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Oncology nurses' perception of cancer pain: A qualitative exploratory study.


Cancer pain and its management are complex and may impact on many aspects of a cancer patient's journey. Despite advances in understanding the aetiology of cancer pain and pharmacological developments, the limited effectiveness of pain treatment remains a challenge for health professionals. Many patients with cancer continue unnecessarily to experience severe unrelieved pain. The present research was conducted to explore how oncology nurses perceive cancer pain in patients for whom they provide care. Five Registered Nurses working in a New Zealand oncology ward were purposefully sampled. Semi-structured interviews were audio-recorded and transcribed verbatim. Subsequently transcripts were analysed using thematic/content analysis. The findings offer insight into how nurses themselves respond to under-treatment of cancer pain. Responses such as frustration, helplessness and emotional distress were reported. Findings of this study were consistent with existing literature, namely identification of shortfalls in training and education, lack of comprehensive assessment of pain, and deficits in pharmacological and non-pharmacological treatment of pain. The study highlights the need for improvement in these areas and identifies the need to further explore issues of cancer pain management with patients themselves.

Key words

Cancer pain; oncology nurses; pain assessment; pain management; education


Pain is one of the most distressing symptoms experienced by patients with cancer undergoing active treatment (Stark, Tofthagen, Visovsky, & McMillan, 2012). Despite advances in understanding the aetiology of cancer pain, pharmacological developments, pain assessment tools and management guidelines, pain often remains poorly managed. Many patients with cancer continue to experience severe and unrelieved pain resulting in unnecessary suffering (Dulko, Hertz, Julien, Beck, & Money, 2010; Fairchild, 2010; Huntoon, 2009). Acute pain can be triggered by surgery and diagnostic procedures such as bone marrow aspirations and repeated intravenous cannulations for chemotherapy drugs (Chapman, 2011). Treatment effects such as chemotherapy-induced neuropathy may also contribute to reported pain (De Grandis, 2007; Lavoie Smith, Cohen, Pett, & Beck, 2010).

Barriers to effective pain management are commonly reported throughout health care systems and may relate to the system, health professionals, and patients themselves (Bennett, Flemming, & Closs, 2011). With regard to nursing oncology practice, a lack of knowledge surrounding opioid delivery and its effects contribute to pain prevalence (Voshall, Dunn, & Shelestak, 2013). Yildirim, Cicek, and Uyar (2008) found that oncology nurses possessed inaccurate knowledge about commonly used analgesics and consequently exaggerated anxiety about the potential for psychological dependence occurring. Furthermore, patients themselves are often reluctant to report pain related to concerns about the impact of subsequent treatment decisions, personal cost, and their own fears of addiction and dependence (Simone, Vapiwala, Hampshire, & Metz, 2012).

Oncology nurses are noted as being at the frontline of cancer pain management (Aycock & Boyle, 2009). Nurses perform and evaluate many interventions for pain management and have an essential role in deciding when changes in plans are required (Bernardi, Catania, Lambert, Tridello, & Luzzani, 2007; Chapman, 2011). This study explored how oncology nurses perceive, experience and assess cancer pain in their patients and, subsequently highlighted factors affecting the delivery of effective pain management strategies.


A qualitative descriptive exploratory study was conducted using semi-structured interviews in order to achieve a detailed exploration of oncology nurses' perceptions of cancer pain in patients were receiving chemotherapy. A purposive sampling method was used to include experienced participants who had knowledge of the phenomenon in question (Berg, 2009; Sandelowski, 2010). The participants were five second-level chemotherapy-certified oncology nurses. The age of participants ranged from 32 to 55 years, with an average time of ten years working in the oncology field. All the available participants were female.

Data were collected using one-to-one semi-structured interviews. Interviews are commonly used to gather in-depth exploration of nurse's perceptions, views, feelings, and experiences (Garton & Copland, 2010). Questions were open-ended to allow flexibility and encourage a richer narrative. Examples of the included questions were: What does pain mean to you?, How do you perceive cancer pain?, Does the pain reported by your patients have any impact on your practice?, How do you feel when your patient is in pain?, How well prepared do you feel to effectively manage a patients pain?. Further prompts, where needed, were used in order to clarify and to extend related concepts of cancer pain management.

