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PAI N MANAGEMENT

A pain education programme to improve patient satisfaction with


cancer pain management: a randomised control trial
Pi-Ling Chou and Chia-Chin Lin
Aim. The purpose of this study was (1) to evaluate the effectiveness of a pain education programme to increase the satisfaction
of patients with cancer with regard to pain management and (2) to examine how patient satisfaction with pain management
mediates the barriers to using analgesics and analgesic adherence.
Background. The patients satisfaction with pain management is not merely an indicator, it is actually a contributor to med-
ication adherence. However, very few studies investigate methods for improving patient satisfaction with pain management.
Design. This study used an experimental and longitudinal design.
Methods. A total of 61 patientfamily pairs (n = 122) were randomly assigned to either experimental or control groups. The
instruments included the American Pain Society outcome questionnaire, the Barriers Questionnaire-Taiwan form, self-reporting
evaluations of analgesic adherence and the Pain Education Booklet. The experimental group (n = 31) participated in a pain
education programme, while those in the control group (n = 30) did not. The two groups were compared using generalised
estimation equations after the second and fourth weeks. A Sobel test was used to examine the mediating relationships among
patient satisfaction with pain management, barriers to using analgesics and analgesic adherence.
Results. The experimental group showed a signicant improvement in the level of satisfaction they felt for physicians and nurses
regarding pain management. For those in the experimental group, satisfaction with pain management was a signicant mediator
between barriers to using analgesics and analgesic adherence.
Conclusions. This research provides evidence supporting the effectiveness of a pain education programme for patients and their
family members in increasing patient satisfaction with regard to the management of cancer pain.
Relevance to clinical practice. It is important for health providers to consider patient satisfaction when attempting to improve
adherence to pain management regimes in a clinical setting.
Key words: barriers to pain management, cancer pain, mediator, nurses, nursing, pain education programme, pain management,
patient satisfaction
Accepted for publication: 9 January 2011
Introduction
Cancer pain is a serious clinical problem and improving the
means by which it is treated is an issue of critical importance
(Gordon et al. 2002, Jain et al. 2008). Assuring the quality of
cancer pain management by systematically evaluating the
methods employed in such treatment can enhance the effec-
tiveness of pain control in patients with cancer (Ward et al.
1998). The patients satisfaction with pain control is an
essential indicator in assessing the quality of cancer pain
management (Sterman et al. 2003, Panteli & Patistea 2007);
however, very few researchers have adopted a longitudinal
Authors: Pi-Ling Chou, MS, RN, Doctoral Student, Graduate
Institute of Nursing, College of Nursing, Taipei Medical University;
Chia-Chin Lin, PhD, RN, Professor and Director, School of Nursing,
College of Nursing, Taipei Medical University and Wan-Fang
Hospital, Taipei, Taiwan
Correspondence: Chia-Chin Lin, Professor and Director, School of
Nursing, College of Nursing, Taipei Medical University, No.250,
Wuxing St., Taipei 11031, Taiwan. Telephone: + 886 2 2377 6229.
E-mail: clin@tmu.edu.tw
1858 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869
doi: 10.1111/j.1365-2702.2011.03740.x
approach to studying pain education as it pertains to this
issue. Patient satisfaction with pain control is not merely an
important indicator. If patients are more satised with their
pain management, they more likely to comply with the advice
of health providers (Hirsh et al. 2005). Previous studies
related to pain intervention have focused on barriers to
changing analgesics and the resulting inuence on patient
adherence to such treatment (Lin et al. 2006, Syrjala et al.
2008). Unfortunately, the means by which these barriers
inuence adherence remains unclear. A deeper under-
standing of the mechanisms involved in patient satisfaction
that dissuade patients from adhering to the prescribed use
of analgesics could prove extremely valuable in clinical
practice.
Background
Patient satisfaction towards their treatment was dened by
Lebow (1982) as the extent to which treatment graties the
wants, wishes and desires of clients. Several studies have
adopted the satisfaction that patients feel towards pain
management as an indicator for assessing the effectiveness of
pain management (de Wit et al. 2001, Jain et al. 2008).
Merkouris et al. (1999) reported that patient satisfaction
might provide the means to evaluate outcomes and act as a
contributor to other outcomes (i.e. adherence), inuencing
the process of recovery. Several researchers have discovered
that patient satisfaction with medical management could be
used to forecast medical outcomes, in addition to acting as an
outcome indicator (Meakin & Weinman 2002). For instance,
studies focusing on older patients suffering from coronary
heart disease discovered that the degree to which patients
adhere to the instructions they received regarding their
medication improves proportionally to the patients satisfac-
tion feel towards an increase in medical management from
their physicians and nurses (Rich et al. 1996, Rybacki 2002,
Simpson et al. 2002). Similarly, if the adherence of patients
increases with medical management, studies could more
accurately predict the outcome of health care services. Most
researchers recognise that patientprovider relationships and
patient satisfaction with those relationships are important
factors in adherence to treatment regimes (Cameron 1996,
Bos et al. 2005). One study indicated that the more satised
patients are with their pain management, the more they
comply with the advice of health care providers (Hirsh et al.
