European Journal of Oncology Nursing 33 (2018) 28–34

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Pain experiences of patients with advanced cancer: A qualitative descriptive T

study
Ozgul Erola,∗, Serap Unsara, Lale Yacana, Meryem Pelinb, Seda Kurta, Bülent Erdoganc
a
Trakya University, Faculty of Health Sciences, Department of Medical Nursing, Edirne, Turkey
b
Sakarya University Faculty of Health Sciences, Sakarya, Turkey
c
Trakya University, Faculty of Medicine, Medical Oncology Clinic, Edirne, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Uncontrolled pain, especially in patients with advanced cancer, affects quality of life negatively and
Pain experience causes negative physical and psychological conditions. The aim of this study was to explore the pain experiences
Pain management of patients with advanced cancer and how they manage with pain, and to present a view of pain management
Daily life approaches of nurses from the perspectives of the patients.
Nursing
Methods: This was a qualitative descriptive study of sixteen hospitalized patients with advanced cancer. Data
Patient with advanced cancer
were collected using semi-structured interviews with patients. Data were analysed by Colaizzi's phenomen-
Adult
ological method.
Results: This study found that patients with advanced cancer who had pain experienced anxiety, helplessness,
hopelessness and many restrictions in daily life as well as inability to manage with pain. Most of the patients
with advanced cancer were not satisfied with their nursing care with regard to pain management. The themes
that emerged were pain perception and experiences, effects of pain on daily life, pain management and man-
agement strategies and the patients’ perspectives about nursing approaches to pain.
Conclusions: This study demonstrated the difficulties of patients with advanced cancer who experienced pain in
their daily lives, yet lack pain management strategies. Furthermore, nurses’ caring approaches to patients with
advanced cancer who experienced pain was found inadequate. Oncology nurses should provide educational
interventions in order to enhance knowledge and skills about pain assessment and non-pharmacologic and
pharmacologic strategies used in pain management.

1. Introduction experienced pain (Economou, 2009). A study conducted with patients

Advanced cancer is described as a cancer that has spread to other
places in the body and usually cannot be cured or controlled with
treatment (National Cancer Institute, 2015). Today, cancer patients live
longer with the significant therapeutic effects of new cancer therapies.
However, pain is still one of the most distressing and burdensome
symptoms of cancer and cancer therapies, affecting all aspects of a
patient's life (Haumann et al., 2017; Rustoen et al., 2009; Rustoen et al.,
2013; Wengström et al., 2014).
The prevalence of pain is extremely high, especially in patients with
advanced cancer. The International Association for the Study of Pain
(IASP) estimated the prevalence of pain as 75% (IASP, 2009). A meta-
analysis demonstrated that 64% of patients with metastatic/advanced
cancer had pain (Van den Beuken-van Everdingen et al., 2007). Another
study found that two-thirds of patients with end-stage cancer
receiving palliative care reported pain prevalence as 88.2% (Ozalp
et al., 2017). Facing an advanced cancer diagnosis is by itself a difficult
life experience for both the patient and the patient's family. The addi-
tion of pain to the advanced cancer diagnosis causes dramatic dete-
rioration of a patient's quality of life in various ways (IASP, 2009).
Having pain at the end of life results in many physical, psychological,
social and economic problems that lead to serious limitations and
worsened quality of life (Augustussen et al., 2017; Morss, 2010). It was
reported that cancer patients had greater fear of dying while suffering
from pain than dying (IASP, 2009).
Although cancer pain is an ancient problem, it is still a mismanaged
and/or undertreated symptom around the world, needing much more
attention by health care professionals (Eaton et al., 2015; Haumann
et al., 2017; Jacobsen et al., 2009). Pain is a subjective experience; it is
a symptom of whatever patients say and experience, so the primary

∗
Corresponding author.
E-mail addresses: ozgulerol@trakya.edu.tr (O. Erol), serapunsar@trakya.edu.tr (S. Unsar), laleyacan@hotmail.com (L. Yacan), meryemilmek@sakarya.edu.tr (M. Pelin),
sedakurt81@gmail.com (S. Kurt), bulenterdogan@trakya.edu.tr (B. Erdogan).

