Content uploaded by Ayfer elçigil
Author content
All content in this area was uploaded by Ayfer elçigil on Aug 21, 2018
Content may be subject to copyright.
Nurses’ Perceived Barriers to Assessment and
Management of Pain in a University Hospital
Ayfer Elcigil, RN, PhD,* Hanife Maltepe, RN, MSc,* Gu
¨lay E ¸srefgil, RN,*
and Kamer Mutafoglu, MD
w
Summary: A self-report questionnaire was answered by 114 nurses
working at the internal medicine, oncology, and surgery clinics.
The most commonly perceived barriers to pain management were
system-related barriers. Lack of psychosocial support services and
patient-to-nurse ratio received the highest ratings. Institutional and
governmental attempts are needed to increase the number of nurses
in the clinics and to establish support services. Nurse-related
barriers were less perceived as an obstacle when compared with the
other barriers. A small percentage of the nurses agreed that nurses’
inadequate knowledge of pain management (10%) and nurses’
indifference (8%) were barriers to pain management. Inadequate
time for health teaching with patients was agreed on by 65% of the
nurses. Most commonly rated physician-related barriers were
inadequate assessment of pain and pain relief by doctors (63%)
and physicians’ indifference (47%). Patients’ difficulty with
completing pain scales (56%) and consumers not demanding
results (53%) were the most commonly reported patient-related
barriers. A significant percentage of the participating nurses
indicated that they have no idea about patient-related barriers.
Regular and continuous pain education programs may help to
establish a supportive team spirit between doctors and nurses.
Key Words: barriers, pain, nurses
(J Pediatr Hematol Oncol 2011;33:S33–S38)
Inadequate treatment of pain is a serious clinical problem
in hospitalized patients and has been well documented for
more than 25 years.
1–4
Pain can be associated not only with
the disease process itself but also with the treatment of
disease. Many diseases such as cancer, sickle cell anemia,
and chronic arthritis may cause pain.
5
It was shown that
90% of the patients terminally ill with cancer had been
suffering from pain.
6,7
Uncontrolled pain impairs the physical, social, and
psychological functions of the patients.
5,7,8
Pain, if left
untreated, can significantly affect the patient’s quality of
life, will to live, or willingness to cooperate during
treatment.
8–13
Inadequate treatment of pain may result in
slowed healing, a higher rate of complications, anxiety,
sleep disturbance, and lowered quality of life.
3,14–17
Several types of barriers to pain assessment and
management in variety clinical settings have been reported
and these barriers can be grouped into 4 themes: patient-
related barriers, nurses-related barriers, physician-related,
and systems-related barriers.
17–23
It is known that the professional-related barriers are
very important to manage the pain.
1
A number of studies
indicate that knowledge deficits, inadequate pain assess-
ment, and reluctance to administer opiates are the most
important barriers for health care professionals in imple-
menting pain management.
16,21–25
The teamwork is essential for optimal pain manage-
ment. Particularly, doctors and nurses should work in close
collaboration.
17,26
Nurses play a critical role in this team
work because they deliver direct patient care on a 24-hour
basis.
26
The nurse should evaluate and monitor the patients
and their relatives attitude, knowledge, and experiences.
The nurses’ perception effects her approach to the patients
in pain.
1,20,25–28
Despite the fact that nurses are the front-
line caregivers in inpatient settings, there is limited data on
the nurses’ perceived barriers to optimal pain management
in our country. In this study, we aimed to define the nurses’
perceived barriers to pain management in clinics where patients
with cancer are hospitalized for diagnosis and treatment.
METHODS
This is a descriptive study searching for the hospital
nurses’ perception of barriers to good cancer pain control.
A self-report questionnaire was given to the hospital nurses
working at the oncology, internal medicine, and surgery
clinics, where mostly patients with cancer had been
hospitalized. As a result of the limited bed capacity in the
oncology hospital, many patients with cancer are hospita-
lized in internal medicine and surgical wards both for
diagnostic interventions and cancer treatment.
There were 178, 140, and 29 nurses working in the
surgery, internal medicine, and oncology clinics, respec-
tively. One hundred fourteen of the nurses answered the
questionnaire voluntarily.
Data and Instruments
A standardized questionnaire was tailored for this
study based on the questionnaires used by the earlier
studies.
17,18,20
The questionnaire consisted of two parts.
