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Abstract

Background:

Nonpharmacological therapies implemented by nurses in clinical practice for patients with cancer pain remain unclear.

Objective:

To investigate nursing support for patients with cancer pain in Japanese palliative care units (PCUs).

Design:

Nationwide online survey.

Setting/Subjects:

Registered nurses in Japanese PCUs.

Measurements:

Herein, we conducted a questionnaire survey to assess the frequency of care implementation for 23 nursing support items for patients with cancer pain with prognoses anticipated in the scale of weeks or months, asking nurses working in PCUs to respond anonymously. We did not perform statistical tests on the results, instead of calculating descriptive statistics on implementation frequencies.

Results:

We requested surveys from 389 PCUs nationwide and 162 participated. Of 2,448 invited nurses, 539 (22.3%) responded. The implementation frequencies for the 23 nursing support items were almost the same for patients with prognosis anticipated in the scale of weeks or months. Approximately 80% frequently provide comfort care (environmental adjustment/mental health care/oral care) and adjust postures and positions. Conversely, support options frequently implemented by <20% of the participants included progressive muscle relaxation therapy, guided imagery therapy, combined therapy, cognitive behavioral intervention, reflexology, self-administered acupressure, exercise, poetry appreciation, auricular acupressure, relaxation using virtual reality, and reiki.

Conclusion:

Our findings indicate that comfort care and positioning adjustments are frequently provided for patients with cancer with prognosis anticipated in the scale of weeks or months to improve well-being. Nursing support practices requiring specialized skills were less frequently implemented. These results offer insights for expanding palliative care support options.

Introduction

In total, 38% of all patients with cancer experience moderate-to-severe pain, while 66.4% of patients with end-stage cancer are affected by pain.¹ Pain has a significant impact on patients’ quality of life and, therefore, requires a comprehensive assessment and management in palliative care.² The National Comprehensive Cancer Network and American Society of Clinical Oncology pain management guidelines recommend pharmacological therapy but also suggest the use of nonpharmacological approaches in combination with pharmacological therapy, depending on the patient’s preference.^3,4 In Japan, the guidelines for cancer pain management only define drug therapy.⁵ However, the Japanese Society for Palliative Medicine also published a guideline regarding complementary therapies in 2016, which mentions health foods, aromatherapy, massage, homeopathic therapy, relaxation, music therapy, acupuncture and moxibustion, and immunotherapy, but does not mention the aspects of nursing support investigated in this study.⁶ In practical reviews on cancer pain management, supporting patients in adopting self-management strategies is recommended; however, evidence on the use of nonpharmacological therapies, such as music and cognitive behavioral therapies, is limited.⁷ Pain is a multifaceted symptom, and pain reduction can be achieved through nonpharmacological therapies that take a psychological and social approach.⁸

Nurses provide comprehensive physical, psychological, and social support and implement care to improve the quality of life of patients experiencing cancer pain. Therefore, knowledge of pharmacological and nonpharmacological care is essential to provide appropriate pain management.⁹ In addition, patients with cancer who are in the final months or weeks of their lives show physical function decline and mental health changes; therefore, efforts are needed to make their stay more comfortable, lessening their burden.¹⁰ Nevertheless, as mentioned above, evidence for nonpharmacological therapies is lacking, and little is known about which nonpharmacological therapies nurses utilize in these patients. In this study, the term “nursing support” refers to nonpharmacological therapies implemented by nurses.

This study aimed to investigate the frequency with which nurses provide nonpharmacologic nursing support in clinical practice to patients with prognosis anticipated in the scale of weeks or months. The results of this survey are expected to provide a prioritization index for pain management in patients with end-stage cancer, for whom individualized care is required but supporting evidence is insufficient.

Materials and Methods

Study design

This study comprised a multicenter cross-sectional investigation of all palliative care units (PCUs) in Japan, in both urban and rural areas. The survey involved registered nurses working in all 389 PCUs across Japan (as of September 14, 2023) and was conducted as part of the Evidence-Practice GAP Study. This study involved a cross-sectional anonymous survey of registered nurses aimed at clarifying nursing practices related to cancer-related symptoms in terminal patients with cancer and the caregiving burden on their families (UMIN000052329).^11–13

Participants

Registered nurses who provided direct patient care in PCUs were included in this study. The exclusion criteria were as follows: (1) nurses in managerial positions, such as head nurses of PCUs; (2) nurses who were temporarily rotating through the PCU from other wards within the same hospital; and (3) nurses who came to the PCU for training from other hospitals. All eligibility criteria were assessed at the time of study enrollment.

