© U.S. Cancer Pain Relief Committee, 1999 0885-3924/99/$–see front matterPublished by Elsevier, New York, New York PII S0885-3924(99)00055-X

Vol. 18 No. 2 August 1999 Journal of Pain and Symptom Management 103

Original Article

Cancer Pain Assessment and Management Recommendations by Hospice Nurses

Paul A. Sloan, MD, Barbara L. Vanderveer, BSN, Janet S. Snapp, BSN,Mitzi Johnson, PhD, and David A. Sloan, MD

Departments of Anesthesiology (P.A.S., B.L.V., J.S.S.), Behavioral Science (M.J.), and Surgery (D.A.S.), University of Kentucky, Lexington, Kentucky, USA

Abstract

Pain is often the most prevalent symptom among cancer patients referred to hospice or palliative care programs. This study was designed to use performance-based testing to evaluate the skills of hospice nurses in assessing the severe pain of a cancer patient and the pain management recommendations they would present to the patient’s primary care physician. Twenty-seven hospice nurses (ranging in experience from 1 month to 10 years) were presented with the same standardized patient with cancer pain. In Part A (7 minutes), one of the investigators checked for predetermined behaviors as the nurses performed the clinical pain assessment. In Part B (7 minutes), the nurses answered questions regarding their recommendations for pain management for the patient seen in Part A. In the admission pain assessment, hospice nurses did well in assessing pain intensity (85%), pain location (70%), and pain-relieving factors (59%). However, only 48% of the nurses adequately assessed the pain onset, and only 44% adequately assessed other symptoms the patient might be experiencing. In Part B, 96% of the nurses recommended opioids, 96% recommended the oral route of administration, and 82% recommended regular dosing of the opioids. Fifty-six percent of nurses included a breakthrough medication in their analgesic recommendations. All of the hospice nurses treated the patient’s fear of addiction in an appropriate manner, and 93% of the nurses recommended increasing the patient’s opioid dosage to treat the persisting pain problem. There were no significant differences among nurses with regard to length of time as a hospice nurse or hospice certification on any of the items in either Part A or Part B. Most practicing hospice nurses were judged to be competent in the assessment and management of the severe pain of the standardized cancer patient, although some deficits were noted. Regular oral opioids were the analgesics of choice. Co-analgesics were rarely recommended.

J Pain Symptom Manage 1999;18:103–110.

© U.S. Cancer Pain Relief Committee, 1999.

Key Words

Cancer pain; assessment; hospice nursing; nurses’ knowledge

Introduction

Pain is often the most prevalent symptomamong cancer patients referred to hospice orpalliative care programs.

1

Pain control for can-cer patients remains a significant problem inhealth care, although standard analgesic andco-analgesic regimens provide adequate pain

Address reprint requests to:

Paul A. Sloan, MD, Depart-ment of Anesthesiology, University of Kentucky Hos-pital, 800 Rose Street, Lexington, KY 40536,USA.

Accepted for publication: October 13, 1998.

104 Sloan et al. Vol. 18 No. 2 August 1999

relief for most patients.

2

Several studies through-out the world have documented the adequacyof cancer pain relief when recommendationsdescribed by the World Health Organizationare followed.

3,4

Palliative Care Medicine and Hospice arecommitted to eradication of pain and othersymptoms experienced by patients with cancer.The standards of the National Hospice Organi-zation call for hospice professionals to provideeffective prescription and nonprescriptionmedications to relieve symptoms related to ter-minal illness.

5

Despite the commitment on thepart of hospice programs to eradicate symp-toms of pain among patients with terminal ill-ness, few studies exist documenting the effi-cacy of the hospice community in managingpain related to terminal illness.

6,7

Performance-based testing has been used todocument deficiencies in the assessment andmanagement of cancer pain by resident physi-cians and family physicians.

2,8

Performance-based testing with standardized patients evalu-ates the performance of a candidate by usingpredetermined objective criteria agreed uponby a consensus of pain experts. Hospice nursesexperienced and involved daily in the manage-ment of cancer pain patients would be ex-pected to be proficient in the assessment andmanagement of cancer pain. We undertook totest this hypothesis among hospice nurses. Thisstudy was designed to use performance-basedtesting to evaluate the skills of hospice nursesin assessing the severe pain of a cancer patientand the pain management recommendationsthey would present to the patient’s primarycare physician.