The interviews were audio-taped to ensure data accuracy. Once transcribed, inductive thematic analysis was conducted to identify codes, categories and themes relevant to the research question (Fereday & Muir-Cochrane, 2006). A Framework Analysis approach was applied (Richie & Spencer, 1994). Immersion in the raw data was achieved by listening to the interview tapes and then repeated reading of the transcripts to ensure familiarity with the data. Index headings were developed by ordering the transcripts with numerical codes around a number of different initial categories. Themes emerged from this process using a 'mapping and interpretation' strategy (Ritchie & Spencer, 1994).

Study 'trustworthiness' was, in part, achieved through bracketing previous theoretical preconceptions (Guba & Lincoln, 1989). Furthermore, the participants were given access to their original transcripts for confirmation (only one declined). No participant presented any issue with their transcript. In addition, member cross-checking of the transcripts was carried out by the primary researcher and two senior researchers; one whose field of medical research is oncology.

Ethical approval for the research was obtained through the Multi-regional Health and Disability Ethics Committee (reference: MEC11/EXP/039). The participants were informed of the objectives of the study and signed informed consent were obtained. Anonymity was maintained during the transcription process and pseudonyms were used to report findings.


Inductive analysis of data resulted in six themes:

Meaning of and interpretation of cancer pain

All participants were second level chemotherapy certified nurses. They mainly cared for patients undergoing chemotherapy or having adjuvant treatment. Most participants described cancer pain as being complex, difficult to treat, and its variability from patient to patient. Some participants viewed cancer as a terminal disease and identified the 'futility' of pain treatment. In this case,
...if the person has a non-curative disease, that pain essentially is
potentially not going to go away ever, they're going to live with it...
it will be there probably until they die because we are not going to
cure the disease. (Sam)

The participants made efforts to understand patients self-reporting of their pain. They nursed patients with different types of cancer and reported that cancer pain was different among patients, often creating difficulties in managing cancer pain as they encountered different symptoms across a range of cancers.
Not having had cancer... I listen carefully you know, I try sort of ...
yeah I try as best I can to understand it from what they tell me.... it
varies from one patient to another and .... different types of cancers.

Expectations, frustration and realities

Most participants expressed the desire to see their patients with little or no pain. They had high expectations of themselves and were committed to achieving the best possible outcomes.
My aim is quite idealistic I suppose, but is to have everybody's pain
under control so that they're either pain free or it is so minimal,
that they're able to do what they want, ...their daily living
uninhibited by pain. (Mara)

I mean, ideally you would like to have no pain at all, but ... I don't
know how realistic that is in all cases, so I think you've got to bring
their pain down to a level that they can deal with, they're comfortable
with. (Kelly)

Despite their desire to see their patients with no pain, nurses reported that their nursing reality was different; often expressing frustration and helplessness. One of the most common factors they reported was not having enough time in their busy schedule.
I think it's hard, ....sometimes when the ward is so busy it's really
hard to try to get, know like these regular meds in, I guess
there are no excuse for not giving things on time, but when the ward is
really, really busy, is hard to be exactly on time. (Kelly)

It's know... you feel your pulse go up, you feel hot,
it's... I find that emotionally.... emotionally draining because you
know you can't do anything and you could be doing better. (Sam)

... you can't get on top of someone's pain, you almost feel that you've
failed them I guess, and these days, particularly, when you've got
sophisticated technology, and we've got quite improved procedures and
methods, but we still can't always get on top of someone's pain, I
don't think...and it doesn't, as a nurse, at the end of an eight hour
shift, I don't think you go away, you don't go home feeling fulfilled,
someone's kind of in just as much pain, or worse pain, when you leave,
than when you came. (Kate)