The first part was designed to identify nurses’ personal and
demographic features, which included age, education,
working place, and years of professional experience.
The second part aimed to evaluate nurses’ perceived
barriers related to patients, nurses, physicians, and the
system. The questionnaire was pretested on 30 nurses for
relevance and comprehensibility. It took about 15 to 20
minutes to complete a questionnaire. The questionnaire was
distributed to be completed by them and was then collected.
Copyright r2011 by Lippincott Williams & Wilkins
Received for publication January 12, 2011; accepted January 24, 2011.
From the *Dokuz Eylul University, Muzaffer Muhit Kayhan Oncology
Hospital, Izmir, Turkey; and wDepartment of Clinical Oncology,
Institute of Oncology, Dokuz Eylul University, Izmir, Turkey.
Reprints: Ayfer Elcigil, RN, PhD, Assistant Professor, School of
Nursing, Dokuz Eylul University, Oncology Nursing Department,
(e-mail: ayfer.aydin@deu.edu.tr).
SUPPLEMENT
J Pediatr Hematol Oncol Volume 33, Supplement 1, April 2011 www.jpho-online.com |S33
It was emphasized that this study was anonymous and
the data would be used only for scientific research.
Participation was voluntary, and oral approvals were taken
from each study participant. Institutional approvals from
the Nursing Department were also obtained.
Statistical Analysis
Data were entered and analyzed using the Statistical
Package for the Social Sciences version 11.5. Before entry,
all data were examined for accuracy. Descriptive statistics
were used to describe nurses’ background characteristics.
Kruskal-Wallis tests (nonparametric comparisons) were
used to compare the differences of nurses’ perceived
barriers according to various demographic groups includ-
ing age, nursing education, and working place. To compare
the differences of years of experience w
2
test was used. A
significance level of P=0.05 was used.
RESULTS
Demographic Characteristics of Participants
The demographic characteristics of the participating
nurses are shown in Table 1. Majority (71%) of the nurses
was 20 to 30 years old, 99% were female, and 77% had a
baccalaureate degree. Years of experience were more than
five years in 54 % of nurses. Fifty-six percent of the
participants were working in the surgical wards.
Perceived Barriers to Assessment and
Management of Pain
In this study, nurses’ perceived barriers to assessment
and management of pain was evaluated in four different
parts; nurse-related barriers, physician-related barriers,
patient-related barriers, and system-related barriers.
Table 2 shows the mean of the barriers that nurses
perceived to assessment and management of cancer pain.
The most commonly perceived barriers to assessment
and management of pain were system-related barriers.
When compared with the other barriers, nurse-related
barriers were less perceived as an obstacle.
The patient-related barriers can be seen in Table 3.
Patients’ difficulty with completing pain scales (56%) and
consumers not demanding results (53%) were the most
commonly reported barriers. A significant percentage of the
participating nurses (45% to 79%) indicated that they have
no idea with regard to 7 of 9 patient-related barrier items.
The nurse-related barriers can be seen in Table 4.
Inadequate time for health teaching with patients was
reported by the 65% the nurses. Most of the nurses (64% to
82%) did not agree with 6 of 7 nurse-related barriers.
A small percentage of the nurses agreed that nurses’
inadequate knowledge of pain management (10%) and
nurses’ indifference (8%) were barriers to pain manage-
ment.
Physician-related barriers perceived by the nurses are
shown in Table 5. Inadequate assessment of pain and pain
relief (63%) and doctor’s indifference (47%) were the most
reported barriers by nurses. More than half of the nurses
disagreed on inadequate knowledge, reluctance to prescribe
adequate painkillers for fear of overmedicating, and lack of
trust in nurses’ assessment of pain. At least one fifth of the
nurses indicated that they had no idea about the physician-
related barriers addressed.