Methods

Twenty-seven hospice nurses (ranging in ex-perience from 1 month to 10 years) were pre-sented with the same standardized patient withcancer pain. The hospice nurses, attending areview course on hospice nursing, volunteeredto complete the 15-minute cancer pain assess-ment and management module. The nursesparticipated from several hospice agencies,and were unknown to the authors, apart fromthe senior hospice nurse who acted as a proc-tor. The nurses were told that the assessmentwas being completed to help evaluate the cur-rent level of expertise of hospice nurses in the

assessment and management of cancer painpatients. Each nurse was asked to complete adetailed pain assessment of the same simulatedstandardized cancer pain patient. The detailsof this method have been previously pub-lished.

2

Our modification of this method foruse in evaluating hospice nurses is elaborated.

Each hospice nurse was given 7 minutes tocomplete a pain history given by an actor por-traying a patient with severe pain caused by un-resectable, terminal rectal cancer. This stan-dardized patient technique was selected inorder to ensure as little variability as possibleon the part of the patient in response to historyquestions asked by each hospice nurse. Thestandardized patient is trained in the tech-nique, and practiced on several occasions withdifferent proctors to ensure reliability of all an-swers. Nurses were asked not to speak with oth-ers about the content of the exam during theremainder of their day. The simulated patientgave consistent responses to each hospice nursewhen asked about the features of the cancerpain history. All nurses were able to completethe pain interview within the 7-minute time pe-riod allotted. When specifically questioned, thestandardized patient described severe, con-stant, low back pain radiating to the right but-tock and knee that had been present for sev-eral months. The pain was described as dulland increasing in severity, now rated as 7 out of10 on a verbal pain intensity scale (0

5

no pain,10

5

worst pain possible). The pain was wors-ened by activity and partly relieved with analge-sics (codeine 15 mg and acetaminophen 325mg) taken on an “as needed” basis. The stan-dardized patient described no motor weaknessor sensory loss in the lower extremities. Thestandardized patient had no previous pain his-tory except occasional migraine, had contin-ued to work, and described no other signifi-cant symptoms. The same standardized patientwas used for all interviews.

The proctor present during the interview en-sured stability of the patients’ responses andconsistency over time. A proctor evaluated thecancer pain assessment interview and rated thehospice nurses on a variety of predetermineditems believed to be important for a detailedcancer pain assessment. The proctor was a se-nior hospice nurse and selected for her manyyears of clinical hospice work. The proctor isvisible during the interview, however does not

Vol. 18 No. 2 August 1999 Hospice Nurses’ Recommendations 105

participate in any manner. During previous re-search, and including the present study, thepresence of the proctor did not visibly disturbany of the participants. The consistency of theproctor ratings was tested and validated priorto the study. It seemed appropriate that a se-nior hospice nurse evaluate the skills of hos-pice nurses completing the pain interview. Spe-cific items such as pain onset, pain location,and pain description were scored as beingdone well, done poorly, or not done at all. Foreach item not performed, scores of 0 weregiven; scores of 1 or 2 were given if the itemwas poorly completed; and scores of 2 or 4were given if the item was done well. Uponcompletion of this interview, the proctor (a se-nior hospice nurse) made global assessmentsof the nurses’ overall performance, and thestandardized patient rated the interpersonalskills of each hospice nurse.

Immediately after the cancer pain assessment,nurses were allowed 7 minutes to answer fourshort answer questions about their recommen-dations for pain management for this standard-ized patient. Each nurse was asked to specifywhat analgesic regimen she would recommendto the attending physician, what additional rec-ommendations she would have for the manage-ment of ongoing severe cancer pain noted at afollow-up visit in spite of the suggested analge-sic therapy, and management strategies to dealwith a patient concerned with addiction to thesuggested analgesics. She was also asked to listalternative nondrug therapies that could beconsidered in the treatment of this patient. An-swers to these short essay questions were evalu-ated by using a predefined objective checklist.The predefined objective checklist was com-pleted by consensus by a panel of pain expertsat the University of Kentucky. This methodol-ogy ensures consistency of evaluation of essayanswers over time. The length of service foreach hospice nurse was recorded, as was thepresence or absence of the nurse’s certificationin hospice care.

Measures of overall performance and of per-formance on specific items on history takingand management recommendations were sum-marized by several descriptive statistics. Pear-son’s correlations were used to determinewhether differences in performance measurescould be attributable to the amount of experi-ence in hospice nursing. Repeated-measures

one-way analyses of variance (ANOVAs) wereused to identify specific items on which thehospice nurses performed best and worst. The0.05 level of confidence was used to identifysignificant differences.