https://doi.org/10.1016/j.ejon.2018.01.005
Received 3 October 2017; Received in revised form 22 December 2017; Accepted 8 January 2018
1462-3889/ © 2018 Elsevier Ltd. All rights reserved.
O. Erol et al.
source is the patients themselves. Therefore, successful pain manage-
ment requires much more attention to patients’ pain perceptions, ex-
periences and management strategies (Economou, 2009; Haumann
et al., 2017). Today, although there are evidence-based guidelines for
the management of cancer pain, nurses still do not assess and care for
cancer pain properly (Eaton et al., 2015). Some studies have revealed
that oncology nurses have little knowledge and inadequate attitudes
and skills about cancer pain management (Alqahtani and Jones, 2015;
Bernardi et al., 2007; Breivik et al., 2009; Yıldırım et al., 2009). A study
demonstrated that oncology nurses believe the benefits of evidence-
based practices, but did not implement them frequently; rather, they
continued to use the same conventional approaches in clinics (Eaton
et al., 2015). Effective pain management needs a holistic care approach
and effective team work by various health care professionals (Haumann
et al., 2017).
There are various studies evaluating the pain experiences of cancer
patients (Jacobsen et al., 2009; Korhan et al., 2013; Larsson and Wijk,
2007; McPherson et al., 2014; Schaller et al., 2015). However, few
studies have investigated the oncology nurses’ pain-related caring ap-
proaches through the eyes of patients with advanced cancer. The aim of
this study was to explore the pain experiences of patients with ad-
vanced cancer and how they manage with pain, and to present a view of
pain management approaches of nurses from the perspectives of the
patients.
2. Methods
2.1. Patients and sampling
This qualitative descriptive study was conducted with sixteen pa-
tients with advanced cancer hospitalized in an oncology clinic of a
university hospital in Edirne city, which is located in Trakya Region,
Northwestern Turkey. This clinic has a 40-bed capacity for inpatients
and an ambulatory chemotherapy unit for outpatients. Each room had
one or two beds. Patients were generally residents of Edirne, close ci-
ties, towns and villages and even from Balkan countries. The data were
collected between September and December 2015.
The sample used in the study was determined according to the aim
of the study and by reviewing the qualitative studies in the literature
(Burnard, 2004; Korhan et al., 2013; Sanders, 2003; Schaller et al.,
2015). A purposeful sampling technique was used to identify the pa-
tients. Patients who were included in the study were those over the age
of 18, within at least 6 months of diagnosis, without communication
difficulties, who volunteered to participate in the study, a diagnosis of
non-small cell lung cancer stage IIIB/IV, advanced gastric and color-
ectal cancer with stage III/IV, and with a Eastern Cooperative Oncology
Group (ECOG) performance score of 3 (capable of only limited selfcare;
confined to bed or chair more than 50% of waking hours), and 4
(completely disabled; cannot carry on any selfcare; totally confined to
bed or chair).
2.2. Ethical considerations
This study was approved by the Ethical Committee of Trakya
University Medical Faculty. Patients who were eligible to participate in
the study were asked for verbal and written consent after being in-
formed about the study's purpose and confidentiality issues.
2.3. Study design
The current study was a descriptive qualitative study. Data were
collected using semi-structured interviews designed to obtain patients'
pain experiences (Box 1). The semi-structured qualitative interviews
were conducted with the guidance of Colaizzi (1978) and Speziale and
Carpenter (2007). Interviews began with general questions related with