TABLE 1. Nurses’ Sociodemographic Characteristics
Sociodemographic Characteristics N %
Sex
Male 1 0.9
Female 113 99.1
Age (y)
20-30 61 71.1
31-40 29 25.4
>41 4 3.5
Years of professional experience
0-1 11 9.6
2-5 49 43.0
6-10 37 32.5
>11 17 14.9
Educational level
Nursing collage 2 1.8
Vocational 16 14.0
Bachelor 88 77.2
Master 8 7.0
Care setting
Medical wards 31 27.2
Surgical wards 64 56.1
Oncology 19 16.7
Total 114 100
TABLE 2. The Mean of Nurses’ Perceived Barriers to Assessment
and Management of Pain
Barriers N Minimum Maximum Mean SD
Patient related 114 1.11 3.00 2.1589 0.51035
Nurse related 114 1.00 3.00 2.4336 0.52975
Physician related 114 1.00 3.00 2.1103 0.53622
System related 114 1.00 2.83 1.7208 0.48768
Total 114 36.00 97.00 71.8860 13.60229
TABLE 3. Patients-Related barriers
Barriers Agree Disagree Do not know
Patients-related Barriers N (%) N (%) N (%)
Patients’ difficulty with completing pain scales (eg, 0-10) 64 (56.1) 20 (17.5) 30 (26.3)
Consumers not demanding results 60 (52.6) 21 (18.4) 33 (28.9)
Patients’ reluctance to take pain medication for fear of addiction 41 (36.0) 17 (14.9) 56 (49.1)
Caregiverr’s indiffrence 40 (35.1) 23 (20.2) 51 (44.7)
Patients’ reluctance to take pain medications because of side effects 39 (34.2) 14 (12.3) 61 (53.5)
Patients reporting their pain to the doctor, but not to the nurse 36 (31.6) 20 (17.5) 58 (50.9)
Patient’s reluctance to take opioids 32 (28.1) 20 (17.5) 62 (54.4)
Patient’s reluctance to report pain 27 (23.7) 16 (14.0) 71 (62.3)
Patients not wanting to bother the nurses 10 (8.8) 14 (12.3) 90 (78.9)
Elcigil et al J Pediatr Hematol Oncol Volume 33, Supplement 1, April 2011
S34 |www.jpho-online.com r2011 Lippincott Williams & Wilkins
Table 6 shows the system-related barriers. Lack of
psychological support services (77%), patient-to-nurse ratio
(74%), and lack of social workers (70%) were the most
commonly perceived system-related barriers by the nurses.
Lack of access to professionals who practice specialized
pain treatment methods (66%), lack of guidelines for pain
management (66%), and difficulty contacting or commu-
nicating with physicians to discuss treatment of pain (61%)
were indicated as being the more common system-related
barrier by the nurses. A significant percentage of the nurses
disagreed on the barriers about inconsistent practices around
giving “as needed” medications for patients (45%), lack of
pain medicine in the market (41%), and lack of equipment or
skill in using equipment (42%).
When the barriers were analyzed according to demo-
graphic variables, no significant differences were found
among nurses according to age (Kw
2
, 0.005; P=0.997),
education level (Kw
2
, 4.905; P=0.179,), and the years of
experience (Kw
2
, 3.434; P=0.329). However, significant
differences were found among work settings (Kw
2
, 38.84;
P=0.000). The nurses who worked in oncology clinics
agreed more on the system-related barriers.
DISCUSSION
Nurses play a crucial role in pain assessment and
management. They often act as mediators between the
doctor and the patient, and serve as the main observer of
pain and discomfort in the patient. Therefore, it is very
important to determine the barriers perceived by nurses to
assessment and management of pain.
2
The pain barriers
experienced by the nurses from different countries have
been defined in a number of earlier studies.
17,18,23
However,
these barriers may show some differences according to some
variables including the undergraduate and postgraduate
education provided to health care professionals, availability
of painkillers in a given setting, and institutional practices.
Despite the fact that nurses are the front-line caregivers in
inpatient settings, there is limited data on the nurses’
perceived barriers to optimal pain management in our
country. Our study aimed to define the nurses’ perceived
barriers to pain management in a university hospital.
The results of this study indicate that nurses perceive a
variety of barriers when attempting to provide optimal pain
assessment and management in our hospital. The most
commonly perceived barriers to assessment and manage-
ment of pain were system-related barriers. When compared
with the other barriers, nurse-related barriers were less
perceived as an obstacle.
Among the system-related barriers, lack of psychoso-
cial support services was the most commonly perceived
barrier. This finding is similar to the results of studies by
Furstenberg et al
18
and Sun et al,
19
which defined the lack
of support systems as being a barrier interfering with
optimal pain management. In our hospital, psychosocial
services are not part of routine patient care. Although
psychological support can be provided to a very limited
number of patients with cancer on demand of the attending
physician, there is no social work for patients. Institutional
and governmental attempts are needed to establish
psychosocial support services for all patients.
