Digital Repository Doctoral Projects Fall 2022 Sustainable Use of Nonpharmacological Pain Techniques in Pediatric Oncology Amanda Sims Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Sims, A. (2022) Sustainable use of nonpharmacological pain techniques in pediatric oncology Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 1 Sustainable Use of Nonpharmacological Pain Techniques in Pediatric Oncology by Amanda Sims A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 _______________________________ ______________________________ Student Name, Credentials (Electronic Signature) Date C _________________________ _____________________________ DNP Project Faculty (Electronic Signature) Date _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: The program director must submit this form and paper. Cynthia Beynon, PhD, RN, CNE December 16, 2022 December 16, 2022 Amanda Sims, DNP-FNP, BSN, RN December 16, 2022 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 2 Table of Contents Abstract ........................................................................................................................................... 4 Sustainable Use of Nonpharmacological Pain Techniques in Pediatric Oncology ........................ 6 Background and Problem Statement ........................................................................................... 6 Diversity of Population and Project Site ..................................................................................... 7 Significance for Practice Reflective of Role-Specific Leadership ............................................. 8 Literature Review............................................................................................................................ 8 Search Methods ........................................................................................................................... 9 Oncologic Pain Management ...................................................................................................... 9 Nonpharmacological Techniques.............................................................................................. 10 Massage................................................................................................................................. 11 Mind-Body Interventions ...................................................................................................... 11 Barriers to Utilization of Nonpharmacological Techniques ................................................. 13 Solutions ................................................................................................................................... 14 Care Provider Education ....................................................................................................... 14 Patient and Family Education ............................................................................................... 15 Discussion ................................................................................................................................. 16 Implications for Practice ........................................................................................................... 17 Framework .................................................................................................................................... 18 Project Plan ................................................................................................................................... 19 Project Design ........................................................................................................................... 19 Needs Assessment ..................................................................................................................... 19 Cost Analysis and Sustainability .............................................................................................. 20 Project Outcomes ...................................................................................................................... 21 Consent Procedures and Ethical Considerations....................................................................... 21 Measuring Intervention Effectiveness ...................................................................................... 22 Project Implementation ................................................................................................................. 22 Project Intervention ................................................................................................................... 22 Project Timeline ........................................................................................................................ 23 Project Evaluation ......................................................................................................................... 24 Data Maintenance/Security ....................................................................................................... 24 Data Collection and Analysis.................................................................................................... 24 Quantitative Results .............................................................................................................. 25 Qualitative Results ................................................................................................................ 26 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 3 Findings..................................................................................................................................... 28 Strengths ............................................................................................................................... 28 Weaknesses ........................................................................................................................... 29 Discussion ..................................................................................................................................... 29 Translation of Evidence into Practice ....................................................................................... 29 Implications For Practice and Future Scholarship .................................................................... 30 Sustainability......................................................................................................................... 30 Dissemination ....................................................................................................................... 31 Conclusion ................................................................................................................................ 31 References ..................................................................................................................................... 