Knowledge and Perceived Competence of Home Care Nurses in Pain Management: A National Survey

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1 Vol. 21 No. 4 April 2001 Journal of Pain and Symptom Management 307 Original Article Knowledge and Perceived Competence of Home Care Nurses in Pain Management: A National Survey Myra Glajchen, DSW and Marilyn Bookbinder, PhD, RN Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York, USA Abstract This national mail survey assessed pain-related knowledge and subjective competence of a random sample of home care nurses across the United States. Other study objectives were to examine the relationship between nurse characteristics, knowledge and perceived competence, and assess continuing education practices. On average, the 1236 nurses scored only 56% of the items correctly, demonstrating stronger knowledge in pain assessment than treatment. Respondents reported most confidence in patient and family communication, discussion of advance directives and pain assessment. The lowest competence was reported in sophisticated pain treatment techniques. The relationship between knowledge and subjective competence was found to be highly significant. Sixty-three percent of the sample displayed a realistic assessment of their pain management knowledge, while 37% under- or overestimated what they knew. It is challenging to engage the latter group who overestimate their competence but score low on pain management knowledge. Educational strategies need to differentiate these two groups and target the audience appropriately. J Pain Symptom Manage 2001; 21: U.S. Cancer Pain Relief Committee, Key Words Pain management, home care, nurses knowledge, nurses competence Introduction Economic forces are driving rapid changes in systems for health care delivery. Among these changes are a shift in the site of treatment from hospitals to the outpatient environment, with increasing expectations for continuity of care in the community. As a result, Address reprint requests to: Myra Glajchen, DSW, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY USA. Accepted for publication: May 22, home care has become one of the fastest growing segments of health care. 1 The shift to home care has had a major impact on the treatment of chronic pain. Home care nurses now play a pivotal role in the outpatient pain management for millions of Americans. These nurses may have frequent and continuous contact with patients at home, and may provide the sole link to the health care system. Often, home care nurses assume primary responsibility for assessment and management of pain, acting as independent practitioners. They are expected to provide physical care, manage numerous pain syndromes with the latest treatment techniques, educate patients U.S. Cancer Pain Relief Committee, /01/$ see front matter Published by Elsevier, New York, New York PII S (01)

2 308 Glajchen and Bookbinder Vol. 21 No. 4 April 2001 and families in self-care, and communicate patients needs to the primary care physician. 2,3 In fact, patients experiencing cancer and nonmalignant pain make up a large part of the caseload for most home care and hospice nurses. 4 Models for education and training of home care nurses are evolving. Monitoring of knowledge and skills is essential to identify deficiencies and provide background for the development of quality programs. The need for skills in pain assessment and management can be addressed only if accurate information about current abilities is obtained. This national survey was undertaken to describe the pain-related knowledge and perceived skills of a representative group of home care nurses across the United States. Review of the Literature: Knowledge in Pain Management Oncology nurses are generally reported to have more extensive knowledge in pain assessment, opioid addiction prevalence, and equianalgesic dosing than non-cancer nurses. 5 However, knowledge deficits in pain management have been documented through surveys among nurses who work in inpatient oncology settings. 6 8 The availability of well-accepted guidelines for cancer pain management 9 11 has permitted benchmarking of knowledge and skills against those required for appropriate care. Deficiencies have been identified in numerous areas, including assessment and principles of opioid pharmacotherapy Surveys of non-oncology nurses have suggested that these deficiencies are more widespread. Lack of knowledge has been demonstrated in the following areas: equianalgesic dosing; duration of action of morphine; general principles of chronic pain management; nonpharmacologic interventions; differences between acute and chronic pain; tolerance and addiction; anatomy and physiology of pain; and opioid pharmacology Recent studies have reported on the treatment of breakthrough pain at home, 23 home infusion therapy, 24 home use of methadone treatment, 25 continuous intrathecal morphine infusion for refractory cancer pain, 26 transdermal fentanyl, 27 and patient-controlled analgesia (PCA). 