Place in managing patient's pain

Relationships between different health professionals were considered important to clarify specific patient cancer care issues. For instance, the participants in this study actively recognised the role of the palliative care team. They identified how the support team influenced the way they managed patient's pain within the oncology unit.
I mean you're not doing it all on your own ... you're bringing other
members of the team as if you've got somebody who is a very
complex case you are not going to be dealing with that all on your own,
you're going to get people like the palliative care team involved or,
the doctors, the physio. (Kelly)

Luckily we have the hospice team, pain management team that...ramp it
up, if there's a person that's in a lot of pain. (Lara)

Unreported pain

The patient's fear of addiction and treatment side effects negatively impacted on the pain management process. The participants' knowledge of interpreting their patients' non-verbal communication was a reported advantage:
I was asking about his pain.... it was like.... he kept saying his pain
was 7 out of 10.... which is obviously very significant pain. If I was
in 7 out of 10 pain, I would be wanting some pain relief.... every time
I asked him he refused pain relief. (Kelly)

When they do get out of bed, you know, they're wincing ... you know,
they appear in a lot of pain.... they might not telling you, but they
may be very obvious to someone else, or another patient says I'm
ringing for (such and such), they appear in a lot of pain and you go up
and say: are you in pain and they say no. Because they don't breathe
well.... or they are not able to take a deep breath, you go: can you
take a deep breath for me, no I can't. (Sam)

Psychological interventions

There was an awareness of the role of psychological interventions on impacting pain management. However, it was reported that demanding work environments, usually outside their control, hindered this type of activity.
Sometimes work does not facilitate....the psychological aspect
patient.... nurses' don't get enough time to sit down with the
patients.... they're that stuff is often overlooked. (Sam)

I think yea, I think sometimes nurses maybe, kind of forget the
non-pharmaceutical things that may be helpful even as simple as
changing someone's position or, um, maybe changing something in their
environment, maybe something they can reach more easily, those kind of
measures in terms of patients pain relief as well. (Kate)

Training and education

Participants openly reported the limitations of the education and training they received related to oncology-related pain assessment, pain pharmacology and pain management. They expressed the desire for ongoing study days in pain management as well as in topics related to pharmacology.
I don't actually, consciously remember having a lot in my training
around pain medication and pain relief ... I guess, rightly or wrongly,
I guess we learned a lot of it through experience. (Kate)

In my training we actually did very little ... study about pain at
all.... In actual nursing training, the course didn't actually cover in
great deal pain or pain management. (Kelly)

It's actually a very good idea to have more educational on board, sort
of in-services about pain management. I would appreciate that, I would
probably get a lot of out of that. (Lara)

I think it's good to have regular study days on pain, just because new
drugs are coming out and the combinations that you can use with
steroids, with anti-inflammatory, and like Gabapentin and how they
work. (Sam)


These study findings provide a New Zealand perspective on previous studies (Portenoy, 2011; Yildirim et al., 2008; Xue, Schulman-Green, Czaplinski, Harris, & McCorkle, 2007). Comprehensive pain assessment is considered as the cornerstone of pain management and, consequently, assessment guidelines have been developed by different organisations. The Joint Commission on Accreditation of Health-care Organisations (JCAHO) advocates assessment of pain as the 'fifth vital sign' - including pain characteristics such as onset, intensity, location, duration, aggravating and relieving factors (Virizuela, Escobar, Cassinello, & Berrega, 2012; Zhu & Weingart, 2012). In this study, the participants reported assessing patients' pain based on their pain intensity only. These guidelines were not mentioned by the nurses interviewed in this study; a finding similar to that reported elsewhere (Cohen et al., 2003; Mitra & Jones, 2012). Pain experience is subjective and personal; hence self-reporting of pain is the single most reliable indicator of pain intensity (Caraceni et al., 2012). Accordingly, participants in this study clearly acknowledged the importance of self-reporting of pain. Reassuringly, this is in contrast with previously reported findings that oncology nurses both underestimated and did not believe the level of pain reported by patients (Bernardi et al., 2007).