2005). Another study on chronic pain in children revealed
that the satisfaction of parents and children is signicantly
correlated with patient adherence (Simons et al. 2010).
Interventions that improve patient satisfaction could have a
positive inuence on the outcome of treatment for cancer pain.
Adherence to analgesic regimens has become one of the
most signicant clinical problems in the management of
cancer pain (Miaskowski et al. 2001). The lack of adher-
ence to analgesics is a result of myths regarding their use
(Tzeng et al. 2008, Valeberg et al. 2008). In the past few
decades, promoting and maintaining adherence to prescribed
analgesic regimens has become an important intervention in
the treatment of patients with cancer (Agency for Healthcare
Research and Quality 2001). As a result, many studies have
developed strict guidelines to ameliorate misconceptions
regarding pain and analgesics, and several of these interven-
tions have signicantly increased patient adherence to the
prescriptions of medical personnel (Ferrell et al. 1993, Lin
et al. 2006, Syrjala et al. 2008). Patients who had been
educated concerning pain intervention were less likely to self-
terminate their medication when the pain decreased. Pain
education programmes appear to be benecial in reducing
patient misconceptions regarding analgesics and improving
patient adherence to their analgesic regimens.
The cancer patients satisfaction feel towards pain manage-
ment programmes is a relatively new topic of discussion and
many of the implications are scarcely understood (Alalo &
Tselios 1996, Sherwood et al. 2000). Evaluating the level of
patients satisfaction with the management of their cancer
pain can provide a deeper understanding of their general
satisfaction with the treatment they receive from their
physicians and nurses. In a study by Sherwood et al.
(2000), patients with cancer who were dissatised with their
pain management perceived a lack of empathy among health
care professionals, who were slow to respond to their
complaints of pain. In addition, the same patients believed
that health care professionals did not have sufcient knowl-
edge or the skills required to properly manage their pain.
Dissatisfaction with pain management may be a reection of
poor pain management provided by health care professionals
(Sherwood et al. 2000).
Several studies have shown that interventions encourage
patients with cancer to overcome the barriers preventing
them from adhering to analgesics meant to reduce their pain.
However, the mechanisms involved in the reduction of such
barriers have never been explored. This study suggests that
patient satisfaction with pain management regimes is a
signicant factor inuencing medication adherence and fully
exploring these underlying mechanisms is crucial. This study
hypothesises that long-term education programmes address-
ing the issue of cancer pain management for patients and
their families would improve patient satisfaction. Patient
satisfaction with pain management could be a signicant
mediating factor among the various barriers to using anal-
gesics and analgesic adherence.
Pain management Pain education to improve pain management
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1859
Methods
Participants and settings
This study, part of which has been published elsewhere (Lin
et al. 2006), is one component of a large randomised control
study. It was conducted in the oncology outpatient clinics of
two hospitals in Taipei, Taiwan. A purposive sample
consisting of outpatients and their primary caregivers was
recruited. Patientfamily pairs enrolled in the study were
randomly assigned to the experimental group or control
group using a computer-generated randomisation scheme
developed by the researcher. Random allocation sequences
and sealed, opaque envelopes were used to ensure security.
Two participants in the experimental group and two partic-
ipants in the control group discontinued involvement in the
study during the second assessment and three participants
stopped treatment after the third assessment. Sixty-one
patientfamily pairs (n = 122) completed the analysis, of
which 31 pairs were in the experimental group and 30 pairs
were in the control group (Fig. 1). Participants had to meet
the following criteria: (1) diagnosed with cancer; (2) expe-
riencing pain due to cancer and currently taking oral
analgesics; (3) over 18 years of age; and (4) ability to
communicate in Mandarin or Taiwanese. Participants suffer-
ing from cognitive impairment or brain metastasis were
excluded from the study. This study used SSIZE SSIZE software
(Hsieh 1991) to estimate the size of the sample from the pilot
study. Scores regarding patient satisfaction were used as the
primary outcome; with a r value of 005 and a test power of
85%. Satisfaction scores in the pretest were 35 (slightly
dissatised) and after two weeks 45 (somewhat satised).
Each group had to be maintained at 30 samples with a
difference of 1 between the two groups.