28 In addition, home care nurses are expected to treat a wide range of patients ranging from the elderly to children. 32 This presupposes that home care nurses are comfortable using a range of pain interventions, from the more conservative methods (oral analgesics) to the more sophisticated technologies (patient controlled analgesia, epidural analgesia, and continuous subcutaneous infusions). Instead, surveys have reported general deficiencies in knowledge about opioid dosing, and an over-reliance on single opioids, coupled with the relative underuse of adjuvant drugs, combination analgesic therapies, and non-pharmacologic pain management strategies Confidence regarding pain management knowledge, the legitimacy of the nurse s role in treatment decision-making, and the role of advocating for patients needs with physicians are the hallmarks of home care pain management. The home care nurse is responsible for pain assessment, communication about patients needs with the primary physician, and implementation of pain management in the home environment. 38 Home care nurses can evaluate the effectiveness of the prescribed pain management regimen, and make modifications as needed. 39 Such management requires a wide repertoire of skills, including assessment of malignant and non-malignant pain, physical and psychological factors, as well as barriers to care. In addition to the home care nurses, family caregivers are central to pain management in the home. The home care nurse is expected to provide appropriate teaching of pain and symptom management, 40 high quality communication, and psychosocial support to families. 41,42 When successful, home pain management improves patients sense of autonomy and range of self-care behaviors 24 27,32 throughout the disease trajectory. But if home care pain management fails, patients may be more likely to require hospitalization and experience loss of control. 43 The impact of unrelieved pain on family members is also increasingly recognized as a source of caregiver burden. A recent study of home care nurses suggests a general lack of confidence regarding pain management knowledge, and an over-reliance on the physician for guidance in pain management. 5 This is problematic, given the expectation that the home care nurse will advocate for best current pain relief techniques 17 and pro-

3 Vol. 21 No. 4 April 2001 Home Care Nurses Knowledge and Competence in Pain 309 vide frequent reassurance to families that effective pain control can be achieved. 26 In a study of 190 elderly cancer patients in Britain, home care nurses reported high degrees of helplessness when treatment failed to alleviate pain. Study findings highlight the need for a strong focus on pain and provision of psychosocial support during training for these nurses. 29 Benefits of both didactic and experiential learning are evident in the nursing literature. Pain Resource Training Programs have been developed for nurses in an attempt to provide both didactic training as well as role models, mentors and expert consultants. 44,45 The underlying rationale for these programs is that providing nurses with new knowledge and confirming the knowledge that they possess, increases their confidence and willingness to administer or recommend specific pain medications. 22 While participating in a pain education program gives nurses more credibility, providing expert mentorship bolsters their effectiveness. 46,47 Continuing education programs in pain management have proven helpful in heightening awareness of and skill in pain management. A pilot program for home care nurses found that education was helpful in increasing knowledge and sense of competence in communication, pain and symptom management, managing death at home, and cultural issues in end-of-life care. 48 Innovative methods of obtaining such education include educational software that the nurse can review at work or at home. For example, Dalton and her colleagues have developed a three-part tutorial series on pain management that includes a self-assessment test. 49 Although the literature on the impact of education on clinical practice is equivocal, recent studies have suggested that past education in pain management had a greater impact on scores than educational level per se. 6 In addition, pain management education combined with more clinical experience and willingness to attend a pain class were associated with higher cancer pain management knowledge. 