Another commonly (74%) expressed system-related
barrier was the patient-to-nurse ratio. This result was also
consistent with some earlier studies.
20,22
When the patient-
to-nurse ratio is high, nurses experience time constrains
which interferes with quality of care. Research from
developed countries may show different figures as it was
in Johnson et al
23
study reporting that only 13% of nurses
identified time as a barrier to pain management. However,
understaffing remains a barrier to optimal patient care in
our country. Each nurse has to take care of 8 to 10 patients
in the hospital where this study was done. There are no
TABLE 4. Nurses-Related Barriers
Barriers Agree Disagree Do not know
Nurses-related barriers N(%) N(%) N(%)
Inadequate time for health teaching with patients (eg, as needed drug order,
alternatives, addiction, etc.)
74 (64.9) 25 (21.9) 15 (13.2)
Inadequate time to deliver nonpharmacologic pain relief measures 27 (23.7) 73 (64.0) 14 (12.3)
Inadequate staff knowledge of pain management 18 (15.8) 83 (72.8) 13 (11.4)
Nursing staff reluctance to administer opiates 16 (14.0) 80 (70.2) 18 (15.8)
Fear of pain medications because of side effects 16 (14.0) 77 (67.5) 21 (18.4)
Inadequate assessment of pain 12 (10.5) 87 (76.3) 15 (13.2)
Nurses indifference 9 (7.9) 93 (81.6) 12 (10.5)
TABLE 5. Physician-Related Barriers
Barriers Agree Disagree Do not Know
Physician-related barriers N (%) N (%) N (%)
Inadequate assessment of pain and pain relief 72 (63.2) 19 (16.7) 23 (20.2)
Doctor’s indiference 54 (47.4) 34 (29.8) 26 (22.8)
Physicians reluctance to prescribe opiates because of the side effects 39 (34.2) 44 (38.6) 31 (27.2)
Inadequate knowledge of pain management 30 (26.3) 58 (50.9) 26 (22.8)
Physicians’ fear of addiction of medicine 24 (21.1) 54 (47.4) 36 (31.6)
Physicians’ reluctance to prescribe adequate pain relief for fear
of overmedicating
18 (15.8) 61 (53.5) 35 (30.7)
Physicians’ lack of trust in the nursing assessment of pain 15 (13.2) 70 (61.4) 29 (25.4)
J Pediatr Hematol Oncol Volume 33, Supplement 1, April 2011 Nurses’ Perceived Barriers to Pain
r2011 Lippincott Williams & Wilkins www.jpho-online.com |S35
nurse aids; therefore, nurses are responsible for all the
nursing care. Therefore, they have been facing time limita-
tion for symptom assessment and management.
More than half of the participating nurses indicated
that the lack of access to professionals who practice
specialized pain treatment methods (66%) and the difficulty
in contacting or communicating with physicians to discuss
treatment of pain (61%) were important barriers to pain
management. In our hospital, nurses and physicians have
been making separate patient rounds. The negative impact
of this disconnection can be clearly seen in these results.
The appropriate assessment and treatment of pain is highly
dependent upon communication between physicians and
nurses. Lack of adequate and accurate communication be-
tween nurses and physicians was reported as an important
barrier to optimal management of pain.
20,23
Van Niekerk
and Martin
20
showed that nurses who did not feel
adequately consulted by physicians were significantly more
likely to encounter barriers such as insufficient cooperation
by patient’s physicians and inadequate prescription of
analgesic medications. A collaborative relationship between
the two professions would ensure that the barriers ex-
perienced by nurses could be resolved in a supportive team
approach. Education on pain management emphasizing the
importance of teamwork, and the role of each health care
professional in the team is essential to overcome this
barrier. Although it has been a widespread practice to order
analgesics “as needed” instead of “around the clock” usage
in our hospital, a significant percentage (45%) of the nurses
disagreed with inconsistent practices around giving medica-
tions as needed. In contrast, lack of pain medicine in the
market was expressed as a barrier only by 26% of the
nurses, although we have been experiencing problems about
the availability of some strong opioids. There is no
immediate release oral morphine available in the market
in Turkey. A sustained release oral opioid appeared in the
market recently. A significant percentage (74%) of the
nurses either disagreed (41%) with this barrier or expressed
that they did not know (33%) about this issue. This finding
may be explained by lack of knowledge on cancer pain
management, as oral opioids are the drug of choice for
moderate-to-severe cancer pain. Another reason for this
finding may be related with the current pain management
practice which involves parenteral use of opioids, particu-
larly for patients with cancer, while they stay in hospital.