patient's sociodemographic and disease related characteristics. As all
29
European Journal of Oncology Nursing 33 (2018) 28–34
patients had advanced cancer, interviews took place at the bedside of
the patients. Moreover, medication and caring activities were intense in
the earlier hours of the day at the clinic. So, especially calm afternoon
hours of the clinic were preferred for interviewing which were suitable
for both patients and environmental conditions. Three researchers (OE,
SU, and LY) recorded the interviews, which were digitally audiotaped,
varied in length from 32 to 65 min; their mean duration was 44 min.
Participants were encouraged to talk freely and to tell stories using their
own words.
2.4. Data analysis
Data were analysed using Colaizzi's phenomenological method
which helped to gain a sense of each participant's pain experience
(Colaizzi, 1978; Speziale and Carpenter, 2007).
The following steps, presented in Fig. 1, were performed according
to Colaizzi's process for phenomenological data analysis (Colaizzi,
1978).
Step 1. Three of the authors listened each recorded interview three
times in order to gain a general sense and understand the patients’
feelings about their pain experiences. Each interview was also tran-
scribed, all expressions, thoughts and senses were written in a diary to
assist in organising and identifying subthemes and themes by a re-
searcher (MP).
Step 2. For each transcript, significant phrases and statements were
extracted in order to understand what was said and the manner in
which it was expressed. Three researchers (OE, SU, SK) checked the
consistency of the extracted meanings and important statements. These
statements were copied to a separate sheet, noting with their pages and
line numbers by a researcher (MP).
Step 3. Significant statements were gleaned from general statements
and they were formulated into meanings. Each significant statement
related to pain experience was studied carefully in order to find a sense
of its meaning. Subsequently, OE and SU assigned codes to the con-
densed meanings.
Step 4. Similar codes were grouped into more comprehensive sub-
themes and themes. All themes and subthemes were discussed with all
reserchers in case of disagreement.
Step 5. The findings of the study were integrated into a detailed
description of pain and pain management strategies of patients with
advanced cancer. Patients’ pain experiences and perspectives about
nursing approaches to pain and pain management were presented.
Step 6. The fundamental structure of the phenomenon was de-
scribed. The meanings gathered from the previous steps of the analysis
were described.
Step 7. Finally, the findings were validated by returning to the
participants for an additional interview, to ensure the study represented
their experiences. Six patients with advanced cancer were invited to
examine the results and they approved the interpretations about their
experiences.
To increase the reliability and trustworthiness seven steps given
above were taken to verify the results. Semi-structured audio recorded
interviews allowed for repeated listening of the data to check emerging
themes and subthemes. Three researchers checked the consistency of
the extracted meanings and important statements whether the final
themes were true to participants' accounts. Emerging themes discussed
with other researchers who had oncology research expertise in an open
process till a consensus reached. Themes, subthemes and examples of
patient narratives were given in Table 2. Participants invited to com-
ment on the research findings and themes and approved the results.
Patient narratives were translated into English in order to facilitate the
readers’ understanding the results.
3. Results
Patients' demographic and disease-related characteristics are
O. Erol et al. European Journal of Oncology Nursing 33 (2018) 28–34