14 Others have found little relationship between nurses pain assessment and their years in practice, age, educational preparation and clinical practice area. 47 Because most previous work has focused on small, convenience samples of oncology nurses, the generalizability of their findings is limited. Few studies have looked across the broad spectrum of nurses in practice, and fewer still have focused specifically on home care nurses. To obtain generalizable data about the knowledge and skills of home care nurses, larger surveys in this population are needed. Study Objectives This study had four objectives: 1) to assess the knowledge of home care nurses in pain management; 2) to describe perceived competence related to home pain management; 3) to examine the relationship between nurse characteristics, knowledge, and perceived competence in pain management; and 4) to assess current continuing education resources and modalities. Methods Design and Data Analysis An exploratory descriptive correlational design was used to answer the study s four research questions. Descriptive analyses were performed on all study variables. Chi-square analyses or one-way analysis of variance (ANOVA) were conducted to determine differences in groups of nurses according to educational level, hours of pain management education, nursing experience, and agency setting. Correlations were performed on the primary study variables to assess relationships between variables and suggest variables for future analyses. Sample A national random sampling of home care nurses was conducted. Access to a sampling frame of 12,500 home care nurse subscribers was available through the Journal of Home Healthcare Nurses Association (JHHNA), the peer-reviewed official journal of the association. In February 1998, surveys were mailed to 4047 nurses, randomly selected by six regions, in order to ensure geographic variability and representativeness. A professional survey research laboratory was used to carry out the survey following Dillman s Total Design survey research methodology. 50 One week following the initial mailing, a postcard follow-up was sent to all subjects of the first mailing. Three weeks af-

4 310 Glajchen and Bookbinder Vol. 21 No. 4 April 2001 ter the original mailout, a second cover letter and replacement was sent to nonresponders. Completed usable surveys were initially obtained from 1229 nurses, yielding a 31% response rate. Efforts to uncover reasons behind non-returns and their possible systematic bias were made. Follow-up telephone calls were made or mailings were sent to 50 subscribers. No consistent bias was found. Reasons for nonresponse included never receiving the survey, no longer at the agency, no longer in practice, and undeliverable surveys. These subjects were excluded from the sampling frame and a final response rate was recalculated as 54%. Survey Tool A 74-item questionnaire was developed by the investigators. To establish face validity, clarity, and order of items in the booklet, 50 nurses from the original sampling frame reviewed an initial draft of the booklet. Their responses were used to revise demographic questions in the booklet. Section I contained 13 items related to sample and agency characteristics. In Section II, a seventeen-item measure of subjective competency was designed for this study. Items measured pain assessment, pain treatment, documentation, communication, physician collaboration, resource coordination, and advance directives. These areas were identified as being of critical importance to home care pain management in an extensive review of the nursing literature. 4 8,12 16,19 21,33,34,36, 44,47,48,51 Nurses were asked to rate their subjective competence on a four-point Likert scale from 1 (very skilled) to 4 (not skilled at all). Each item was scored individually, while adding scores on all 17 items created a global measure of subjective competence. Scores ranged from 4 64, with lower scores representing higher competence. Section III had 44 knowledge items, including a subset of 31 true/false items, and 13 items derived from the Wisconsin Pain Knowledge Scale, which is routinely given as part of a statewide pain initiative to train Pain Resource Nurses. 52 Items answered correctly were summed to create a Knowledge Index ranging from 0 44, with higher scores reflecting higher knowledge. Table 1 Characteristics of Nurse Sample Characteristic n % Highest Degree Obtained Diploma Associate Bachelor Masters/Doctorate Hours Formal Nursing Pain Education Years in General Nursing Years in Home Care Nursing Nurses Employed in Agency Monthly Agency Home Visits The number of responses vary slightly because of missing data. Fig. 1. Response Rate Distribution by Region.