The participant recruitment procedure was carried out as follows: First, study information and participation requests were sent to the administrators of all PCUs in Japan. Subsequently, documents containing the details of the survey were sent by post to the facilities that had agreed to participate, and the managers of those facilities subsequently distributed the documents to the nurses working at the PCU. Then, nurses who agreed to participate in the survey accessed the online questionnaire and answered the questions. Consent was deemed given by each participant’s response to the questionnaire. As this questionnaire survey was conducted anonymously, the participants were informed in advance that they could not withdraw their consent once they had agreed to participate and answered the questionnaire. Data were collected from nurses providing direct care in PCUs between October 2023 and March 2024. The nurses completed the survey anonymously using Lime Survey Cloud (Lime Survey GmbH, cf. https://www.limesurvey.org/ja).

Measurements

In this online survey, nurses working in palliative care units were questioned regarding the current state of nursing practice for cancer pain among patients with a prognosis in the scale of weeks or months. A previous scoping review highlighted 22 types of nursing support practices that nurses can feasibly implement to support cancer pain management.¹⁴ In addition, a preliminary survey was conducted among nine experienced nurses, based on which 1 item was added to the 22 items extracted in the scoping review: “adjusting comfortable body positions and postures,” which was mentioned as a routine practice performed for end-stage cancer pain relief. The nursing support investigated in this study thus comprised 23 items. The content of this survey was checked by seven researchers who are experts in palliative care, and a pre-test was additionally conducted on nurses involved in cancer nursing before the primary survey to check the validity of the content.

The 23 nursing support items were as follows: adjusting comfortable postures and positions, adjustments to home care programs, aromatherapy massage, auricular acupressure, cognitive behavioral interventions, combined therapy (progressive muscle relaxation [PMR]/relaxation/guided image therapy/cognitive therapy), comfort care (environmental adjustment/mental health care/oral care), education and psychological care, education focused on self-care management, education programs focused on knowledge and information provision, education using coaching skills, exercise, foot baths, guided image therapy, massage therapy, music therapy, the narrative approach, poetry listening, PMR, reiki, reflexology, relaxation therapy using virtual reality [VR], and self-administered acupressure. The explanations of these nursing support contents in the questionnaire were determined based on a scoping review. These nursing support measures were evaluated using a five-point Likert scale (not at all, rarely, sometimes, frequently, and very frequently) to assess nursing practice status based on monthly and weekly prognoses of patients with cancer. In addition, participant characteristics, such as age, sex, years of nursing experience, years of experience in a palliative care unit, education, qualifications, and other background information, were collected. The questionnaire included a total of 53 questions: 46 asking about the implementation status of 23 items of nursing support for cancer pain patients with prognosis anticipated in the scale of weeks or months, one question asking for free-form answers regarding nursing support implemented in addition to the 23 items, and six questions asking about patient characteristics.

Statistical analysis

Descriptive statistics were calculated using EZR to determine the background of the participants and the frequency of nursing support. We did not calculate the statistical significance of the frequency of implementation of the 23 nursing support measures and only present the descriptive statistics. The EZR component of the R software was used to calculate the descriptive statistics.¹⁵

Research ethics

The study was approved by the Clinical Research Ethics Review Committee of the Mie University Hospital (U2023-011) and registered in the University Hospital Medical Information Network (UMIN0000 52329). All participants were informed regarding the survey at the start, and only those who consented to participate were included. Participants were able to leave the survey at any time, while the survey was conducted anonymously, and only fully completed surveys were used. This study complied with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

Results

A total of 389 facilities, comprising all the PCUs in Japan, were invited to participate. From the 162 facilities that consented, 2,448 registered nurses were invited to participate in the questionnaire survey, with responses obtained from 539 (22.0%) nurses. The average age of the respondents was 42.3 ± 9.8 years, and >90% were women. The average years of nursing experience was approximately 19 years, and the average years of experience in the PCU was approximately 5 years (Table 1).

Table 1.