Box 1
Interview questions

Can you describe your experiences about pain?

- What is the meaning of pain for you?

- What do you think about the cause of your pain?
- Have you been experienced such a pain before? If yes, can you describe and explain your pain experiences in the past?

How do you manage with your pain?

- Do you use non-pharmacologic approaches (herbal products, or some other complementary therapies) for pain management?
- Do you take medications in order to relieve pain?
- Do you use any other approaches?

What are the effects of pain on your daily life?

- How does pain affect your life?

- Do you have restrictions in your daily life because of pain?
- How do you feel yourself when you have pain?

What do you think about the nursing approaches to pain?

- Do the nurses assess your pain? If yes, how do they assess your pain?
- Do you tell the nurse when you have pain, or do you expect the nurse to ask you?
- If you rate your pain as a score between 0: no pain, 10: very severe pain;

At which point do you inform the nurse?

- Do the nurses help you coping with pain?

- What do you think about the nurses' pain management approaches in terms of timely intervention, giving necessary care and information?

Fig. 1. Data collection and transcribing process.

1. To read and write the
participants'
explanations/experiences via
listening the records three
times

2. Recording of important
Written approval, ethics explanations/statements
committee approval explored phenomenon

Collection of data by voice 3. Formulate the meaning of

Data collection and recording during these significiant statements
transcribing process
face-to-face interview from general statements

Listening to the records and 4. Combining and gouping

grouping of data according the statements with the
to similar characteristics subthemes and themes
(Colazzi Method)

5. Integrate findings into an

exhaustive description of the
phenomenon "pain" being
studied

6. Detailed record of
participants' experiences

7. Formulate of the basic

structive (final description)
of the phenomenon "pain" by
combining all the
evaluations

30
O. Erol et al. European Journal of Oncology Nursing 33 (2018) 28–34

Table 1 depression and social isolation. Some of them mentioned that they did
Demographic and disease characteristics of patients with advanced cancer. not even want to see their loved ones. They could not manage daily
household chores and became dependent on other family members.
Characteristics Mean ± SD
n (%) Patients also mentioned experiencing behaviour changes such as be-
coming aggressive, having a lower tolerance to events and people and
Age, years 62.75 ± 7.32 general pessimism. The most common problem was poor sleep; several
Gender, male 13(81.3)
patients mentioned the use of sleeping pills.
Working status
Retired 11(68.8)
Housewife 3(18.8) 3.3. Pain management and management strategies
Working 2(12.4)
Marital status, married 15(93.8) This theme contains pain management and management strategies
Education level
of patients with advanced cancer. The subthemes of this theme were;
Illiterate 1(6.3)
Primary school 9(56.1) “nonpharmacologic approaches”, and “pharmacologic approaches”.
Secondary school 1(6.3) In this study, cancer patients generally reported the use of non-
High school 3(18.8) pharmacologic approaches to relieve pain, such as praying, changing
University 2(12.5)
position, having a hot bath, walking, watching TV and engaging in
Income 15(93.8)
Low 1(6.2) crafts. Praying to God for healing and namaz (an Islamic pray ritual,
Middle 15(93.8) performed five times a day) were the most common approaches used by
Diagnosis period, years 3.19 ± 4.47 patients with advanced cancer. It was seen that most of the patients
Clinical diagnosis were refuged to God according to Islamic belief that “even though all
Lung cancer 8(50)
remedies are said to be exhausted, God sees us and gives the best, no
Colon cancer 6(37.5)
Gastric cancer 2(12.5) need to lose hope”. Herbal product use was rare in the study group;
Disease status, metastatic 16(100) some patients never used and nor believed in the benefits of herbal
products. Generally, patients avoided using pharmacologic agents until
Mean ± SD: Mean and standart deviation. the intensity of their pain increased and became unbearable. Less than
half the patients stated that they immediately informed the nurses
presented in Table 1. Four themes emerged through the findings of the about their pain and the need for medication. A few of them reported