Instruments
The American Pain Society (APS) outcome questionnaire
The APS outcome questionnaire was developed from qual-
ity assurance studies, using identical tools for exploring
patient satisfaction with regard to the treatment of cancer-
related pain (Ward & Gordon 1994, Miaskowski et al.
1994). The standards proposed by the Quality Assurance
Committee of the APS were adopted in the development of
the questionnaire used in this study. In addition, the views
of patients regarding the means by which their doctors and
nurses managed their pain were also included (Max et al.
1991, Agency for Health Care Policy and Research 1994).
The questionnaire was translated into Mandarin using a
translation and back-translation method to ensure accuracy.
This questionnaire included three parts: (1) a patient
assessment of their satisfaction with the method of pain
management employed by their physician(s); (2) a patient
assessment of their satisfaction with the method of pain
management employed by their nurse(s); (3) a patient
assessment of their satisfaction with the overall treatment
they received for the management of their pain. This study
was scored on a six-point Likert scale ranging from 6 for
very satised 1 for very dissatised to establish reli-
ability and validity (Lin 2000, Panteli & Patistea 2007).
The Barriers Questionnaire-Taiwan form (BQT)
Ward and Colleagues proposed the Barriers Questionnaire
(BQ), which was specically developed to measure barriers to
the use of analgesics in patients with cancer (Ward et al.
1993). The BQT was translated and modied specically for
Taiwanese participants. It comprises nine subscales with 34
items (Lin & Ward 1995). Based on the results of content
analysis of the Taiwanese population, several items were
added to the BQT. The subscale of fear of injection was
dropped; and a three-item subscale labelled religious fatal-
ism was added. Another three-item subscale labelled P.R.N.
was also added. The nal BQT consisted of nine subscales,
Declined participation
(n = 19)
Not interested (n = 10)
Felt too burdensome (n = 4)
Other reasons (n = 5)
Randomised (n = 68)
Allocated to the
experimental group
(n = 34)
Allocated to the
control group
(n = 34)
Completed
assessment at T1
(n = 34)
Complete follow up at
T2 (n = 32)
Too ill (n = 2)
Completed
assessment at T1
(n = 34)
Complete follow up at
T2 (n = 32)
Transferred to hospice ward (n = 1)
Did not wish to continue (n = 1)
Complete follow up at
T3 (n = 31) Did not
wish to continue (n = 1)
Complete follow up at
T3 (n = 30)
Died (n = 1)
Missed because researcher
was unavailable (n = 1)
Assessed for eligibility
(n = 87)
Figure 1 Flow chart of the trial.
P-L Chou and C-C Lin
1860 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869
with 34 items (Lin 2001). These subscales included the fol-
lowing: (1) addiction (three items); (2) disease progression
(three items); (3) pain tolerance (three items); (4) fatalism
(three items); (5) religious fatalism (three items); (6) P.R.N. or
as needed (three items); (7) concern about side effects
(10 items); (8) fear of distracting physicians (three items); and
(9) a desire to be good (three items). The BQT asks patients to
rate the extent to which they agree with each item on a scale
from 0 (do not agree at all) 5 (agree very much). This study
used both subscale scores and total score in the analyses. The
reliability and validity of the BQT were previously estab-
lished (Chang et al. 2002, Lin et al. 2006).
The Taiwanese version of the Morisky Medication Adherence
Measure (MMAM-T)
A structured four-item self-reporting measure of analgesic
adherence developed by Morisky et al. (1986) was adminis-
tered to patients to measure their compliance with analgesics.
The theory underlying this measure is that errors of drug
omission can occur for any or all of the following reasons:
forgetfulness, carelessness, cessation of the drug when feeling
better and use of the drug when feeling worse. The sum of the
yes answers provided a composite measure of non-adher-
ence. The total score ranged from 04, with higher scores
indicating a greater degree of adherence. The group showing
a high degree of adherence received a total score of 4; the
group with moderate adherence received a score of 23 and
the group with low adherence received a score of 01. A
Taiwanese sample with cancer pain veried the reliability and
concurrent construct validity of this measure (Tzeng et al.
2008).
Brief Pain Inventory-Chinese version (BPI-C)
This study uses the BPI-C version to measure the intensity of
pain and the degree to which pain interfered with daily
activities (Wang et al. 1996). The rst part of the BPI com-
prised the following four, single-item measures of pain
intensity, with each item rated on a scale of 0 (no pain) 10
(the worst pain I can imagine): (1) worst pain, (2) least pain,
(3) average pain and (4) pain now. A Taiwanese sample with
cancer pain established the reliability and validity of this
measure (Wang et al. 1996, Lin et al. 2006, Tsai et al. 2007).