Characteristics of Participants (n = 539)

Characteristics	n (%) or mean (SD)
Age (years)	42.3 (9.8)
Sex
Female	551 (94.8)
Male	26 (4.8)
Prefer not to answer	2 (0.4)
Years of nursing experience	18.6 (9.6)
Years of experience in the palliative care unit	4.8 (4.3)
Educational background
Vocational school (including junior college)	456 (84.6)
University	64 (11.9)
Master’s program (pre-doctoral program)	10 (1.9)
Doctoral program (post-doctoral program)	1 (0.2)

The frequency of implementation of the 23 nursing support items was calculated as the percentage of responses on a 5-point Likert scale and is shown using a stacked bar graph (Fig. 1). The graphs for the implementation rate of the 23 items of nursing support for patients with a monthly or weekly prognosis appear almost identical. Moreover, approximately 80% of nurses responded “frequently” or “very frequently” regarding the provision of nursing support through comfort care and adjusting comfortable postures and positions . In addition, the nurses reported adjusting comfortable postures and positions for >80% of patients with a weekly prognosis and approximately 80% (78.8%) with a monthly prognosis as “very frequently” or “frequently.” In contrast, <20% of respondents frequently or very frequently performed the following 11 items of nursing support: PMR, guided imagery therapy, combined therapy, cognitive behavioral intervention, reflexology, self-administered acupressure, exercise, poetry appreciation, auricular acupressure, relaxation using VR, and reiki (vertical line drawn at 80%, Table 2).

FIG. 1.

Frequency of implementation for patients with predicted prognosis weekly or monthly.

In addition to the 23 types of support investigated in this study, the free response section also listed other types of nursing support provided by PCU nurses, such as hot compresses, cold compresses, walks to change one’s mood, interaction with pets, decorating the patient’s room with objects they like (photos, pictures, flowers, etc.), and planning seasonal events (for example, during the Setsubun festival, when people throw beans to drive out evil spirits, patients can replace the evil spirits with pain and throw beans to drive out their pain).

Discussion

In this study, we investigated the frequency of implementation of 23 nursing interventions to support patients with cancer pain in Japanese PCUs with prognosis in the scale of weeks or months. Our results indicated that across patients with prognoses in the scale of weeks or months, the nursing support implementation frequencies seem very homogenous. Two types of support were frequently provided to patients with cancer pain: comfort care and adjusting comfortable positioning and posture. In contrast, 11 types of support were rarely provided: PMR, guided imagery therapy, combined therapy, cognitive behavioral intervention, reflexology, self-administered acupressure, exercise, poetry appreciation, auricular acupressure, and relaxation using VR.

Most participants provided comfort care. Comfort care is a form of support that is provided according to the patient’s wishes and situation and includes support for the patient’s physical comfort (environmental maintenance, such as ventilation and cleaning, and coordination of visits), support for the patient’s emotions and feelings (encouraging the patient to face their feelings and change their mood), and hygiene and oral care.¹⁶ The nurses who participated in this study presumably aimed to reduce pain by communicating closely with patients, giving them a sense of security and satisfaction, and providing a comfortable environment. The intensity and perception of pain can be altered by changing the elements of a patient’s life experience. Providing a comfortable and secure environment is thought to have a positive impact on pain relief.¹⁷

Another frequently performed nursing support involved adjusting the patient’s position and posture to make them more comfortable. This intervention is a form of nursing support that is carried out on a regular basis.¹⁸ Studies have investigated the adjustment of posture and position in specific treatments and situations^19,20; however, to the best of our knowledge, no intervention studies exist on consistent care for patients with cancer pain. This is because the same position or posture is not always universally comfortable for all patients, and it is necessary to consider each patient individually. As such, it is essential to confirm the patient’s comfortable posture through dialogue with the patient and daily observation.²¹ Therefore, in the same way as with comfort care, the nurses who participated in this study may have considered their relationship with the patient, which respects the patient’s comfort as part of pain care, even when adjusting the position.