present study: Pain perception and patient experience, effects of pain on that if they were at home, they went to emergency clinics in order to
daily life, pain management and management strategies, patients’ cope with pain.
perspectives about nursing approaches to pain. All themes and sub-
themes were presented in Fig. 2. The examples of patient narratives 3.4. Patients' perspectives about nurses’ approaches to pain
according to themes and subthemes were summarized and presented in
Table 2. This theme embraces the findings related with patients' perspectives
about nursing approaches to pain and consists of two subthemes:
3.1. Pain perception and patient experiences “perspectives about the nurses' pain assessment” and “perspectives
about the nurses’ pain management”.
This theme includes pain related perceptions and experiences of This study demonstrated that nearly half of the patients with ad-
patients with advanced cancer and consists of three subthemes: “the vanced cancer were not satisfied with nurses’ caregiving with regard to
meaning of pain”, “thoughts about the reason of pain”, and “past ex- pain and pain management. Nurses were perceived as health care
periences about pain”. providers who did, what the phsicians told them to do. They could not
In this study, pain experiences of patients with advanced cancer perform systematic and proper pain assessment and did not use effec-
differed from one individual to another with different variations; in- tive pain management strategies, in the eyes of the patients.
tensity ranged from moderate to severe. Most of the patients described
pain as an unpleasant and disturbing experience with negative physical 4. Discussion
and emotional consequences. Patients described different reactions
when they had pain; while most told nurses immediately, a few tried to Cancer pain is still a devastating problem that is not properly un-
be calm and patient and informed the health care professionals when derstood or managed (Haumann et al., 2017; Jacobsen et al., 2009;
the severity of their pain increased. When we asked about past ex- Larsson and Wijk, 2007; Narayan, 2010). The results of our study de-
periences with pain, some patients reported that they had not experi- monstrated that patients with advanced cancer experienced significant
enced pain since receiving their cancer diagnosis, while others reported physical and psychosocial problems related with pain; similar to find-
experiencing mild pain, e.g., a headache or back pain. Most of them ings of earlier studies (Rustoen et al., 2013; Wengström et al., 2014;
stated that prior to diagnosis, they never had such intense pain, which Yıldırım et al., 2009). As pain is a subjective experience, it is essential to
could be relieved with analgesics. Having intense pain at the end of life explore the meaning of pain for patients and their past experiences with
was defined as an extremely difficult experience to bear. regard to pain. Since, all of the patients had advanced cancer they ex-
perienced pain and mentioned their pain experiences with negative
3.2. Effects of pain on daily life thoughts and feelings. It is important for health care professionals to
determine patients’ perceptions about pain and its management, be-
This theme includes effects of pain in daily life of patients with cause pain-related feelings, thoughts and beliefs affect the survey of the
advanced cancer. The subthemes of the second theme were: “fatigue/ pain management. In this study, all patients reported that they did not
tiredness, “powerlessness”, and “restrictions”. ever experience such a strong pain before cancer diagnosis. Their pain
This study demonstrated that pain affected the daily life activities of experiences differed from one and other, with intensity ranging from
advanced cancer patients in many ways. Patients emphasized feeling moderate to severe. Panteli and Patistea (2007) also determined that
fatigue, powerlessness, lack of energy and physical inactivity; most of 42% of cancer patients experienced moderate pain, and 53% experi-
the patients complained of poor sleep. Unrelieved pain caused anxiety, enced moderate to severe pain.
a sense of helplessness and hopelessness. Patients with advanced cancer In this study, patients generally complained about fatigue, lack of
expressed that pain disrupted their daily life, social relations and caused energy, powerlessness, poor sleep, physical inactivity, social isolation