5 Vol. 21 No. 4 April 2001 Home Care Nurses Knowledge and Competence in Pain 311 Table 2 Responses to True/False Statements in Pain Knowledge Survey (n 1236) Item T/F Answered Correctly (%) If the patient can be distracted from his pain this usually means that he does not have high pain intensity. F 92 Following an initial dose of an opioid analgesic, subsequent doses should be adjusted in accordance with the individual patient s response. T 91 Elderly patients cannot tolerate strong medications such as opioids for pain. F 84 Opioid analgesics are best ordered on a prn basis to encourage minimal dosing and reduce the risk of addiction. F 83 Parents assessment of the child s pain intensity is not reliable. F 82 Patients may sleep in spite of severe pain. T 81 Because of an underdeveloped nervous system, children under the age of two have little sensitivity to painful stimuli and limited memory of painful experiences. F 80 Patients with a history of substance abuse who require IV opioids should not be given patient-controlled analgesia. F 73 A placebo can be used to determine if pain is real. F 69 Local anesthetics may provide relief of neuropathic pain that is unresponsive to other drugs. T 69 Beyond a certain dose of non-opioid analgesics (e.g., Motrin, Tylenol) increases in dose will not increase pain relief. T 69 Comparable noxious stimuli produce the same intensity of pain in different people. F 67 The World Health Organization (WHO) analgesic ladder suggests that pain is best managed with single analgesics rather than with a combination of drugs. F 65 Beyond a certain dose of opioid (morphine, Dilaudid), increases in dose will not increase pain relief. F 64 In order to be effective, heat and cold should only be applied to the painful area. F 61 Children can reliably report the intensity of their pain. T 61 Respiratory depression rarely occurs in patients who have been receiving opioids over several months. T 57 Anticonvulsant drugs such as carbamazepine produce optimal pain relief after a single dose. F 56 Changes in vital signs are reliable indications of pain severity. T 56 Corticosteroids such as dexamethasone are standard emergency treatment of suspected malignant spinal cord compression. T 52 If opioids (narcotics) are used during the pain evaluation period, they will mask your ability to correctly diagnose the cause of pain. F 51 Treatment of neuropathic pain may be particularly responsive to anticonvulsant drugs. T 49 Treatment of neuropathic pain with amitriptyline is often compromised by sedation, urinary retention, and orthostatic hypotension. T 47 Haloperidol has prominent analgesic properties. F 44 Adjuvant analgesics such as the tricyclic antidepressants and anticonvulsants should not be used in combination with opioid analgesics or NSAIDS. F 44 Morphine 10 mg IM is approximately equal to meperidine (Demerol) 100 mg IM. T 43 Although benzodiazepines provide relief of painful muscle spasm, they are not effective analgesics. T 38 The usual duration of action of meperidine (Demerol) is four hours. F 24 Lancinating pain may be particularly responsive to therapy with anticonvulsant drugs. T 23 Non-drug interventions (such as distraction and imagery) used alone can often relieve pain. F 19 Research shows that hydroxyzine (Vistaril) is a reliable potentiator of opioid analgesia. F 13 Results Sample Characteristics, Knowledge and Subjective Competence Sample characteristics are described in Table 1. Forty-three percent of nurses were baccalaureate-prepared and another 16% had graduate degrees. Respondents were experienced nurses, averaging 9.5 years in home care nursing and more than 10 years in general nursing (79%). Education in pain management was low, with 38% reporting one hour of pain education and another 34% receiving up to five hours. Nurses reported working in agencies varying in size and patient volume, with most reporting monthly agency home visits of twenty or less. Figure 1 illustrates response rates by region and the percent of each within the total population. The sample reflected the total population regionally, with a representative geographic spread. The percentage of nurses correctly responding to the 44 knowledge items is shown in Table 2. The highest knowledge was demonstrated in the following five items related to pain assessment, reassessment and dosing: believe the patient s report of pain, even if the patient can be distracted from the pain (92% correct); the importance of re-assessment following the initial opioid dose (91% correct); ability of elderly patients to tolerate strong opioids (84% correct);

6 312 Glajchen and Bookbinder Vol. 21 No. 4 April 2001 need for continuous, rather than prn, dosing of opioids (83% correct); and the reliability of using parents assessment of their child s pain (82% correct). The lowest percent correct was obtained in seven items related to pain treatment. These were: Vistaril as an unreliable potentiator of opioid analgesia (13% correct); non-drug interventions used alone cannot alleviate pain (19% correct); lancinating pain is responsive to anticonvulsant therapy (23% correct); usual action of duration for meperidine (23% correct); benzodiazepines do not provide effective analgesia (38% correct); dose conversion of morphine to meperidine (43% correct); and benefits of adding tricyclics and anticonvulsants as adjuvants to opioids and NSAIDS (44% correct). The seventeen items of subjective competence were rated as skilled (very and somewhat) and unskilled (somewhat and not at all). Table 3 shows