Nursing and cancer pain

BACKGROUND AND OBJECTIVES: A major complaint of cancer patients is pain. In Brazil, it is estimated that 62 to 90% of cancer patients have some type of pain; however in Brazil pain is still inadequately controlled and managed for cancer patients, being that 24.5 to 46.6% have their pain inadequately managed. This study aimed at identifying in the Brazilian literature the status of nursing assistance and knowledge about cancer pain to deepen knowledge about nursing care practices for painful cancer patients. CONTENTS: This is an exploratory study by means of integrative literature review. National studies in Portuguese language and fully available in LILACS, Scielo and BDENF databases, published between 2002 and 2012 were used, achieving a final sample of 24 articles, which were grouped in 3 thematic axes portraying difficulties faced by nurses to assist painful cancer patients, going from poor knowledge to the scarce number of professionals, in addition to the scarcity of studies addressing the theme. CONCLUSION: Results of our study have contributed to the scientific background of the nursing team, giving them support for the acquisition of pain management skills, especially with regard to its adequate measurement, major aspects of intervention and predominant stumbling-blocks for pain management.


INTRODUCTION
A major complaint of cancer patients is pain which manifests in all neoplastic process stages.In Brazil, it is estimated that 62 to 90% of cancer patients have some type of pain 1 .The World Health Organization (WHO) states that pain is an unpleasant, sensory and emotional experience, associated to actual or potential injuries.So, pain is considered a syndrome resulting from the physical-chemical interpretation of noxious stimulations and their interaction with individual features such as mood, the symbolic meaning given to sensory phenomena and individual cultural and affective aspects 2 .
REVIEW ARTICLE DOI 10.5935/1806-0013.20150027Inadequate pain management is common worldwide.According to WHO data, from five million people dying of cancer every year, 80% die without receiving adequate pain control 3 .In Brazil, 24.5 to 46.6% of cancer patients have their pain inadequately controlled.Brazil is considered the second Latin American country where cancer patients feel the most pain 4 .The practice of assisting cancer pain patients is very broad and its evaluation is the key-point for care planning, requiring educational support of nursing professionals for pain handling and managing 5 .So, reviewing knowledge by means of literature articles about cancer pain patients' evaluation and care is relevant for current health context.Scientific production on oncologic nursing is indispensable, being critical for the basis that shall support clinical practice 6 .Nurses should be aware of the need for acquiring knowledge and training to effectively play their role, thus leading to successful pain management.This study aimed at identifying in the Brazilian literature the status of assistance and the understanding of nursing teams about cancer pain, to deepen knowledge of nursing practices and care of cancer pain patients.

CONTENTS
This is an exploratory study, by means of integrative literature review of national studies in Portuguese and fully available in Latin-American and Caribbean Literature on Health Sciences (LILACS), Scientific Electronic Library Online (Scielo) and Nursing Database (BDENF), published between 2002 and 2012.For studies selection, a search was carried out on cancer pain knowledge, using the following descriptors: "Pain"; "Oncologic Nursing"; "Nursing Assistance" and "Humanization of Assistance".It was observed that few articles on cancer pain were published in the last 10 years; just 24 articles were identified.There is a limited production on the proposed subject because along the years this interest has remained inexpressible, considering the limited number of studies.As from content analysis, the following aspects were observed: cancer pain evaluation by the nursing team; nursing and cancer pain patients; and major factors contributing for the difficulty of nursing assistance to cancer pain patients.Distribution of 24 selected articles according to type of study and authors, and the percentage of selected articles approaching subjects on each axis are shown in tables 1 and 2. The discussion of nursing and cancer pain is influenced by different factors which are explained in the following axes.