Results

History

Of the 12 history questions, two hospicenurses asked more than 80% of the questions;similarly, two nurses asked only 25% of the ques-tions. The modal number of questions askedwas 67% of the questions; the mean was 54.9%,and the median was 58.3% questions asked.More than half of the hospice nurses asked morethan half of the history questions. Across all theitems, obtaining about half of the informationindicates that few hospice nurses performedvery well. Because some of the items were moreimportant than others, some items that weredone well were scored as four, whereas otherswere scored two. Thus, it was possible that eventhough many hospice nurses omitted somequestions, they asked the most important ones.However, total performance scores on the his-tory showed that, of 34 points possible, themean score was 17.6 (SD

5

5.60). This findingalso suggests that the hospice nurses’ perfor-mance was not exemplary.

Table 1 contains the percent of hospicesnurses not performing items (i.e., asking ques-tions on those items) and the percent of hos-pice nurses performing each item well in thehistory portion. Several items stand out as be-ing done well by most of the hospice nurses:asking questions about pain location, pain in-tensity, and relieving factors. Two items werelargely overlooked by hospice nurses: askingquestions about the patients’ previous pain his-tory and psychosocial history. When perfor-mance was scored as 0 for “not done,” 1 for“done poorly,” and 2 for “done well,” analysisof variance confirmed these findings, showingthat there were significant differences acrossthe performance on the 12 history items(F[11,286]

5

10.71,

P

,

0.0001). Inspection ofthe means and confidence intervals for theitems scored in this way (Table 2) shows thatthe confidence intervals for performance onpain location and intensity are well above per-formance on other items. A confidence inter-val is a range within 95% probability of cover-

106 Sloan et al. Vol. 18 No. 2 August 1999

ing the true population value. Thus, these datashow that performance on previous pain his-tory and psychosocial history are well belowperformance on the rest of the items.

Four global performance ratings (0 to 4scale; 0

5

poor; 4

5

outstanding) on the his-tory portion of the case were obtained fromproctors, and one global rating was assigned bythe standardized patient. Figure 1 shows themean ratings and confidence intervals for thefour global performance ratings. As can beseen in the figure, the proctor rated the orga-nization and overall performance similarly.The proctor also rated the effectiveness of hos-pice nurses’ interaction with the standardizedpatient similarly to the rating assigned by thestandardized patient assessing interpersonalskills of the hospice nurses. These ratings rep-resent above-average ratings and confirm thefindings from the history items: the hospicenurses performed slightly above average on thehistory portion of the standardized cancer painpatient case. Proctors also made a categoricaljudgment about the competency of each hos-pice nurse: 17 of the 27 hospice nurses (63%)were judged to be competent in their perfor-mance on the case.

To determine which of the history items dis-tinguished 17 “competent” hospice nurses fromthe 10 nurses judged “not competent,”

t

-testswere used to examine differences in groupscores on each of the items. These analysesshowed that hospice nurses judged to be com-petent performed better on two items: pain on-set [means (SD): 1.2, (0.95) versus 0.3 (0.68),

t

[25]

5

2.79,

P

,

0.01] and aggravating factors

[means: 1.4 (0.87) versus 0.3 (0.48),

t

[25]

5

4.27,

P

,

0.001]. Hospice nurses judged as com-petent were also rated as more organized [means(SD): 2.9 (0.78) versus 1.2 (0.63),

t

[25]

5

6.11,

P

,

0.0001] and as interacting more effectivelywith the standardized patient [means 3.2 (0.81)versus 1.9 (0.99),

t

[25]

5

3.44,

P

,

0.01]. Thestandardized patient also rated more highlythose hospice nurses who had been judged com-petent [means (SD): 3.1 (0.78) versus 2.0 (1.1),

t

[25]

5

2.91,

P

,

0.05]. No other differenceswere significant.