In this study, lack of standardized clinical guidelines
for pain treatment was indicated as a barrier by 66% of the
nurses. It has been reported that pain management guide-
lines contribute to nurses’ pain knowledge and attitudes.
4,29
More effective pain management practice can be achieved if
clinical practice guidelines are tailored to the specific type of
the institution and the available resources within a given
setting.
Lack of alternatives for nonpharmacologic pain
management was agreed on by the 47% of the nurses.
Nonpharmacologic pain management modalities remain a
neglected treatment option in our hospital because of time
limitations and lack of expert staff.
Among the patient-related barriers, more than half of
the nurses agreed with the patients’ difficulty with com-
pleting pain scales (56%) and consumers not demanding
results (53%). This result can be related that the pain
assessment scales were taking place in a very busy nursing
chart, representing an obstacle to concentrate on the scales.
Therefore, a pocket pain assessment scale was developed
and distributed to all hospital nurses.
The nurses in this study disagreed with any difficulty
about patients’ reporting their pain. Some studies searching
for the patient perceived barriers reported obstacles, such as
the reluctance to report pain, nonadherence to treatment
regimens, fear of dependency, anxiety over being a bad
patient, concerns about disturbing health care providers,
and fear of side effects.
4,12,21,23
The nurses in this study did
not agree with the patient-related barrier with regard to
patients’ avoidance to complain pain to not to disturb the
nurses, which was reported as a barrier in some studies.
17,18
Pain has been regularly assessed in the clinics where
the study was conducted. As nurses has been asking
patients about their pain at designated intervals, nurses
did not indicate any problem with the patients’ reporting of
pain. However, the nurses reported difficulty in collaborat-
ing with doctors to manage the reported pain.
A significant percentage of the participating nurses
(45% to 79%) indicated that they have no idea with regard
to 7 of 9 patient-related barrier items. This may reflect the
time constrains that nurses have been experiencing because
of the high patient-to-nurse ratio. A good-quality commu-
nication with patients to define pain-related issues requires
time. Nurses spend most of their working hours to give
curative treatment in these settings. This finding may also
be related with nurses’ awareness and knowledge on good
pain management.
2,27
We need further studies searching for
the knowledge and attitude on pain management.
In this survey more than half of participating nurses
disagreed with nurse-related barriers, except for inadequate
time for patient education, which was reported by 65% the
TABLE 6. System-Related Barriers
Barriers Agree Disagree Do not know
System-related barriers N (%) N (%) N (%)
Lack of psychosocial support services 88 (77.2) 10 (8.8) 16 (14)
Patient-to-nurse ratio 84 (73.7) 18 (15.8) 12 (10.5)
Lack of social workers who is experienced in oncology settings 80 (70.2) 6 (5.3) 28 (24.6)
Lack of guidelines for pain management 75 (65.8) 20 (17.5) 19 (16.7)
Lack of access to professionals who practice specialized pain treatment methods 75 (65.8) 20 (17.5) 19 (16.7)
Difficulty contacting or communicating with physicians to discuss treatment of pain in patients 70 (61.4) 28 (24.6) 16 (14)
Not having a documented pain treatment plan for each patient 61 (53.5) 38 (33.3) 15 (13.2)
Lack of alternatives nonfarmacologic therapy for pain Management (cold, hot, acupunctur) 53 (46.5) 34 (29.8) 27 (23.7)
Narcotic prescription regulation 48 (42.1) 40 (35.1) 26 (22.8)
Inconsistent practices around giving as needed medications for patient 41 (36.0) 51 (44.7) 22 (19.3)
Lack of medicine in markets 30 (26.3) 47 (41.2) 37 (32.5)
Lack of equipment or skill in using equipment 37 (32.5) 48 (42.1) 29 (25.4)
Elcigil et al J Pediatr Hematol Oncol Volume 33, Supplement 1, April 2011
S36 |www.jpho-online.com r2011 Lippincott Williams & Wilkins
nurses. It has been shown that inadequate assessment and
management were among the most commonly encountered
barriers to pain control.