that nurses rated their subjective competence as highest in the areas of patient/family communication, pain assessment, and discussion of advance directives. In all but two items, most nurses ( 60%), rated their subjective competence as somewhat and very skilled. The lowest Table 3 Nurses Ratings of Subjective Competence (n 1236) Item Somewhat and Very Skilled (%) Communication with patients and families 93 Pain assessment 92 Discussion of advance directives 92 Pain reassessment following intervention 89 Documentation 89 Collaboration with the patient s physician 89 Coordination of other services/resources 89 Referral for other medical services 87 Patient and family education 86 Implementation of pharmacologic interventions 79 Development of a pain management plan of care 77 Side-effect management 75 Implementation of non-pharmacologic interventions 74 Symptom management 70 Programming and management of IV PCAs 59 Equianalgesic conversions 32 Programming and management of spinal analgesia infusion pumps 22 Subjective competence rated: 1 very skilled; 2 somewhat skilled; 3 somewhat unskilled; 4 not at all skilled. competence was reported in programming and managing intravenous patient controlled analgesia pumps, equianalgesic dose conversions, or infusion pumps for spinal analgesia. The relationship among background characteristics and both knowledge and subjective competence were examined using bivariate correlational analyses. No significant relationships were found between knowledge scores and hours of pain management education, years in nursing, or level of education. There was also no relationship between education level, years experience in nursing, or years experience in home care nursing and global subjective competence scores. The only trend toward significance was found between hours of pain management education and subjective competence, although the correlation was weak. A statistically significant association was found between pain management knowledge and subjective competence (chi-square , P ; Figure 2). For this analysis, the sample was divided into four groups: Cell A shows those nurses who rated their competence and knowledge as low; Cell B reflects those nurses who scored high in pain management knowledge but low in competence; Cell C shows those who rated their competence in pain management as high, but scored low in knowledge; and Cell D refers to those nurses who scored high in knowledge and sense of competence. Fifty-two percent (n 640) of the home care nurses, as shown in Cells A and B, rated their competence as low. Regarding pain management knowledge, the sample was more evenly divided, with 49% (n 605) of the sample scoring in the low knowledge range (Cells A and C), and 51% scoring in the high knowledge range (Cells B and D). The most congruence was associated with the 32% of the sample in Cell A (low competence and low knowledge), as well as the 31% in Cell D (high competence and high knowledge). Taken together, these findings suggest that 63% of this sample portray a realistic insight into the strengths and weaknesses in their pain management knowledge. Finally, Figure 2 reflects that 37% of the sample underestimated (20%) or overestimated (17%) their pain management knowledge. Figure 3 illustrates that the most frequent modes of continuing education were agency in-service training (92%), and participation in quality improvement studies (85%). Delivery

7 Vol. 21 No. 4 April 2001 Home Care Nurses Knowledge and Competence in Pain 313 Fig. 2. Association between subjective competence and overall knowledge. of educational materials took place most frequently through videotapes and printed materials. Three-quarters of the sample received education through competency ratings of their clinical skills and periodic home visits made by agency supervisors. Almost half of the sample reported attending half-day conferences at outside agencies and reading newsletters. Discussion The first objective of the survey was to assess the knowledge of this group of home care nurses in pain management. We found that, on average, this group of nurses scored only 56% of items correctly, demonstrating stronger knowledge in pain assessment and less knowledge in pain treatment. This is not surprising, given that previous pain education among this group of nurses was low, with 38% reporting only one hour of such education. These findings suggest that pain treatment should be stressed in continuing education programs for home care nurses. Future research should focus on improving knowledge in the specific areas identified in this study, namely, the use of adjuvant medications, nondrug interventions, equianalgesic dosing, and opioid pharmacology. The second objective was to describe the subjective competence of home care nurses in practices related to home pain management. Nurses reported the most competence in patient/family communication, discussion of advance directives, pain assessment, and reassessment. They felt least competent in the more sophisticated pain treatment techniques, such as using adjuvant drugs, equianalgesic conversions, and IV PCA or spinal infusion pumps. This lack of confidence might lead to timidity or rigidity in prescribing practices. These insights should be built into future educational programs aimed at home care nurses. The third objective was to examine the relationship between nurse characteristics, knowledge, and perceived competence in pain management. No significance was found among Fig. 3. Continuing Education, Resources and Practices.

