Ta-ble 3), but the sense of control over pain also decreased
(Table 5).
Discussion
The results confirmed our hypothesis that structured pain
education reduces the negative pain experience of cancer
patients and increases their sense of control over pain.
Compared to patients in the control group, patients who
received 5 days of pain education had significantly less
pain intensity on average and least pain intensity. These
findings are similar to those of most previous studies in
that pain education was found to decrease patients’ pain
[8, 10, 12, 30, 33]. However, the mean scores of pain
intensity found in the previous studies, except in that by
De Wit et al. [10], were not reported directly, so a
com-parison between our findings and only those of De Wit et
al. is possible. The magnitude of the decrease in pain
intensity in the current study was larger than that found
by De Wit et al., particularly for pain intensity on
aver-age. Pain intensity on average in the experimental group
dropped from a moderate level (mean€SD 5.00€1.07) at
pretest to a mild level (2.8€1.61) at posttest. Also, the
worst pain intensity in the experimental group dropped
from a severe level (6.73€2.22) at pretest to a moderate
level (5.33€2.13) at posttest. These findings suggest that
our consecutive 5-day pain education protocol was a
relatively powerful intervention for helping cancer
pa-tients control their pain intensity.
The between-group comparison also showed that
misconceptions about pain were significantly decreased at
posttest among patients receiving pain education. The
results were similar to those of previous studies [2, 8, 10,
12, 33]. In addition to supporting previous assumptions
and empirical findings on the effects of pain education on
patients’ misconceptions about pain control, we further
found that a 5-day structured brief PEP can significantly
enhance patients’ sense of control over pain and decrease
negative thoughts about pain (catastrophizing). This
pat-tern of findings, particularly for the sense of control over
pain, contrasted with the pattern seen in the control group,
where sense of control over pain decreased, with mean
scores of 2.53 at pretest and 1.63 at posttest (t=2.42,
P<0.05). At posttest, the findings are particularly
inter-esting and meaningful for pain education. Even though
our PEP was not specifically directed at changing
pa-tients’ negative cognition about their overall pain
expe-rience, it offers promise in helping patients develop a
more positive cognition about their ability to effectively
manage pain. The results strongly suggest that the more
skills and knowledge a patient has about pain
manage-ment and the use of analgesics, the greater is his or her
sense of control. The findings also support our assumption
that pain is a multidimensional experience [1], influenced
not only by sensory processes but also by cognitive
pro-cesses.
Interestingly, pain interference with daily life was
decreased in both groups as shown by the within-group
pre- and posttest comparison, but the difference between
the groups was not significant. This lack of difference in
pain interference between the groups was probably due to
both groups’ posttest improvement. Two possible reasons
might explain the results. First, hospitalized patients have
a very limited “daily life” (free time and activities) within
the hospital setting. Therefore, even though the magnitude
of change in pain intensity was obviously great between
the two groups, this variable may not have much
influ-ence on the activities listed in the interferinflu-ence scale, such
as “enjoyment of life”. Second, patients in the control
group received a routine visit from the nurse research
assistant once a day. This visit may have increased
pa-tients’ sense of being supported and cared for (for
ex-ample, the pain interference on “relations with other
people” dropped significantly in the control group but not
in the experimental group), thus decreasing the overall
pain interference. The latter reason may also help to
ex-plain the apparent decrease in worst pain intensity in the
control group, although this decrease was not significant
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The preliminary results of our structured PEP are very
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In conclusion, our preliminary results strongly support
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obtained through regular daily medical care. We therefore
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and integrated into clinical cancer pain management.
AcknowledgementsThe authors gratefully acknowledge the sup-port and assistance of the patients who participated in this study. The authors also thank Claire Baldwin for her English editing.
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