Axis 1 -Cancer pain evaluation by the nursing team
Six articles have shown that measurement is the fastest way to apply and calculate pain intensity by means of a number  27 Silva & Pimenta 28 Exploratory-descriptive research Cross-sectional, descriptive, exploratory study or a value.There are several methods to measure and perceive pain; most widely used are visual analog scale (VAS) and numeric verbal scale (NVS).One article shows that nurses are limited to using NVS, not using McGill method and Differential Descriptors Scale (DDS), thus not taking into consideration subjective and multidimensional pain aspects evaluated by such evaluation methods.VNS aims at measuring pain intensity in clinical contexts and numeric values.Patients have to be aware of their thoughts and actions and refer pain on a scale from zero to 10, being zero "no pain" and 10 "maximum imaginable pain" 29 .This scale is applicable to oriented patients with good cognitive capacity who, in a context of intensive care, may be waiting, for example, for surgical procedures 15 .Another mentioned scale is VAS, which is similar to NVS, however it is mandatory for patients to have visual contact with the scale and they should be able to point or signal to the examiner the level of their pain 29 .Twenty-seven studies have shown that nurses admit that just measurable and objective data do not effectively and thoroughly evaluate cancer pain in all its biopsychossocial aspects.These findings confirm a different study 16 which states that nursing care also assumes being attentive to subjective patient complaints, to be able to act in the course of the symptom, thus providing comfort and wellbeing.The nursing team has shown some limitations in measuring and evaluating cancer patients' pain, in handling patients' pain and in administering adequate therapy.According to three studies, nurses have stated that even with some pain evaluation tools, there are several obstacles related to lack of protocols to guide the nursing team.

Axis 2 -Nursing and cancer pain patients
Based on the analysis of selected articles, nursing interventions for cancer pain patients should be based on several aspects which are described below: • Importance of Nursing Actions Systematization (NAS) implementation: in our study, 3 out of 24 analyzed articles have shown the need for care systematization through NAS to reach quality assistance; • When pain is not systematically evaluated, it may be underestimated and important factors may be missed.Inadequate pain evaluation and unawareness of available strategies for its control are factors which may impair the handling of this symptom 8,12,18,21 ; • Holistic approach: Four studies have observed nursing attention to meet cancer patients needs in all their aspects (physical, emotional, social and spiritual), where nurses should tirelessly act to eliminate or minimize patients anxieties and desires; however, to do so, it is necessary for the professional to have a unique nursing profession profile, constantly looking for technical-scientific knowledge and acting in an interpersonal and humanized way, because nursing professionals need to interpret the subjectivity of every patient to reach the desired goal which is their quality of life 19 ; • A broadly mentioned factor among authors, within the holistic focus, is spiritual need; individuals' faith is a very strong point for their treatment and nurses should be fully aware of this requirement; • Importance of the family: holistic care also implies welcoming patients' families, providing them with all needed information about treatment, intercurrences and questions raised during therapy 10 .A major factor in this context is confidence conveyed by the nursing team to patients and their families, but for this feeling to be conquered, profes-sionals have to act in empathic, responsible and competent ways, being sensitive to the pain of others 2 ; • Three hundred and fifteen studies have observed that due to the level of complexity of cancer patients care, it is paramount that nursing professionals are prepared, by getting cancer-related technical-scientific and socio-cultural knowledge, in addition to professional experience in oncology to be able to manage all technical, educational and research interventions planning, with focus on prevention, management and rehabilitation of cancer pain patients.

Axis 3: Major factors contributing for the difficulty of nursing assistance to cancer pain patients
After the analysis of selected studies, it was possible to show major nursing assistance problems with regard to cancer pain patients, which are described below: • Five studies have shown that an obstacle to adequate cancer pain patients' management is health professionals' lack of knowledge and update, especially with regard to pain evaluation and its adequate management.Very often, nurses are even somewhat knowledgeable about the subject however they do not carry out such systematization due to the large number of cancer patients for a limited number of nurses, leading to overloaded and inadequate assistance.These difficulties have as consequence the inadequate attention to patients' pain complaints, causing them suffering and distress, which is currently inadmissible; • A considerable issue within this theme is the complexity of pain evaluation, because this is a subjective feeling inherent to the cognitive of each patient, requiring from nursing professionals ability and insight to find out actual and potential, apparent or hidden needs, so that they may act in a more positive and humanized way in managing such pain.

CONCLUSION
We believe that this study results may contribute to support nursing team technical-scientific knowledge, giving them support to acquire skills on pain management, especially with regard to adequate measurement, major interventions and major obstacles impairing nursing assistance in controlling cancer patients pain.

Table 1 .
Distribution of articles by type of study and authors.Belém,