The Pain Education Booklet
The primary researcher in this study developed the Pain
Education Booklet using concise descriptions and illustra-
tions to provide important information specic to Taiwanese
patients with cancer and their family caregivers, addressing
concerns of reporting pain and using analgesics. This pocket-
sized booklet is 16 pages long and addresses nine common
concerns. A panel of experts validated the content of the Pain
Education Booklet. Further modications to the content of
this booklet were made according to comments from patients
and experts. Cancer outpatients previously used this booklet in a
pain education programme (Chang et al. 2002, Lin et al. 2006).
Karnofsky Performance Status (KPS)
This study used the KPS to assess the performance status of
patients. The KPS is rated on a scale of 1100, in steps of 10.
The KPS has demonstrated a high level of predictive validity
(Buccheri et al. 1996).
Procedure
A research assistant approached patientfamily groups to
describe the study and obtain informed consent. On the day of
the rst interview, the patients in the experimental group lled
out the APS outcome questionnaire, the BQT, the BPI-C and
the self-reported measure of analgesics. They also ll out a
demographic questionnaire. After the patients had completed
the questionnaire, the research assistant provided a pain
education intervention session for patients and family caregiv-
ers, using the Pain Education Booklet. Researchers conducted
the session in a private room at the outpatient unit, to avoid
interruptions. The research assistant discussed all of the
content covered by the booklet and encouraged patients and
family caregivers to ask questions. The pain education session
took approximately 3040 minutes to complete. Patients and
family caregivers were encouraged to call phone numbers
included the booklet, following the education session, if they
required answers to any questions. Each participant received a
copy of the pain education booklet. The second and third
interviews were conducted two and four weeks after the pain
education session, respectively. At each interview, the patients
were asked to complete the questionnaire again. Researchers
took the chance to answer any questions the patients or family
caregivers had and reviewed the information on pain educa-
tion. Patients and their family caregivers in the control group
received conventional care. Patients in the control group
individually and independently completed the questionnaires
on pain and demographic data during the rst interview. They
complete the questionnaires during the two- and four-week
follow-up interviews. The control group did not receive an
education programme. The research assistant only answered
questions asked by patients or family caregivers. If the
interviewer observed that a patient appears to be in pain or
distress, or if a patient verbalised pain or distress, the
assessment or follow-up would cease until the patient was
relieved fromthese symptoms. Noadverse events or side effects
resulted from the intervention.
Pain management Pain education to improve pain management
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1861
Data analysis
This study used complete analysis to interpret the collected
data. The generalised estimating equations (GEE) analyses
the effects of the pain education programme on patient
satisfaction, and the Sobel test under the SAS SAS system (version
8.2; SAS Institute Inc., Cary, NC, USA) assesses the mediating
role on the barriers to using analgesics and analgesic adher-
ence. To account for repeated measurement dependence that
might occur at the two- and four-week intervals (Liang &
Zeger 1986, Zeger & Liang 1992, Lin et al. 2006), GEE were
used to analyse whether the pain education programme
improved patient satisfaction with nurses and physicians.
The GEE analysis compensated for the baseline heterogeneity
(differences existing before the intervention) between the
experimental and control groups and the effects of maturation
(changes in outcome variables resulting from the passage of
time). To control for the effect of pain intensity on patient
satisfaction, this study factored the mean pain intensity (worst
pain + average pain + least pain + painnow/4) intothe analytic
model. As hypothesised in this study, patients in the experi-
mental group displayed a greater degree of satisfaction regard-
ing pain management. The patients satisfaction with regard to
pain management was a signicant mediator between barriers
to using analgesics and analgesic adherence. The Sobel test
described by Baron and Kenny (1986) and Preacher and Hayes
(2004) was used to examine the mediating effects of variables.
In this manner, we were able to estimate the direct, indirect and
total effects of the causal relationships involving this mediating
variable. In this study, the Sobel test under the SAS SAS system
(version 8.2) was used to assess the mediating role of patient
satisfaction on barriers to using analgesics and analgesic
adherence.
Ethical approval
This study obtained approval from the Human Subject
Committee of the hospital. All subjects signed written
informed consent forms.
Results
Demographic information
The participants in this study suffered from various forms of
cancer, including nasopharyngeal (21%), breast (18%), oral
(16%), liver (13%), lung (6%), colorectal (6%) and various
others (20%). In the experimental group, 61% of the
participants were women. The mean age was 55 (SD
1438). The mean years of education were 774 (SD 423).
The mean KPS score was 81 (SD 138). The mean pain
intensity score was 331 (SD 137) before intervention.
Among these participants in the experimental group, the
cancer identied in 77% of the test subjects had metastasised.