31
O. Erol et al.
Table 2
Themes & subthemes and examples of narratives (n = 16).
Themes & Subthemes
Pain perception and patient experiences
- the meaning of pain
- thoughts about the reason of pain
- past experiences about pain
Effects of pain on daily life
- fatigue/tiredness
- powerlessness
- restrictions
Pain management and management strategies
- non-pharmacologic approaches
- pharmacologic approahes
Patients' perspectives about nurses' approaches to
pain
- perspectives about the nurses' pain assessment
- perspectives about the nurses' pain management
and economic problems due to pain. Another study (Lindqvist et al.,
2008), found that patients with prostate cancer having skeletal metas-
tasis had a dominant experience of lack of energy and fatigue. Not only
the cancer, but also the other problems such as constipation, stomach
ache and backache related to cancer therapies also had detrimental
effects on patients' lives (Morss, 2010). Pain means many restrictions
and disabilities in a patient's life. Schaller et al. (2015) reported that
more than half of cancer patients had to make changes in daily activ-
ities because of fatigue and weakness; the disease had negative effects
European Journal of Oncology Nursing 33 (2018) 28–34
Examples of Narratives
• “Pain is a bad experience. I could not think pleasant things when I had pain, ….feel myself helpless and hopeless …. ”
(Patient 6)
• “… I did not experience such a pain before in my life …. “This kind of pain was unbearable.” (Patient 7, 10)
• aggressive
“Pain makes me miserable and angry. Everything seems a huge problem, when I had pain.” (Patient 7). “ … … I became
and try to fight with everyone, I did not tolerate to smells like onion while cooking. (Patient 10)
• Iuncomfortably
felt mad when I had pain.” “My pain is because of a mass in my abdomen. My abdomen is enlarged and I feel myself
full.” (Patient 1)
• “Idiagnosis;
felt a burning, choppy pain starting from my chest and spreading towards my scapula … the doctor told me the
it was cancer. After chemotherapy, the severity of my pain decreased …” “I had no pain till I was 65 years old.
As I did not experience pain before, I do not know what to do with pain …” (Patient 2)
• “Idoctor
never had pain before. I did not even take a health report to rest in my 30 full-time working years. I never went to
for simple reasons …” (Patient 3)
• ““I….feel.Pain means sleepless nights, gives so much discomfort and I even gave up on my life …. .” (Patient 8)
• only dailytiredness and powerlessness to go to work and do something, all the tasks are waiting for me …. Pain restricts not
life, it disturbs working life and causes economic problems.” (Patient 5)
• “It(Patients
disturbed all my life, I could not walk, breathe, I could not sleep …. Even my posture, I could not sit comfortably …”
8, 9)
• husband
“… … I do not want to get up from my bed, I eat a little … and then return back to bed …. . I force myself to walk, my
holds my arms and supports me during walking …. Pain disrupted my nutrition too, I do not want to eat … …
only half of a medium meatball … … that's all. (Patient 2)
• “want
…. Because of pain, I could not go out, do even an easy household or visit any neighbour … I am in social isolation, not
to hear anyone's voice …” (Patient 1)
• “I“…hadI feltdifficulty falling asleep and woke up almost five times a night because of pain …” (Patient 3)
• curtains and myself in depressed mood, fatigue, dizziness, all make me miserable … so I do not want to do anything, close the
stay in bed for many hours … I even do not want to see my grandchild who is my favourite person …”
(Patient 6)
• “… I pray to God for my healing and namaz (an Islamic pray ritual, performed five times a day) in order to manage with
the pain. I drink lemon mint tea for my stomach and lemon balm tea to prevent vomiting.” (Patients 1, 12, 14, 15, 16).
• ““…….I Itake
take a fetal position when I have pain. I used a corset, the corset was good for abdominal pain …” (Patient 1)
• “… When aI havehot bath … bathing relaxes me so much, feel myself better …” (Patient 3)
• cancer diagnosis, pain, I walk along the corridor at home, do some stretching exercises with my spring tool. Before the
I walked 5 km/three days a week, I was very healthy and surprised how this disease found me. I like
using herbal products, often drink sage and thyme tea. I always mix a spoon of pollen and jungfer with some honey or
sometimes yogurt and eat them for healing everyday …” (Patient 3)”
• “… I walked around at home, watched TV and slept …. not to concentrate on my pain …” (Patient 2, 4)
• “… I had an ancient therapy which is bloodletting with cupping, it is popular nowadays. I also received some
physiotherapy but did not use any other products.” (Patient 8)
• “… My wife bought a syrup made from aloe vera in order to reduce my pain. But the doctor did not give permission to
drink it, so I did not use it …” (Patient 2)
• “… I generally resisted using medications when I had pain, because they disturb my stomach. If I had unbearable pain, I
told the nurse …” (Patient 1)
• “… I usually take an analgesic and have a long sleep all day.” (Patient 4, 7)
• “I take my antidepressant drug, it makes me feel better. I do needlework like knitting as a therapy, spend a lot of time in
the garden … I forget my illness while digging the soil. Now, I am planning what to plant for this year.” (Patient10)
• “ …. I do not take any medicine immediately, I wait some time to relieve pain. If its intensity increases and becomes
unbearable, then I take medicine.” (Patient 12)