Recommendations for Pain Management

In the second part of the objective struc-tured clinical examination (OSCE), hospicenurses made pain management recommenda-tions in response to four questions. The pre-defined checklist specified elements of correctanswers, and, as in the history part of the case,these elements were scored according to theirimportance in managing the patients’ pain,with scores ranging from one to six points. Thechecklist elements and total scores for each ofthe four questions were (1) analgesic recom-mendations (10 checklist elements for a possi-ble total of 25 points); (2) fear of addiction(three elements for a possible total of 10 points);(3) nondrug analgesics (seven elements for apossible total of 10 points); and (4) ongoingsevere pain (six elements for a possible total of8 points). On average, the hospice nurses scored32.5 points (of 53 points possible) on the secondpart of the OSCE. Comparison of the meansand standard deviations for each of the fourquestions showed that hospice nurses did wellon the first question specifying their analgesic

Table 1

History Performance

a

of Hospice Nurses (

n

5

27)

History items % Not done % Done well

Introduces self 51.9 25.9Pain onset 51.9 37.0Temporal pattern of Pain 48.1 40.7Pain location 3.7 70.4Pain description 40.7 48.1Pain intensity 11.1 85.2Aggravating factors 40.7 40.7Relieving factors 25.9 59.3Previous pain history 77.8 7.4Other symptoms 55.6 37.0Medical history 37.0 22.2Psychosocial history 96.3 0.0

a

Numbers represent the percentage of hospice nurses omittingitems (Not done) or performing well (Done well).

Table 2

History Performance of Hospice Nurses (

n

5

27)

History items Mean Confidence interval

Introduces self 0.74 0.40–1.08Pain onset 0.85 0.48–1.23Temporal pattern of pain 0.93 0.55–1.31Pain location 1.74 1.45–1.89Pain description 1.07 0.70–1.45Pain intensity 1.74 1.48–2.00Aggravating factors 1.00 0.64–1.36Relieving factors 1.33 0.99–1.68Previous pain history 0.30 0.06–0.54Other symptoms 0.82 0.43–1.20Medical history 0.85 0.55–1.16Psychosocial history 0.04

2

0.04–0.11

Vol. 18 No. 2 August 1999 Hospice Nurses’ Recommendations 107

recommendations (mean

5

17.4, SD

5

4.02)and well on the second question dealing withmanaging the patient’s concern about addic-tion (mean

5

8.0, SD

5

0). However, the hospicenurses performed much more poorly in specify-ing alternative nondrug therapies (mean

5

3.0,SD

5

1.29) and in making follow-up recommen-dations (mean

5

4.1, SD

5

1.80). There was nocorrelation among any of the four pain manage-ment questions, suggesting that each questionwas testing a different skill.

Specifically, regarding the first question in PartB, almost all of the hospice nurses recommendedprescribing an opioid via an oral route (96.3%),and most recommended that it be taken regu-larly (81.5%) and specified a written dosage(77.8%). Somewhat fewer hospice nurses recom-mended that oral nonsteroidal anti-inflammatorydrugs (NSAIDs) be prescribed (66.7%), andfewer still recommended that they be taken regu-larly (37.0%) and specifying a written dose(40.7%). More than half of the hospice nurses(59.3%) recommended adding an analgesic onas “as needed” basis, but no hospice nurse recom-mended a co-analgesic.

On the second question, when queriedabout their management plan when the pa-tient refused to take the analgesics because of aconcern about addiction, all of the hospicenurses specified that they would explain to thepatient that opioid addiction was not an issue(100%) and would continue the analgesics(100%). No hospice nurse stated that she wouldinclude or continue alternative treatments.

Regarding the third question, of the alterna-tive nondrug therapies that hospice nurses con-sidered for treating the patient’s pain, those mostfrequently specified were relaxation (63.0%) andmassage or heat therapy (77.8%). Very fewnurses (7.4%) mentioned transcutaneous electri-cal nerve stimulation, and no hospice nursesmentioned radiotherapy, nerve block, or acu-puncture.

Finally, on the fourth question, most of thehospice nurses’ follow-up recommendations fortreating persistent severe pain specified increas-ing the opioid dosage (92.6%). Fewer hospicenurses recommended increasing the NSAIDdosage (22.2%), changing the opioid (40.7%),or changing the route of administration (7.4%).Fewer still added a co-analgesic (7.4%), andnone recommended adding a nondrug therapy.

Nursing Experience and Certification

The years of experience of the hospicenurses ranged from zero to more than 10 yearsof experience (mean

5

2.5; SD

5

2.82). Eightof the 27 nurses were certified registered nursesin hospice. Because one would expect years ofexperience or certification to be related to per-formance, Pearson product moment correla-tions (or

t

-tests) were used to examine the rela-tionship between experience or certificationand performance on the case. Findings showedthat neither experience nor certification was re-lated to scores on the history part or to the glo-bal ratings of performance or judgment ofcompetence in the first part of the standardized

Fig. 1. Hospice nurse ratings (95% upper confidence interval) on global history items (0 5 poor, 4 5 outstanding).