In the control group, 60% of the patients were women.
The mean age was 59 (SD 1660). The mean years of
education were 857 (SD 488). The mean KPS score was 85
(SD 114). The mean pain intensity score was 376 (SD 194)
before intervention. Among these participants in the control
group, the cancer identied in 70% of the test subjects had
metastasised. No signicant difference was displayed be-
tween the two groups regarding the prescriptions (ex:
NSAID, codeine/tramadol, morphine, fentanyl, adjuvant
drugs) provided by physicians. No signicant demographic
differences were noted between the two groups, with the
exception of treatment status (i.e. patients who received
chemotherapy or radiotherapy vs. those who received
neither), which reached signicance (p = 002).
Determining whether the pain education programme
improved patient satisfaction with the pain management
provided by nurses
There was no signicant difference at baseline (p = 01065) in
patients satisfaction levels between the two groups. The
control group showed a signicant maturation effect in the
second and fourth weeks (p = 00027 and p = 00073).
However, the elevation slope of the experimental group
was signicantly higher than that of the control group in both
the second (p < 00001) and fourth weeks (p = 00002),
after adjusting for the effects of treatment and mean pain
intensity. Clearly, the pain education programme signicantly
increased patient satisfaction with the nurses. The satisfac-
tion felt by the experimental group regarding the pain
management of nurses increased signicantly from 395
during the pretest to 518 by the fourth week. On the
contrary, the satisfaction felt by the control group was 428
during the pretest and 472 by the fourth week. Although
both groups displayed a signicant elevation in satisfaction
levels from the pretest to the fourth week, only a minimal
increase in patient satisfaction was observed between the
second week and the fourth week (Fig. 2; Table 1).
Determining whether the pain education programme
improved patient satisfaction with pain management
conducted by physicians
The baseline scores of the experimental group were signi-
cantly lower than the control group with regard to satisfac-
tion with the pain management conducted by physicians
P-L Chou and C-C Lin
1862 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869
(p = 00002). The control group showed signicant matura-
tion in the second week (p = 00415). However, the elevation
slope of the experimental group was signicantly greater than
the control group in both the second (p < 00001) and the
fourth weeks (p < 00001) after adjusting for baseline
heterogeneity, the effect of treatment and mean pain inten-
sity. The pain education programme signicantly improved
patient satisfaction with physicians. The satisfaction felt by
the experimental group regarding the pain management of
physicians increased signicantly from 454 during the pretest
to 564 by fourth week. In contrast, the satisfaction felt by the
control group was 511 during the pretest and 545 by the
fourth week. Despite the signicant improvement in satisfac-
tion in both groups between the pretest and the fourth week,
only a slight improvement was observed in patient satisfac-
tion between the second week and the fourth week (Fig. 3;
Table 2).
Determining the mediating role of patient satisfaction
with nurses to barriers in using analgesics and adherence
to the prescribed use of analgesics
One of the objectives of this study was to determine whether
patient satisfaction with nurses was a mediating factor
between barriers to using analgesics and adherence to the
prescribed use of analgesics. The results revealed that in the
experimental group, patient satisfaction with pain manage-
ment was a mediator between barriers to using analgesics and
adherence to the prescribed use of analgesics (p < 00001),
accounting for 4773% of the observed mediation (Table 3).
However, no mediation relationship was observed in the
control group. Figure 4 shows a path analytic model of the
relationships related to patient satisfaction with nurses,
barriers to analgesic use and adherence to the prescribed
use of analgesics.
Determining the mediating role of patient satisfaction
with physicians on barriers to the use of analgesics and
adherence to the prescribed use of analgesics
This study examined patient satisfaction with physicians to
determine whether a mediating relationship existed between
satisfaction and barriers to the use of analgesics and
adherence to the prescribed use of analgesics. The results
showed that in the experimental group, patient satisfaction
with pain management was a mediator between barriers to
using analgesics and adherence to the prescribed use of
analgesics (p < 00001), accounting for 4556% of the
mediation (Table 3). However, no mediating relationship
Patients satisfaction with nurses (n = 61)
1
2
3
1
2 3
0
1
2
3
4
5
6
Test time
S
c
o
r
e

Experimental group
Control group
Experimental
395 507 518
Control
428 47 472
1 2 3
Figure 2 Patients satisfaction score with nurses of Experimental
Group and Control Group (1 = pretest, 2 = second week, 3 = fourth
week). Note: Score was estimated with a generalised estimating
equations model of the patient satisfaction with nurses.