8 314 Glajchen and Bookbinder Vol. 21 No. 4 April 2001 background characteristics, knowledge, and subjective competence. However, the relationship between pain management knowledge and subjective competence was found to be highly significant, in keeping with findings from other key studies. 6,14,48 In this sample, 63% of the nurses displayed a realistic assessment of their pain management knowledge, while 37% over- or underestimated what they knew about pain management. Those nurses who rated their competence as low might be more open to continuing education efforts, but it might be more challenging to engage those professionals who overestimate their competence but really score low on pain management knowledge. Therefore, educational strategies need to be developed which can differentiate these two groups and target the audience appropriately. To target the group that overestimates their knowledge and skill, a systematic program of education, feedback, and QI could be implemented. Seasoned clinicians can be engaged in a train the trainer model, where they are encouraged to See one, do one, teach one. This was successfully implemented at Memorial Sloan-Kettering several years ago. 13 The model is labor intensive, requiring commitment to a unit by unit approach, and including both cognitive (knowledge) and behavioral (skillbased) learning. First, nurses are provided with baseline pain education through videotapes and written materials. Second, the model should have a mechanism for feedback about the application of pain management principles through case presentations, focus groups, and group discussion. Third, formal quality improvement (QI) processes should be implemented to ensure adherence to the standards of pain assessment and reassessment through documentation. To engage the nurses who underestimate their knowledge, we would recommend a three-part skills laboratory, to build up their sense of competence and confidence. Such a series is currently underway at Beth Israel Medical Center, as a joint venture between the Department of Nursing and the Department of Pain Management and Palliative Care. In this model, fifteen nurses attend classes various units, with the goal of reaching 600 nurses in total. Skills labs cover three topics: pain standards and documentation practices (Lab 1); use of the PCA pump (Lab 2); and principles of pain management (Lab 3). Each four-hour session is comprised of didactic and practice components, with the use of algorithms for managing acute and chronic pain. Less confident nurses are given immediate feedback, one-on-one training, and a hands-on component. Change will be measured by a before after competency test, so accountability is built in, and remedial sessions will be offered as needed. The fourth and final objective was to assess current continuing education resources and practices for this group of home care nurses. Almost 60% of this sample had bachelors, masters, or higher degree in nursing; an average of 9.5 years in home care nursing; and more than 10 years in general nursing; yet the majority reported less than five hours of pain management education. This finding is supported by Ferrell s recent review of more than 50 nursing textbooks, showing little or no content in pain and palliative care. 51 Limitations Several limitations of this study may limit the generalizability of our findings. First, the relatively low response rate raises questions about non-responders, their demographics, pain knowledge, and subjective competence. Second, many home care nurses work per diem for several different agencies simultaneously, as was the case in this sample. A relationship with several agencies may have reduced the specificity of certain responses, especially those related to continuing education practices. Third, the nurses ratings of their competence was purely subjective in nature, with no validation through clinical observations or chart review. Therefore, we have no way of verifying whether the greater sense of competence among the 60% who rated themselves as somewhat and very skilled would be translated into clinical practice. Conclusions Home care nurses must treat a wide variety of patients and diagnoses, and function as autonomous, self-directed independent practitioners, yet they may lack both the knowledge and the confidence to manage pain effectively. Patients who receive high quality pain manage-