108 Sloan et al. Vol. 18 No. 2 August 1999

cancer patient case. In addition, these factorswere not related to performance on the fourquestions of the recommendations for painmanagement. In part, this finding was attrib-uted to the relatively uniform performance ofthe hospice nurses on the objective structuredclinical examination.

Discussion

Health care practitioners dedicated to theevolving specialty of palliative medicine andhospice care frequently encounter the symptomof pain among patients in the terminal phasesof their illness. Nurses caring for hospice pa-tients will probably have the most frequent con-tact with cancer pain patients and will be re-quired to complete frequent pain assessmentsto follow existing medical guidelines for thetreatment of cancer pain, or to make manage-ment recommendations to the team concern-ing cancer pain. Most participating hospicenurses were judged to be competent in the as-sessment of a standardized cancer pain patient.A global assessment rated the hospice nurses’performance on Part A as average and theirperformance on the cancer pain managementscenarios in Part B as excellent. The perfor-mance of nurses practicing in the field of hos-pice fares very well when compared with find-ings of several studies among nonhospicenurses from the United States, which demon-strate inadequate knowledge about commonlyused opioid analgesics, the use of pain-ratingscales, issues of opioid-related addiction and tol-erance, titration of opioids to analgesia or intol-erable side-effect, equianalgesic dose ratios, andknowledge of the World Health OrganizationCancer Pain Management Guidelines.

9–14

Thisfinding is in agreement with those of otherstudies, which have shown that nurses who carefor patients with cancer are more knowledge-able and have more appropriate attitudes aboutpain management than nurses whose principalfunction does not involve caring for patientswith cancer.

7,15

The performance of this groupof hospice nurses is most easily comparablefrom findings to previous research using a simi-lar structured clinical examination with a stan-dardized cancer patient. The hospice nurses’performance in both cancer pain assessmentand management recommendations exceeded

that of resident housestaff physicians

2

and fam-ily physicians.

16

A focused pain history is extremely impor-tant in the assessment of a cancer patient withpain. Hospice nurses performed well in obtain-ing specific items of pain intensity, pain-reliev-ing factors, and pain location. The frequent useof pain intensity assessment is encouraginggiven a recent study demonstrating that, in gen-eral, documentation of the use of pain intensityrating tools was lacking in most hospital chartsin a large, university-affiliated, teaching hospi-tal in an urban area of the Northeast.

17

Hospicenurses in our study, however, performed poorlyin the pain history regarding items such as painonset, previous pain history, questions regard-ing other symptoms, and pertinent psychoso-cial history. This finding demonstrates the needfor continuing education in all aspects of a fo-cused pain history among nurses caring for hos-pice patients. It is important to obtain a historyof other symptoms from a patient with cancerpain, because this information may affect theroute of administration chosen for analgesicadministration. It is unclear why hospice nursesperformed poorly in obtaining a psychosocialhistory. The psychosocial assessment of hospicepatients is clearly important in hospice philoso-phy.

18

One explanation is that the hospicenurses would assume that a detailed psychoso-cial history would have been taken as part of aroutine new patient admission and evaluation;therefore, they did not ask additional questionsduring the focused pain history.

The overall evaluation of the hospice nurses’pain assessment by faculty members was slightlyabove average. This rating was similar to theoverall patient evaluation of the nurse candi-date. The use of simulated and actual cancerpatients in the assessment and education ofhealth care professionals is exciting. Researchamong surgical housestaff and medical studentshas suggested a role for patient assessment ofthe performance of health care professionals.

19

Additional research is clearly indicated for fur-ther testing and developing this novel assess-ment and educational strategy.

The four short questions about the manage-ment of the patient with cancer pain tested theability of the hospice nurse to suggest appro-priate analgesics for severe pain, to suggesttreatment of ongoing severe pain, and to dis-cuss opioid and addiction issues, along with al-

Vol. 18 No. 2 August 1999 Hospice Nurses’ Recommendations 109

ternative nonmedication therapies for cancerpain management. Each question apparentlytested a different skill, because there was nocorrelation among the four pain managementquestions. The hospice nurses performed ex-tremely well on the analgesic recommenda-tions for cancer pain management. Almost allnurses recommended the regular use of oralopioids in the treatment of this standardizedpatient. The use of oral opioids is a hallmarkand a basic requisite for the treatment of mostpatients with cancer pain. Most hospice nursestested apparently understand and embrace thiscancer pain management strategy. Two-thirdsof hospice nurses also recommended the useof oral NSAIDs in addition to the oral opioidsrecommended. The use of “as needed” opioidanalgesics in addition to regular maintenancedosing has been recommended as standardtreatment for patients with cancer pain.