18
In our survey, most of the nurses
(64% to 82%) did not agree with 6 of 7 nurse-related
barriers. Only a small percentage of the nurses agreed that
nurses’ inadequate knowledge of pain management
(10%) and nurses’ indifference (8%) were barriers to pain
management.
The nurses’ lack of knowledge on pain management
was indicated as a pain barrier by only 16% of the
participants. Although this study did not evaluate the
nurses’ knowledge and attitude on pain management, a
number of studies indicate that knowledge deficits and
inadequate pain assessment are the most important barriers
for health care professionals in implementing pain manage-
ment.
1,20,22,26
Lack of regular and persistent assessment of pain by
the doctors was the most commonly (63%) perceived
physician-related barrier by the participating nurses in our
survey. Doctors’ indifference to pain (47%) was another
perceived barrier. More than half of the nurses disagreed on
inadequate knowledge, reluctance to prescribe adequate
painkillers in patients for fear of overmedicating and lack
of trust in nurses’ assessment of pain. At least one fifth of
the nurses indicated that they had no idea about the
physician-related barriers addressed. This shows the nega-
tive impact of lack of communication between the nurses
and doctors.
The nurses indicated that they had difficulty contact-
ing or communicating with physicians to discuss treatment
of pain. It has been reported that the barriers to effective
pain management encountered by nurses were affected
by their relationship with physicians.
20
When the barriers
were analyzed according to demographic variables, no
significant differences were found among nurses according
to age, education level, and the years of experience.
However, significant differences were found among work
settings; the nurses who worked in oncology clinics agreed
more on the system-related barriers. This finding may
be related to the high incidence of pain in patients with
cancer.
In conclusion, this study showed that the system-
related barriers, particularly high patient-to-nurse ratio and
lack of psychosocial support services, were the most
commonly perceived pain barriers by the nurses in our
hospital. Institutional and governmental attempts are
needed to increase the number of nurses in the clinics. This
would help with increasing the time allotted to each patient.
Teamwork is essential for providing good-quality pain
management in hospitals. It is important to establish
a supportive team spirit between doctors and nurses. For
this, meetings should be held between these two groups of
health professionals to facilitate the discussion of pain
management problems and to review recommendations for
solutions.
There are studies showing that education is effective in
eliminating the barriers standing in the way of the evaluation
and management of pain. For this reason, there should be
regular and continuous education programs for all health
professionals who are involved in the pain management. We
need to define the knowledge and attitude of nurses and
doctors in our hospital with an aim to set up a continuous
education program on pain management. In addition,
evidence-based pain management guidelines should be drawn
up for the clinical use of doctors and nurses.
ACKNOWLEDGMENT
The authors thank all nurses for their cooperation in
carrying out this study.
REFERENCES
1. McCaffery M, Rolling Ferrell B, Pasero C. Nurses’ personal
opinions about patients’ pain and their effect on recorded
assessments and titration of opioid doses. Pain Manag Nurs.
2000;1:79–87.
2. Zhang CH, Hsu L, Zou BR, et al. Effects of a pain education
program on nurses’ pain knowledge, attitudes and pain assessment
practices in China. J Pain Symptom Manage. 2008;36:616–627.
3. Vallano A, Malouf J, Payrulet P, et al. Prevalence of pain in
adults admitted to Catalonian hospitals: a cross-sectional
study. Eur J Pain. 2006;10:721–731.
4. Oldenmenger WH, Sillevis Smitt PAE, van Dooren S, et al. A
systematic review on barriers hindering adequate cancer pain
management and interventions to reduce them: a critical
appraisal. Eur J Cancer. 2009;45:1370–1380.
5. Payne R. Chronic pain: challenges in the assessment and
management of cancer pain. J Pain Symptom Manage. 2000;19:
S12–S15.
6. Bruera E, Kim HN. Cancer pain. JAMA 2003;290:2476–2479.
7. Gauthier LR, Rodin G, Zimmermann C, et al. Acceptance of
pain: a study in patients with advanced cancer. Pain. 2009;143:
147–154.
8. Zaza C, Baine N. Cancer pain and psychosocial factors: a
critical review of the literature. J Pain Symptom Manage. 2002;
24:526–542.
9. Tanaka K, Akechi T, Okuyama T, et al. Impact of dyspnea,
pain, and fatigue on daily life activities in ambulatory patients
with advanced lung cancer. J Pain Symptom Manage. 2002;23:
417–423.