• “I did not use any other therapies and did not think that they were beneficial …. I only did what my doctor told me to do
and received medical therapy.” (Patients 5, 6, 7, 16)
• “… Nurses generally ask questions such as ‘do you have pain?’ and if I say yes, they give an analgesic.” (Patients 1, 7,
11, 12, 13, 14, 15, 16).
• “… Nurses never ask if I have pain or not. I tell them if there is any problem, but the doctors asks me about pain at every
visit …” (Patients 2, 9).
• “… Nursing approach to pain is not good … not bad …”. “… Nurses only asked me about pain. They do not use any score,
scale, to measure my pain … only yes or no.” (Patient 5)
• “Nurses do not have time to ask us pain. They have a lot of work to do. But I tell them when I had pain.” (Patient 3)
• “… Nurses only give ordered medications, they do not do anything except this … no information … They only do their
task, talk and smile with each other while giving medications, without regarding our pain. We need more information and
tenderness …” “...they approached us technically, but we are not machines, we have emotions. (Patient 6)
• “Nurses ask when it's time to give an analgesic. If I had pain, they gave; no pain no medication …”. “They tell us why they
give a medication and its effects. It is good for me …” (Patient 8)
• “Nurses ask me about pain while giving medications. They do not give any information about pain and how to cope with
it … They only do what the doctor says …” (Patient 10)
on social and family life as well. McPherson et al. (2014) reported that
most of the patients talked about the loss of functioning and being
dependent on others when discussing pain. Korhan et al. (2013) stated
that pain affected physical and psychological functions of cancer pa-
tients negatively, and caused problems such as anxiety, hopelessness,
depression, dependency, sleep disorders and fatigue. Webber et al.
(2011) expressed that cancer pain completely changed patients' lives;
they felt exhausted and lacked appetite. Similar to these findings, pa-
tients with advanced cancer also mentioned the heavy burden of cancer
32
O. Erol et al.
Pain perception Effects of pain Pain management Patients’ perspectives
and experiences on daily life and management about nursing approaches
of the patients strategies to pain
-The meaning of -Fatigue/ tiredness, -Non-pharmacologic -Perspectives about the
pain powerlessnes approaches nurses’ pain assessment
-Thoughts about -Restrictions -Pharmacologic -Perspectives
nurses’ the reason of pain approaches
-Past experiences
about pain
pain affecting all aspects of their lives in the present study.
As cancer is a life-threatening disease which is difficult to control,
especially patients with advanced cancer have more tendency use
complementary therapies in order to fight with cancer and treatment
related effects, strengthen immune system, and provide stress man-
agement (Truant et al., 2013). In this study, patients reported the fre-
quent use of nonpharmacologic approaches such as praying to God,
namaz, changing position, having a bath, walking, massage, herbal
supplements (e.g., sage and thyme tea, lemon balm tea, a nigella-
pollen-honey mixture, raisin kernel and molasses), watching TV, cup-
ping, engaging in crafts, etc. to relieve pain. All the participants had
advanced cancer, high ECOG scores and metastasis, which meant
worsening of prognosis and a lower quality of life. A similar finding was
stated in a Turkish study that reported that patients with metastatic
disease and a worse quality of life showed a high tendency to use
complementary and alternative medicine, and frequently used methods
were found as religious practices (68.2%), and herbs (37.4%) (Can
et al., 2009).
In this study, as all patients were Muslim with an advanced cancer
diagnosis, religious practices were commonly seen among patients. This
might be related with the fact that patients having advanced cancer felt
themselves vey close to God, and only prayed to God wishing to heal
and/or die without pain. A few patients reported the use of some nu-
tritional (e.g., yogurt, pollen, honey, harnup molasses) and herbal
(sage-thyme tea) supplements. McPherson et al. (2014) reported that
patients with advanced cancer used non-pharmacological interventions
such as moving or changing position, resting, talking and being with
others, hot or cold interventions, massage and prayer in order to relieve
pain. In present study, unfortunately, patients did not express any
nonpharmacologic approaches implemented or suggested to them by
the nurses. Nurses need increased awareness in their pain management
roles, including non-pharmacologic approaches and supporting both
the patient and the family.
The present study found that patients with advanced cancer used
pharmacologic agents such as pomades, opioids, epidural steroids and
analgesics to relieve pain. Some patients also stated that they waited to
see whether their pain intensity would increase or decrease, and in-
formed the nurse or the physician when it became unbearable. This
might be related to the unwanted side effects of pharmacologic ap-
proaches. Because side effects of pharmacologic therapies also create
other problems such as constipation, affecting quality of life negatively,
so patients avoid to take them (Jacobsen et al., 2009; Morss, 2010).
Although pharmacologic agents provide rapid relief, patients often
hesitated to use them and preferred to use the ‘wait and see’ approach
(McPherson et al., 2014). Therefore, nurses play a key role not only in