Table 1 Generalised estimating equations model of the patient satisfaction with nurses (n = 61)
Variable
Regression
coefcient
Standard
deviation Z p
Intercept 42817 02391 1791 <00001
Experimental vs. control group 02321 01438 161 01065
Second week vs. pretest 04204 01401 300 00027*
Fourth week vs. pretest 04358 01624 268 00073*
Interaction between second week and group 06991 01561 448 <0001*
Interaction between fourth week and group 07895 02134 370 00002*
Treatment status (yes vs. no) 02535 01539 165 00995
Mean pain intensity (worst pain + average pain + least pain + pain now/4) 00646 00421 153 01248
Interaction between second week and group shows the difference between the experimental and control groups in change between pretest and
second week. Interaction between fourth week and group shows the difference between experimental and control groups in change from pretest
to fourth week. The change in the experimental group is represented by the change in the control group plus the interaction term.
*p < 005.
Pain management Pain education to improve pain management
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1863
was evident in the control group. Figure 5 displays a path
analytic model of the relationships between patient satisfac-
tion with physicians, barriers to analgesic use and adherence
to the prescribed use of analgesics.
Discussion
Very few studies have examined the effectiveness of inter-
vention on patient satisfaction with pain management. Even
fewer studies have shown signicant improvements in patient
satisfaction with pain management, despite implementing
educational interventions. One long-term study (de Wit et al.
1997) conducted in the Netherlands in 1997 focused on 313
homecare patients with cancer. During hospitalisation, health
care professionals conducted face-to-face pain education
followed by a telephone-delivered reiteration of pain educa-
tion on the third and seventh days following discharge. The
researchers found no signicant improvement in satisfaction
with pain control, despite a reduction in pain intensity (de
Wit et al. 1997). Yates et al. (2004) conducted a pain
education programme with 189 homecare patients with
cancer. During the return visit, the health care professionals
administered a pain education session with the patients and
conducted a telephone interview one week after the visit.
Although the programme enhanced the perception of control
in the minds of patients, no signicant difference in patient
satisfaction with pain management was observed between the
rst week and second month following the intervention
(Yates et al. 2004). This may be attributed to the fact that the
interviews on pain education were conducted over the
telephone without face-to-face contact between patients and
medical staff. In addition, the education did not involve any
family members. In this study, however, pain education
consisted of an extended, face-to-face intervention involving
patients and family caregivers.
Previous studies have revealed that the level of patient
satisfaction with pain control might be inuenced by multiple
factors. Sherwood identied three factors inuencing the
patients satisfaction feel regarding pain management. These
factors included previous experience with pain (affecting
beliefs and attitudes regarding pain management and expec-
tations about pain); patient appraisals of health care profes-
sionals (if the health care professionals managed pain with
empathy, care, sufcient knowledge and technique); and
personal experience managing pain (such as the involvement
of family caregivers in the treatment plan and the develop-
ment of effective strategies to cope with pain) (Sherwood
et al. 2000). Studies have also investigated the satisfaction
felt by patients with terminal cancer regarding pain manage-
ment using phenomenology. These studies revealed three
1
2
3
1
2
3
0
1
2
3
4
5
6
Test time
S
c
o
r
e
Experimental group
Control group
Experimental
group
454 552 564
Control
group
511 541 545
1 2 3
Patients satisfaction physicians (n = 61)
Figure 3 Patient satisfaction with physicians in the Experimental and
Control Groups (1 = pretest, 2 = second week, 3 = fourth week).
Score was estimated by generalised estimating equations model of
patient satisfaction with physicians.
Table 2 Generalised estimating equations model of patients satisfaction with physicians (n = 61)
Variable
Regression
coefcient
Standard
deviation Z p
Intercept 51124 01894 270 <00001
Experimental vs. control group 05722 01535 373 00002*
Second week vs. pretest 02970 01457 204 00415*
Fourth week vs. pretest 03396 01853 183 00069*
Interaction between second week and group 06812 01579 431 <00001*
Interaction between fourth week and group 07566 01953 387 00001*
Treatment status (yes vs. no) 00359 00875 041 06817
Mean pain intensity (worst pain + average pain + least pain + pain now/4) 01437 00371 387 00001
Interaction between second week and group shows the difference between the experimental and control groups in change between pretest and
second week. Interaction between fourth week and group shows the difference between experimental and control groups in change from pretest
to fourth week. The change in the experimental group is represented by the change in the control group plus the interaction term.
*p < 005.
P-L Chou and C-C Lin
1864 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869
themes inuencing patient satisfaction with pain manage-
ment: communication, planning and trust. Patients expect
health care professionals to communicate in an open and
honest manner regarding pain management. After physi-
cians and nurses gain the trust of patients, patients show an
increased willingness to participate in the pain management
plan (Bostrom et al. 2004). Other factors that may con-
tribute to patient satisfaction with pain management
include a greater degree of social support (Jamison et al.