10. Vallerand AH, Templin T, Hasenau SM, et al. Factors that
affect functional status in patients with cancer-related pain.
Pain. 2007;132:82–90.
11. Lin C, Lai Y, Ward S. Effect of cancer pain on performance
status, mood states, and level of hope among Taiwanese cancer
patients. J Pain Symptom Manage. 2003;25:29–37.
12. Potter VT, Wiseman CE, Dunn SM, et al. Patient barriers to
optimal cancer pain control. Psychooncology. 2003;12:153–160.
13. Keefe FJ, Ahles TA, Sutton L, et al. Partner-PGuided cancer
pain management at the end of life: a preliminary study. J Pain
Symptom Manage. 2005;29:263–272.
14. Wells N, Murphy B, Wujcik D, et al. Pain-related distress and
interference with daily life of ambulatory patients with cancer
with pain. Oncol Nurs Forum. 2003;30:977–986.
15. Yates P, Edwards H, Nash R. A randomized controlled trial of
a nurse administered educational intervention for improving
cancer pain management in ambulatory settings.Patient Educ
Couns. 2004;53:227–237.
16. Broekmans S, Vanderschueren S, Morlion B, et al. Nurses’
attitudes toward pain treatment with opioids: a survey in a
Belgian university hospital. Int J Nurs Stud. 2004;41:183–189.
17. Coker E, Papaioannou A, Kaasalainen S, et al. Nurses’
perceived barriers to optimal pain management in older adults
on acute medical units. Appl Nurs Res. 2010;23:139–146.
18. Furstenberg CT, Ahles TA, Whedon MB, et al. Knowledge
and attitudes of health-care providers toward cancer pain
management: a comparison of physicians, nurses, and phar-
macists in the state of new hampshire. J Pain Symptom
Manage. 1998;15:335–349.
19. Sun VCY, Borneman T, Ferrell B, et al. Management: an institu-
tional change model. J Pain Symptom Manage. 2007;34:359–369.
20. Van Niekerk LM, Martin F. The impact of the nurse-physician
relationship on barriers encountered by nurses during pain
management. Pain Manag Nurs. 2003;4:3–10.
21. Gunnarsdottir S, Donovan HS, Serlin RC, et al. Patient-
related barriers to pain management: the barriers Question-
naire II (BQ-II). Pain. 2002;99:385–396.
J Pediatr Hematol Oncol Volume 33, Supplement 1, April 2011 Nurses’ Perceived Barriers to Pain
r2011 Lippincott Williams & Wilkins www.jpho-online.com |S37
22. Ware LJ, Bruckenthal P, Davis GC, et al. Factors that
influence patient advocacy by pain management nurses: results
of the American society for pain management nursing survey.
Pain Manag Nurs. 2010;1–8. DOI: 10.1016/j.pmn.2009.12.001.
23. Johnson DC, Kassner CT, Houser J. Barriers to effective
symptom management in hospice. J Pain Symptom Manage.
2005;29:69–79.
24. Bernardi M, Catania G, Tridello G. Knowledge and attitudes
about cancer pain management: a national survey of Italian
hospice nurses. Cancer Nurs. 2007;30:E20–E26.
25. Mrozek JE, Werner JS. Nurses’ attitudes toward pain, pain
assessment, and pain management practices in long-term care
facilities. Pain Manag Nurs. 2001;2:154–162.
26. Igier V, Mullet E, Sorum PC. How nursing personnel judge
patients’ pain. Eur J Pain. 2007;11:542–550.
27. De Rond MEJ, de Wit R, van Dam FSAM, et al.
Pain monitoring program for nurses: effects on nurses’ pain
knowledge and attitude. J Pain Symptom Manage. 2000;19:
457–467.
28. Patirakia EI, Papathanassogloua EDE, Tafasb C, et al.
A randomized controlled trial of an educational intervention
on Hellenic nursing staff’s knowledge and attitudes on cancer
pain management. Eur J Oncol Nurs. 2006;10:337–352.
29. Pargeon L, Hailey BJ. Barriers to effective cancer pain man-
agement: a review of the literature. J Pain Symptom Manage.
1999;18:358–368.
Elcigil et al J Pediatr Hematol Oncol Volume 33, Supplement 1, April 2011
S38 |www.jpho-online.com r2011 Lippincott Williams & Wilkins