caring for patients with pharmacologic agents, but also in observing the
effects and adverse effects of these therapies.
Patients' perspectives and insights about the nurses' pain assessment
and management activities are key elements in managing cancer pain.
A lack of consistent pain assessment among health care professionals
was one of the most important barriers to effective advanced cancer
pain management (Haumann et., al., 2017; Jacobsen et al., 2009). In
European Journal of Oncology Nursing 33 (2018) 28–34
Fig. 2. Themes and subthemes.
about the
pain management
this study, nursing approaches to pain were found to be insufficient in
the view of the patients. Nearly half of the patients with advanced
cancer expressed that the nurses did not ask them if they had pain or
not. No systematic pain assessment was done in the clinic, most of the
patients stated that nurses asked about pain during medication hours
and did not use any scale or score, answeres were only verbal “yes” or
“no”. Systematic and proper assessment of pain with valid instruments
and documentation of these practices are important and beneficial in
terms of obtaining basis for pain treatments, monitoring patient re-
sponses, and providing safe and quality care to patients (Vallerand
et al., 2011). The patient and the family need to know that the nurse
gives importance to pain and does everything to relieve the patient's
pain. Since oncology nursing is an area of expertise that is continuously
developing, evidence-based practices in this area are much more fre-
quently used and shared easily between nurses. Oncology nurses are
expected to have knowledge and give high quality of care to cancer
patients fighting many devastating cancer symptoms. Unfortunately,
studies have shown that nurses do not have adequate knowledge or
skills in pain management. Alqahtani and Jones (2015) found that
many nurses working in oncology clinics had inadequate knowledge
and assessment skills in pain management. Moreover, Charalambous
(2015) stated that nurses did not use evidence-based interventions in
cancer pain management, although they believed in their positive ef-
fects. In this study, some patients were not satisfied with the nurses'
caregiving attitudes, caring relationship and communication. They did
not find nurses' efforts sufficient to relieve their pain and described
them as only giving medications ordered by the physicians. Although
some patients stated that nurses had heavy workloads, most expressed
that the doctors asked and cared about their pain more than the nurses.
Beck et al. (2010) reported that the most significant factors affecting the
patients' care-related satisfaction were being looked after, timely re-
sponses, receiving individualised care and sufficient knowledge. Panteli
and Patistea (2007) determined that patients were satisfied with their
communications about pain and pain management issues; the patients
informed by physicians and/or nurses about pain management were
more satisfied. Torresan et al. (2015) reported that physicians were
seen as a source of authority and their advice on pain therapy was
found to be more valuable. Patients and families sometimes get tired
while managing with cancer pain, as it is an ongoing process that also
needs tolerance and patience. Therefore, they need comprehensive,
holistic pain management programmes within a multidisciplinary ap-
proach.
5. Limitations
There are some limitations to the current study. The study is limited
to patients admitted to only a cancer centre in Turkey. In addition, the
results were based on individual interviews and demonstrated the ex-
periences of hospitalized, advanced cancer patients with stages III and
IV. Therefore, findings may not be transferable to all cancer patients.
The sample comprised predominantly male patients. We can explain the
gender clumping by the fact that half the sample had lung cancer,
33
O. Erol et al.
which is the most prevalent cancer type in Turkey and which is seen
mostly in men; six other patients had colon cancer, which is the third
most prevalent cancer type; two patients had gastric cancer, which was
the fourth prevalent cancer type seen in both genders.
6. Implications for research and/or practice
The findings demonstrated that systematic pain assessment was not
used by the nurses which could be one way of improving pain man-
agement. Patients with advanced cancer need much more attention of
nurses’ pain assessment and management interventions. Nurses should
provide high-quality care using a holistic approach to reduce pain and
pain-related physical and psychosocial symptoms of patients with ad-
vanced cancer by using reliable tools. They should also support and
guide patients and families in the use of effective non-pharmacologic
pain management strategies.
7. Conclusions
This study demonstrated the difficulties of patients with advanced
cancer who experienced pain in their daily lives. Moreover, nurses’
caring approaches related to pain assessment and management of pa-
tients with advanced cancer were not adequate. The results of this study
demonstrated that patients with advanced cancer need much more at-
tention of nurses when coping with pain. Oncology nurses should
provide educational interventions in order to enhance knowledge and
skills about pain assessment and management with non-pharmacologic
and pharmacologic approaches.
Conflicts of interest
This study was not supported financially by any organization or
people. None declared.
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