1993) and the physicianpatient relationship, manifesting
itself as an awareness of empathy and condence in
physicians and nurses (Jamison et al. 1993), such that
patients trust their health care providers (McCracken et al.
1997, Jensen et al. 2004). In addition, a recent study
revealed the four main factors inuencing satisfaction with
the quality of pain management. These included adminis-
tering treatment in a respectful manner, the provision of a
safety net, the efcacy of pain management and the
involvement of the patient as a partner. Among the four
factors, a collaborative relationship between patients and
health care professionals was the most important factor in
pain management determining the degree of control per-
ceived by patients (Beck et al. 2010).
In this study, several factors may explain how providing
pain education contributes to improving patient satisfaction
with pain management. Long-term engagements consisting of
multiple face-to-face visits with systematic pain education
provided patients with the opportunity to discuss how pain
management ought to be implemented. Such discussions
provided the opportunity to describe pain symptoms, evaluate
the effectiveness of medication and discuss the pain manage-
ment plan with physicians and nurses during every clinical
visit. In addition, researchers encouraged patients to take
an active role in their pain treatment and health care
BQT
score
Adherence
049* 085*
Without mediation: 087*
With mediation: 046*
Patient
satisfaction
with nurses
Figure 4 The mediation relationship of patient satisfaction with
nurses on the Barriers Questionnaire-Taiwan form score and anal-
gesic adherence in the experimental group. *p < 005.
BQT
score
Adherence
047* 084*
Without mediation: 087*
With mediation: 047*
Patient
satisfaction
with physicians
Figure 5 The mediation relationship of patient satisfaction with
physicians on the Barriers Questionnaire-Taiwan form score and
analgesic adherence in the experimental group. *p < 005.
Table 3 Sobel test for the mediation effects of patient satisfaction with nurses and physicians on the barriers adherence relationship in the
experimental group
Std b SE p-value
Test of mediation pathway of patient satisfaction with nurses
Barriers (predictor) adherence (outcome) 087 014 <00001
Barriers (predictor) satisfaction (mediator) 049 008 <00001
Satisfaction (mediator) adherence (outcome) 085 016 <00001
Barriers (predictor) adherence (outcome) with mediator 046 015 00028
Mediation results Per cent of the total effect
that is mediated:
4743%
Test statistic: 393 p-value: <00001
Test of mediation pathway of patient satisfaction with physicians
Barriers (predictor) adherence (outcome) 087 014 <00001
Barriers (predictor) satisfaction (mediator) 047 008 <00001
Satisfaction (mediator) adherence (outcome) 084 017 <00001
Barriers (predictor) adherence (outcome) with mediator 047 015 00022
Mediation results Per cent of the total effect
that is mediated:
4556%
Test statistic: 382 p-value: 00001
p-value at 005 level.
Std b, standardised beta coefcient; SE, standard error.
Pain management Pain education to improve pain management
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1865
professionals were expected to keep lines of communication
open regarding the outcomes of pain management interven-
tion. When patients experience care and empathy delivered in
a consistent manner, they perceive their relationship with
health care professionals as collaborative. These factors may
contribute to improving perceptions of pain management.
The factors that inuence adherence are multidimensional.
Several scholars have taken a socio-psychological perspective
in suggesting several factors that inuence patient adherence,
including the physicianpatient relationship, the communi-
cative skills of physicians, the provision of information and
social support (Cameron 1996, Ryan 1999, Lowe et al.
2000). The behaviour and attitudes displayed by health care
professionals can positively or negatively inuence the
adherence of patients (Cameron 1996). One important factor
contributing to the under-treatment of cancer pain is a lack of
adherence to the therapeutic regimen (Lin et al. 2006, Tzeng
et al. 2008, Valeberg et al. 2008). In previous studies, pain
interventions signicantly increased patients knowledge of
pain, but did not improve their adherence to taking analgesics
(Wells et al. 2003, Miaskowski et al. 2004). These results
indicate that merely enhancing patient knowledge with
regard to medication does not signicantly improve adher-
ence to taking prescribed medication. Patient adherence is
inuenced by multidimensional elements, such as socio-
psychological perspectives, which health care professionals
must consider when attempting to break down barriers that
prevent patients with cancer from taking analgesics. Such
considerations could be far more effective than merely
focusing on enhancing patient knowledge. Improving patient
satisfaction with medical care is another way to increase
adherence to prescribed analgesic use, thereby improving the
management of cancer pain.
