Introduction
Hospice patients facing end-of-life issues are often faced with significant amounts of pain that can add stress and anxiety to the experience. Palliative care for these patients should include an effective protocol for reducing pain; however, research suggests that many hospice patients do not experience adequate pain relief from pharmacotherapy. In one study of over 12,000 hospice patients prescribed morphine, oxycodone, or fentalyl for pain relief, approximately one-third of patients still reported moderate to severe levels of pain (Weschules, et al., 2006). Research suggests that some forms of complementary and alternative medicine, including massage therapy, meditation, and biofeedback, may be effective adjuncts to pharmacological therapy for pain relief (Tan, et al., 2007). Based upon this concern, the following research question was proposed: For hospice patients suffering from pain, does the addition of complementary and alternative techniques such as massage therapy, meditation, and biofeedback to standard pharmacological pain management protocols improve the amount of pain relief in a 24-hour time period? The change plan described in the next section utilizes the Rosswurm and Larrabee (1999) model to implement an evidence-based change in the care of hospice patients with regards to pain management.
Change Plan Overview
Assess the Need for Change
In the first step of the model, practitioners should collect internal data and compare it with external data to determine the need for change (Rosswurm & Larrabee, 1999). To complete this step, hospice nurses will collect data pertaining to levels of patient pain over a 24-hour period. The Visual Analog Scale, in which patients rate their pain on a scale of 0 to 10, will be used. Measurements will be obtained at least three times over a 24-hour period in which the patient received continuous pain medication. The results from this data collection effort will be compared to studies published in the literature, such as that by Weschules, et al. (2006), which indicates that many hospice patients do not experience adequate pain relief from narcotics.
Link Problem-Intervention-Outcomes
To link the problem, which is ineffective pain management related to terminal cancer using pharmacotherapy, with interventions and outcomes, the nurses should turn to the Nursing Interventions Classifications (NIC) and Nursing Outcomes Classifications (NOC). An appropriate nursing diagnosis would be acute/chronic pain related to the disease process of cancer, including nerve compression, or involvement of tumors or visceral organs. The desired outcomes stemming from this diagnosis would be Pain Control, which would involve both a pharmacological regimen and the use of alternative therapies that foster relaxation and diversional activities. Pain management through the use of pharmacotherapy and relaxation techniques shall be adopted as a nursing intervention. Upon identification of the outcome and general interventions, a more specific intervention should be chosen. This would be based on the information gathered in the third step of the model.
Synthesize Best Evidence
In this step, the nurse chooses and refines the outcomes and interventions identified in the previous step. Specific activities that should be completed during this step include a comprehensive review of the literature and a grading of the strength of research evidence (Sidani and Braden, 1998). A preliminary literature search revealed studies that support the use of alternative therapies to assist with pain management. Two studies reported hospice patients may be receptive to the use of alternative therapies such as massage therapy, meditation, and biofeedback for pain management as an augment to conventional medicine such as the use of morphine, oxycodone, or fentalyl for pain relief (Corbin, Mellis, Beaty, & Kutner, 2009; Elliot, Kealey, & Olver, 2008). Other studies suggest that massage therapy and biofeedback may be beneficial in reducing pain related to cancer over a short-term time period (Tan, et al., 2007; Kutner, et al., 2008; Tsai, Chen, Lai, Lee, & Lin, 2007).
Design a Change in Practice
Based upon the evidence identified in the previous step, a practice protocol would be created. The protocol would specify the details on the use of massage therapy or biofeedback as an adjunct to pharmacological treatment, including when to administer, how to administer, and how to assess the impact of the new therapy. Prior to implementing the protocol, approval would be obtained from hospice administration, and nurses who would perform the protocol steps would receive training. Information about a pilot test of the protocol would be communicated to all involved stakeholders. The pilot test would be implemented using a small subset of the nursing staff and patients. In this regard, a sample of five nurses and ten patients will be used in the pilot test. In this pilot study, five of patients will be used as a control group whereas the other five shall be the experimental group. The control group shall only be subjected to pharmacological treatment while the experimental group shall be subjected to both the pharmacological, and complementary and alternative treatment such as massage therapy and biofeedback. Pain control among the participants in the two study groups shall be measured and the difference, if any, noted down. The results of the evaluation of the pilot study, which would center on the outcome of improved pain control in hospice cancer patients, would determine to what extent the protocol would be implemented facility-wide.
Implementing and Evaluating Change in Practice
During administration of the pilot project, project coordinators would gather data concerning nursing staff feedback; patient feedback; patient pain ratings; feasibility of the protocol; and risks and benefits to both staff and patients. An important measureable goal is a reduction in patient-reported pain levels over a 24-hour period after receiving the changes specified in the new protocol. The pilot test shall be effective if the coordinator shall monitor the process closely, and is available to provide the answers to various questions. There will be a need for follow-up reinforcement of the practice change overseen by the coordinator. An analysis of the data collected shall be conducted and interpreted to decide on whether there were notable differences in the indicators before and after the pilot study. In the analysis and interpretation, several questions shall be answered. Some of these questions include: Were the appropriate structural variables for the study provided? Do the information collected show that the new protocol was implemented as intended? If the answer to this is “yes”, then what impact did the new protocol had on the patient outcome? It should be noted that when the protocol is implemented in an inappropriate manner, then there is a chance for harmful impacts on the patient. Nonetheless, during the consideration of the results, it should be noted that patient outcomes are usually affected by various factors apart from the intervention. Such other factors include the characteristics of the patients, the staff, and the context, as well as the interpersonal aspect of care (Sidani and Braden, 1998). Based upon an analysis of this data, the project coordinators in conjunction with other staff and administration would decide whether to adopt, reject, or modify the protocol. During the evaluation of data, feasibility, benefits and risks shall be considered. The opinions from the stakeholders shall be considered during data evaluation.
Integrate and Maintain Change in Practice
If the data gathered from the pilot project supports adoption of the new pain management protocol, then the change would be implemented facility-wide and all staff trained in the new activities. Continuing education efforts would be developed to assist in the training and to facilitate acceptance of the change. Patients would also be educated regarding the changes. Periodic evaluations would be conducted to ensure adherence to the protocol and continued positive outcomes.
Summary
Based upon internal and external evidence that suggests hospice patients suffering from cancer-related pain do not experience adequate pain relief from current pharmacological protocols, a practice change was suggested in which complementary therapies, such as massage and biofeedback, are used as adjuncts to current treatments. The proposed Change Plan encompasses the six steps of the Rosswurm and Larrabee (1999) model: collection of internal data to support the need for change and comparison with published data regarding pain management in cancer patients; specifying an outcome of pain control and an intervention related to pain management; conducting a literature search to identify high-quality research in support of interventions such as biofeedback and massage with this population; creating a treatment protocol based on the evidence; conducting and evaluating a pilot study; and formally adopting the change plan with ongoing training and evaluation.
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