20

Morethan half of the tested hospice nurses recom-mended adding such an opioid in addition toregular scheduled dosing for this standardizedpatient. These results are encouraging; how-ever, additional education is needed to ensurethat all nurses are aware of the importance of“as needed” opioid analgesics added to mainte-nance opioid therapy. Only 21% of family phy-sicians previously tested prescribed an opioidfor breakthrough pain.

16

No hospice nurse recommended a co-anal-gesic for the initial management of severe can-cer pain. Although the use of co-analgesics isnot mandatory in the initial management ofcancer pain, the fact that no nurse recom-mended their use suggests that additional edu-cation about the use of co-analgesics in themanagement of cancer pain is indicated. Phar-macists can play an important role on the hos-pice team in the treatment of terminally ill pa-tients by reminding health care professionalsof the use of adjuvant drugs in the manage-ment of cancer pain.

21

The fear of patient addiction to opioids usedfor pain control has been cited as a knowledgedeficit among nurses and as a barrier to ade-quate cancer pain management.

22

Previous sur-veys have suggested that nurse education atboth the undergraduate and the continuingeducation levels needs to be changed to in-clude explicit information about the likeli-hood of opioid addiction resulting from opioidadministration for pain relief.

10

It is encourag-

ing that all hospice nurses continued to pro-vide appropriate opioid analgesics for the pa-tient worried about opioid addiction and thatthey gave the patient an explanation of the ir-relevance of the opioid addiction issue. Incomparison with an earlier study, our studyfound a higher percentage of hospice nurseswith the correct understanding of the role ofaddiction in cancer patients.

7

Although analgesic medication remains theprincipal means of treatment of cancer pain,nondrug therapies have been recommended inthe overall management of pain and the facilita-tion of patient comfort.

23

Most hospice nursestested were aware of nondrug analgesic therapiessuch as relaxation, massage, and heat therapy.Further education appears to be necessary re-garding the use of radiotherapy, nerve blocks,transcutaneous nerve stimulation, and acupunc-ture in the multimodal treatment of cancer pain.

The treatment of severe cancer pain that per-sisted despite the use of regular opioid analge-sics was handled well by most of hospice nurses,who followed the recommended treatment ofincreasing the opioid dose. Because hospicenurses have a good understanding of the use ofopioid analgesics and titration to analgesia orintolerable side effects, they are in a good posi-tion to make management recommendations tothe primary care physician. Only a very fewadded a co-analgesic to the treatment regimen;this finding highlights the need for furtherteaching regarding the use of co-analgesics inthe management of cancer pain.

Although the mean years of experience of thehospice nurses exceeded 2 years, some nurseshad just completed basic training and were justentering their clinical hospice practice. Ourfindings did not show any difference in perfor-mance on the basis of years of experience orcertification in hospice nursing. One explana-tion is that the preparation of hospice nursesbefore initiation of their practice was excellent;thus, even inexperienced hospice nurses have agood understanding of cancer pain assessmentand management. Alternatively, the short timeof testing may be inadequate to distinguish per-formance differences among hospice nurses ofvarying experience and education. Additionaland more detailed performance examinationsare necessary to test this hypothesis and to delin-eate any performance differences that may infact be present in the more experienced nurses.

110 Sloan et al. Vol. 18 No. 2 August 1999

The use of the standardized patient exami-nation was helpful in determining the compe-tency of nurses practicing in hospice regardingtheir assessment of and management plan fora patient with cancer pain. The evaluation ofthe patient interview and management planfor a patient with cancer pain was developed byconsensus from an interdisciplinary panel ofpain experts at the University of Kentucky. Itwould be helpful in future research to applythis evaluation tool in other centers, includingthe testing of senior clinicians knowledgeablein the area of pain management. Future stud-ies could also use this method with nurses notespecially involved with oncology patients totest the skills of nonhospice nurses in the man-agement of cancer pain. In addition, this typeof objective testing could be used as a tool forindividual hospices in their quality assuranceprograms. Furthermore, by giving feedback onperformance to nurses immediately after thestandardized patient interaction, this form oftesting could be used as an instructional pro-gram for hospice personnel.

24

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