Results of this study indicate that the implementation of
pain education noticeably increased satisfaction scores dur-
ing the second- and fourth-week follow-ups, compared with
the satisfaction scores in the pretest. Nevertheless, the scores
of the experimental group regarding satisfaction with pain
management provided by nurses signicantly improved from
507 in the second week to 518 by fourth week. In addition,
satisfaction with the pain management provided by physi-
cians increased from 552564 by the fourth week. How-
ever, this incremental improvement was insufcient to
achieve statistical signicance. This study adopted a Likert
six-point scale for the satisfaction questionnaire. Patients
satisfaction felt towards the pain management provided by
nurses was 395 during the pretest, which was between
somewhat unsatised and somewhat satised. In the
second week, the level of satisfaction signicantly increased
to display a score between satised and extremely satised.
On the other hand, patient satisfaction with their physician
was between somewhat satised and satised with a score
of 454 during the pretest, signicantly improving to a point
between satised and extremely satised by the second
week. The above results reveal that patients felt satised to
extremely satised by the second week of pain education.
However, no signicant difference in the change of satisfac-
tion felt by patients was observed during the fourth week.
Because this study only tracked patient satisfaction for four
weeks, no demonstrable change in follow-up satisfaction was
observed. This study suggests several possible explanations
for the lack of signicant changes in satisfaction between the
second and fourth weeks. First, the score regarding the
satisfaction of pain management displayed extremely right-
skewed distribution. Owing to the inuence of ceiling effect,
the margin of improvement was limited. In addition, long-
term follow-up investigation regarding the ongoing commu-
nication between cancer outpatients and physicians revealed
that dimensions such as interest/engagement or friendliness/
warmth were signicantly correlated with the patients
satisfaction felt towards physicians one week or three -
months after outpatient visits. In addition, the correlation
coefcient showed nearly no change, suggesting that there
were no signicant changes in patient satisfaction with
physicians over the short-term or the long-term (Ong et al.
2000). Other studies have also mentioned that testretest
reliability related to satisfaction with physicians was moder-
ately correlated after four weeks (r = 041) (Lam et al. 2005).
Meanwhile, the testretest coefcient regarding patient
satisfaction adopted by the consultation satisfaction ques-
tionnaire was 082 within three weeks (Baker & Whiteld
1992). These studies revealed that patient satisfaction
regarding physicians is relatively stable correlated across
time. Additionally, we must not exclude the degree to which
subsequent interaction with other staff members or patients
cloud these relationships. Because this study only collected
follow-up data for four weeks, we were unable to investigate
long-term changes with regard to satisfaction. Therefore, we
suggest a future study including long-term follow-ups to
gauge changes in the level of patient satisfaction with pain
management.
This study was limited by several factors. First, it was not a
double-blind study. Second, patient satisfaction with physi-
cians or nurses accounted for 45564773% of the mediation
effect on barriers to using analgesics and adherence to the
prescribed use of analgesics. Other factors, such as social
circumstances or medication side effects may have inuenced
these relationships, but remain unexplored. Third, the sample
size used to conduct the Sobel test used to estimate the
mediation effect was small.
P-L Chou and C-C Lin
1866 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869
This is the rst study investigating pain education as a way
to improve the long-term patient satisfaction feel towards
pain management, with an examination of the mediating
effect of patient satisfaction on pain control. This study
found that systematic, face-to-face pain education involving
multiple visits with patients and family caregivers can result
in the long-term enhancement of patient satisfaction with
pain management.
Conclusions
This study veried that patient satisfaction is a mediator with
regard to the barriers to using analgesics and analgesic
adherence. The outcome of the study not only supports the
efcacy of pain education programmes among patients,
family caregivers and medical personnel to improve patient
satisfaction but also emphasises the important role of patient
satisfaction in improving analgesic adherence in patients with
cancer. This change in behaviour could ultimately result in
improvements in the management of cancer pain.
Relevance to clinical practice
Patient satisfaction with physicians and nurses operates
partially as a mediating factor and cannot be discounted
when attempting to improve adherence to the prescribed use
of analgesics. The results of this study show that with respect
to the control of cancer pain, the enhancement of patient
satisfaction can signicantly improve patient adherence. If
physicians and nurses attend only to the delivery of knowl-
edge concerning medication, they may fail to convey to
patients the respect, empathy and active listening patients
need to feel fully satised with their physicians and nurses and
improve patient adherence to the prescribed use of analgesics.
Acknowledgements
The NSC 89-2314-B-083-069 from the National Science
Council in Taiwan funded this study. The authors thank Ms
Denise Dipert for her careful review and for editing this
manuscript.
Contributions
Study design: PLC, CCL; data collection and analysis: PLC
and manuscript preparation: PLC, CCL.
Conict of interest
None declared.
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