9 Vol. 21 No. 4 April 2001 Home Care Nurses Knowledge and Competence in Pain 315 ment in the hospital may experience a decline in service once they enter the home care system, where the home care nurse is the primary liaison with the formal system. Educators need to offer a wide variety of educational opportunities to promote the competence necessary to manage pain. Continuing education courses should be designed after a thorough needs assessment, so that specific learning needs can be identified and targeted during training. While this task will fall to the home care agencies themselves, collaborations with state cancer pain initiatives and pain centers of excellence can do much to bridge these gaps. Role Model, Pain Resource Nurse, observership, and faculty scholars programs and quality improvement efforts may be more effective in changing practice, given that they target both knowledge and competence simultaneously. Acknowledgments This survey was supported by an unrestricted educational grant from Knoll Pharmaceutical Company, New Jersey, USA. References 1. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Vital and Health Statistics, The National Home and Hospice Care Survey: 1994 Summary. 2. Coyle N, Cherny NI, Portenoy RK. Subcutaneous opioid infusions at home. Oncology 1994;8(4): Callahan RR. Patient care coordination of adult oncology patients in home health. Home Health Care Manage Prac 1999;11(3): Plaisance L, Price TF. A stepwise guide to cancer pain management in the home. Home Health Care Nurse 1999;17(2): Loborde EB, Texidor MS. Knowledge and attitudes toward chronic pain management among home health care nurses. Home Health Care Manage Prac 1996;9(1): Clarke EB, French B, Bilodeau ML, et al. Pain management knowledge, attitudes and clinical practice: the impact of nurses characteristics and education. J Pain Symptom Manage 1996;11(1): Johnston Taylor E, Ferrell BR, Grant M, Cheyney L. Managing cancer pain at home: the decisions and ethical conflicts of patients, family caregivers and homecare nurses. Oncology Nursing Forum 1993;20(6): McCaffery M, Ferrell BR. Opioids and pain management: what do nurses know? Nursing 1999;29(3): Max, M. American Pain Society Quality Assurance Standards for Relief of Acute Pain and Cancer Pain. (In) Bond, MR; Charlton, JE, Woolf, CJ, (eds): Proceedings of the VI World Congress on Pain. Amsterdam, The Netherlands: Elsevier, , Management of Cancer Pain. Clinical Practice Guideline No. 9. AHCPR Publication No Rockville, MD. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, March, Rockville, MD. 11. Spross, JA, McGuire, D, Schmitt, RM. Oncology nursing society position paper on cancer pain management (Part II). Oncology Nursing Forum 17: , McCaffery M, Ferrell BR. Nurses knowledge about cancer pain: a survey of five countries. J Pain Symptom Manage 1995;10(5): Bookbinder M, Coyle C, Kiss M, et al. Implementing national standards for cancer pain management: program model and evaluation. J Pain Symptom Manage 1996;12(6): Vortherms R, Ryan P, Ward S. Knowledge of, attitudes toward, and barriers to pharmacologic management of cancer pain in a statewide random sample of nurses. Research in Nursing and Health 1992; 15: Ryan P, Vortherms R, Ward S. Cancer pain: knowledge, attitudes of pharmacologic management. J Gerontological Nursing 1994;20(1): McCaffery M, Ferrell NR, O Neil-Page E, et al. Nurses knowledge of opioid analgesic drugs and psychological dependence. Cancer Nursing 1990; 12: Ark PD, Nies M. Knowledge skills of the home healthcare nurse. Home Healthcare Nurse 1996; 14(4): Ferrell BR, Johnston Taylor E, Grant M, Corbisiero RM. Pain management at home: struggle, comfort and mission. Cancer Nursing 1993;16(3): Magrum LC, Benzten C, Landmark S. Pain management in home care. Sem Oncol Nurs 1996;12(3): Coyle N. Home care for patients with cancerrelated pain. In E. Arbie (ed) Neurosurgical Treatment of Pain Caused by Malignancy. Futura Publishing Co. Inc., Mount Kisco, NY, pp Furstenberg CT, Ahles TA, Whedon MB, et al. Knowledge and attitudes of health-care providers toward cancer pain management: pharmacists in the state of new hampshire. J Pain Symptom Manage 1998;15(6): Dalton JA, Blau W, Carlson J, et al. Changing the relationship among nurses knowledge, self-re-

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