Rushton, Eggett, and Sutherland (2003) reported that oncology nurses have difficulty in understanding the pharmacology of analgesics. For example, almost 40% of them did not know that 30 mg of oral morphine would be equivalent to morphine 10mg intravenous. Participants in this study were not able to clearly articulate knowledge of mechanisms of action or dosages of pain management drugs. However, they openly admitted to a deficit of knowledge in relation to cancer pain and its management, and expressed the desire for further knowledge. Added to the educational limitations, work conditions adversely affected the physical and emotional health of the nurses. They viewed oncology nursing as a difficult occupation. High rates of stress in oncology nurses are related to suffering, grief, and death exposure on a regular basis (Dougherty et al., 2009). Furthermore, Saltmarsh and De Vries (2008) found that nurses experienced high levels of emotional distress during cytotoxic administration due to fears relating to chemotherapy side-effects and cytotoxic spillage. Although this study did not examine such issues, it highlights further competing demands on nurses to adequately monitor and manage cancer pain. Accounts of participants' work in the oncology unit illustrated the highly technical and skilled nature of cancer care. Other factors such as rotating shifts added to their stress levels. Organisational factors such as shortages of staff and lack of resources also hindered nurses' use of non-pharmacological pain alleviation methods in the management of cancer pain. This fact is well documented outside New Zealand (Fleming, 2010; Mcilfatrick et al., 2006; Saltmarsh & De Vries, 2008).


This was a single site study with a small sample size. Therefore, the ability to make any generalisation from these findings is limited. The sample consisted of five oncology nurses working in one oncology centre and these may not be representative of all oncology nurses in New Zealand. Factors such as where nurses received their first or second level chemotherapy certification were not recorded.

In order to extend the findings of this study, further research into the oncology nurses' experiences and practices related to cancer pain in other oncology units in New Zealand is recommended. The present findings could be compared and contrasted with patients' experiences through undertaking similar studies investigating patients themselves.


The findings of this study are consistent with studies from the wider international literature. This study highlights issues concerning oncology nurses experiences of cancer pain and the various factors that facilitate or hinder effective pain management in an oncology unit in New Zealand. While nurses' attitudes to managing cancer pain were generally positive, there was a need for further education concerning both the pathophysiology of cancer pain management and pharmacological interventions. The study findings highlighted the on-going effects of organisational barriers, such as the business of the ward, heavy workload, and the lack of staff and resources--on both pharmacological and non-pharmacological pain alleviation methods. Personal barriers such as emotional distress, frustration and helplessness, especially related to the under-treatment of pain, emerged as a further barrier.

It is evident that current methods of training and education do not always prepare nurses with the appropriate knowledge and skills needed for providing effective cancer pain management strategies. Therefore, on-going informal and formal educational programs should be in place to improve nurses' knowledge and practices in cancer-related pain.

Concluding statement

The competing demands on nurses in a busy oncology unit along with knowledge deficits in pain management issues may lead to the under-treatment or mismanagement of cancer pain. More concerted and effective training and education is seen as the most appropriate strategy to overcome this dilemma - as well as appropriate resources put in place to facilitate putting extended training into effective practice.

Alicia Garcia, MN, RN, Clinical Teaching Associate, Massey University, School of Nursing, Palmerston North, NZ

Dean Whitehead, PhD, MSc, BEd, RN, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia

Helen S. Winter, MSc (oncology), BSc (hons), MBBS, Regional Cancer Treatment Service, MidCentral District Health Board, Palmerston North, NZ

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Alicia Garcia, MN, RN, Clinical Teaching Associate, Massey University, School of Nursing, Palmerston North, NZ

Dean Whitehead, PhD, MSc, BEd, RN, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia

Helen S. Winter, MSc (oncology), BSc (hons), MBBS, Regional Cancer Treatment Service, MidCentral District Health Board, Palmerston North, NZ
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Author:Garcia, Alicia; Whitehead, Dean; Winter, Helen S.
Publication:Nursing Praxis in New Zealand
Article Type:Report
Geographic Code:8NEWZ
Date:Mar 1, 2015
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