Although some studies have demonstrated the effectiveness of these 11 items of support on pain reduction, the nurses who participated in this study rarely implemented them.^22–33 There are several possible reasons why these types of support were not implemented. One reason why nursing support may not be implemented is due to a lack of specialized knowledge, tools, and skills that may prevent the implementation of care involving, for instance, guided imagery therapy, VR-based relaxation, reflexology, and auricular acupressure. If there were opportunities to learn about and train to improve skills in this form of support, and if audio data for implementing PMR therapy and imagery therapy were readily available, it would be easier to incorporate them into clinical practice. Another possible reason is that it takes 20–60 minutes for some interventions, making them difficult for busy clinical nurses to carry out.^29,31,33,34 Of the 23 types of support we listed, massage, reflexology, and Reiki require the patient to receive treatments, necessitating the nurse providing care to set aside considerable time. However, there are also many types of care that do not require the care provider to be continuously present, such as music therapy, where the patient chooses and listens to their favorite music, and relaxation using VR. By selecting care that matches the time constraints of the care provider and the patient’s preferences in clinical settings, the range of pain relief care could be expanded. Moreover, the effectiveness of these forms of support to reduce pain may not always be recognized. The 23 items in this study were intended to provide various approaches to cancer pain relief; however, the nurses who participated in this study may not necessarily have recognized the effectiveness of these supports for pain relief. Overall, this research shows that there are many options for nursing support for pain relief. However, further research into these support methods is needed to establish the evidence for each pain nursing support method, and it is also hoped that there will be more opportunities for learning and training in specific care provision methods in order to introduce these nursing support methods into clinical practice increases. Such research will allow these nursing support methods to be introduced into clinical practice. Furthermore, if the cost is high, it is not likely to be easily implemented. One such example is relaxation therapy using VR; while advances in VR technology and evidence of its effectiveness are accumulating, its high implementation cost and lack of awareness among health care professionals may be the reason why it is not currently applied in clinical settings.^22–24 Finally, nonpharmacological cancer pain relief may not always be implemented because of patient burden concerns: as with the results of the Delphi survey we conducted, there may have been concerns about exercise implementation, particularly for patients in the terminal stage of their illness.^33,35

This study had several limitations. First, the study’s low response rate of 22.0% may have introduced bias in favor of nurses who are particularly keen to participate in such interventions, and this limits the generalizability of the results. One of the reasons for this low response rate may be the use of a Web-based survey, which did not allow for follow-up reminders to nonrespondents. Furthermore, we believe that employing alternative methods, such as paper-based surveys, may have resulted in a higher response rate. Additionally, strategies such as follow-up reminders or combining multiple survey modes (e.g., Web and paper) should be considered to improve response rates and representativeness in future studies. In addition, the study was conducted in Japanese PCUs and may have been influenced by Japanese culture; thus, they may not be applicable to other cultures. As such, the low participation rates and possible cultural influences on practice may limit generalizability. Furthermore, because this was a self-report questionnaire survey, we were unable to verify if the nursing support indicated by the respondents is actually being implemented. Another limitation is that this study did not investigate the reasons why specific intervention measures were not implemented. Further research is needed to increase the options for nursing support providing pain relief. Despite these limitations, this study provides valuable insights for future research and clinical practice.

Conclusion

Our finding indicated that across patients with prognoses n the scale of weeks or months, the nursing support implementation frequencies are quite homogenous. Among the 23 nursing support practices investigated, comfort care and adjusting comfortable positioning and posture were frequently implemented. In contrast, 11 types of support were infrequently utilized, including PMR, guided imagery therapy, combined therapy, cognitive behavioral intervention, reflexology, self-administered acupressure, exercise, poetry appreciation, auricular acupressure, and relaxation through VR. In order to expand the possibilities of nursing support for patient pain, further research is required on nonpharmacological nursing interventions, including the development of easy-to-use intervention methods in clinical practice, and the demonstration of intervention effects through high-quality research designs.

Footnotes

Acknowledgments

The authors would like to thank all the participants and the recruiting organizations for their collaboration in this study. The authors also thank Editage () for English language editing.

Authors’ Contributions

M.M., M.K., K.K., K.N., Y.K., Y.M., Y.S., and J.K. contributed to the preparation, drafting, and editing of this scoping review. M.M. created the questionnaire on pain and analyzed the results, while J.K. conducted the questionnaire survey and collected the data. All authors contributed to the preparation and editing of the article and read and approved the final version of this article.

Author Disclosure Statement

There are no conflicts of interest to disclose.

Funding Information

The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by JSPS KAKENHI (grant number 21H03236). The funders had no role in the study design, data collection and analysis, decision to publish, or article preparation.

Abbreviations Used

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Nursing Practice for Patients with Cancer Pain with Predicted Prognosis of Months or Weeks: A Multicenter Cross-Sectional Study in Japan

Abstract

Background:

Objective:

Design:

Setting/Subjects:

Measurements:

Results:

Conclusion:

Introduction

Materials and Methods

Study design

Participants

Measurements

Statistical analysis

Research ethics

Results

Discussion

Conclusion

Footnotes

Acknowledgments

Authors’ Contributions

Author Disclosure Statement

Funding Information

Abbreviations Used

References