33 Appendix A ................................................................................................................................... 40 Appendix B ................................................................................................................................... 41 Appendix C ................................................................................................................................... 43 Appendix D ................................................................................................................................... 44 Appendix E ................................................................................................................................... 48 Appendix F.................................................................................................................................... 51 Appendix G ................................................................................................................................... 59 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 4 Abstract Nonpharmacological pain techniques effectively relieve pain in the pediatric oncology population. Despite multiple systematic reviews and studies supporting their usage, these techniques are underutilized, contributing to the overprescription of narcotics and unrelieved pain in this population (Kwekkeboom et al., 2012; Radossi et al., 2018; Thrane, 2013). Improving pediatric oncology nurses’ knowledge of available techniques may increase nonpharmacological pain method exposure and usage. Purpose: This DNP project aims to improve nurses’ knowledge of nonpharmacological pain techniques and increase utilization. Methodology: Nurses working in the pediatric oncology unit at Primary Children’s Hospital were given a pre-survey to assess their knowledge regarding and use of nonpharmacological pain management interventions. The 54 registered nurses attended an educational in-service. They were provided with handouts regarding the efficacy of nonpharmacological pain management with a specific focus on guided imagery and hand/foot massage. Adjustments were made to nursing report sheets and patient teaching outlines to increase the visibility and usage of these nonpharmacological pain interventions. Nurses were asked to complete a post-survey to assess changes in knowledge and utilization. Results: Fifty-four nurses received the in-service and 26 completed the post-class evaluation survey. Seventy-three percent of the surveyed participants found the learning intervention to be beneficial. The post-class evaluation results (N=15) showed increased usage of thought-replacement and breathing techniques, essential oils, progressive muscle relaxation, massage therapy, and heat/cold therapy. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 5 Implications for Practice: Increasing access to evidence-based, effective pain relief methods may improve pediatric oncology patients’ quality of life. Educating nurses about available techniques at their facilities increases their knowledge and utilization of these techniques with patients. Keywords: nonpharmacological pain techniques, nurse education, pain, pediatric oncology SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 6 Sustainable Use of Nonpharmacological Pain Techniques in Pediatric Oncology Pain prevalence among cancer patients is estimated to be 64% in patients with advanced metastatic disease, 59% in patients receiving anticancer therapy, and 33% in patients who have completed cancer treatment (Beuken-Everdingen et al., 2007). The pediatric population runs a close parallel, with 60% of cancer survivors experiencing long-term side effects from treatment (CureSearch for Children’s Cancer, 2020). Jiang et al. (2019) found that chronic pain is the most common, persisting symptom in cancer survivors in the United States. Recent estimates show that chronic pain affects up to 5.39 million cancer survivors across the nation and correlates with higher health care costs, decreased compliance with treatment, and poor quality of life. In addition, unmanaged pain increases the incidence of depression and anxiety (Bair et al., 2003). Linder & Hooke’s (2019) report on the pediatric population supported these findings, where pediatric oncology patients described their pain as becoming part of who they are. Evidence supports nonpharmacological pain techniques in the pediatric oncology population (Jacob, 2014; Thrane, 2013). Deng et al. (2009) recommend mind-body practices such as cognitive-behavioral therapy, breathing techniques, and distraction for concurrent use with traditional cancer treatments. Researchers also recommend therapeutic touch and massage (Deng et al., 2009). This project aims to provide evidence to support nonpharmacological pain techniques and create sustainable use in the pediatric oncology patient population, promoting maximum pain relief and quality of life. Background and Problem Statement Pain is an unavoidable, dynamic, and complex aspect of oncology treatment. Pain can be acute and chronic, and types of pain may be experienced separately or concurrently (Jacob, 2014). Linder & Hooke (2019) report that pediatric cancer patients frequently rate general, SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 7 headache, and procedural pain levels as moderate to severe. Patients experience acute pain after invasive surgical procedures and as a side effect of chemotherapy and radiation. Chronic pain, which typically lasts longer than six months, may be caused by the progression of disease and infection (Jacob, 2014). Untreated pain leads to prolonged stress responses in the body, resulting in increased infection susceptibility, decreased gastrointestinal function, metabolic changes, and increased potential to develop long-term, chronic pain syndromes (Jacob, 2014). Singh & Chaturvedi (2015) found that some patients fear pain more than death. Pain is a subjective experience that varies in the presentation, indicating a need for variety and flexibility in management techniques to ensure adequate pain control (Hackett et al., 2016). According to a hospital-wide survey, nonpharmacological pain techniques continue to be vastly underutilized at Primary Children’s Hospital (PCH) in Salt Lake City, Utah (S. Stokes, personal communication, June 26, 2021). Many nurses are unaware of what nonpharmacological pain management methods are available and accepted, and they lack confidence and knowledge in how to use them. This knowledge gap contributes to inadequate pain control and over-prescription of narcotic analgesics. Providing education and discussion for patients and nurses regarding available techniques may improve nonpharmacological pain technique utilization and patients’ quality of life. Diversity of Population and Project Site The Cancer/Transplant unit at PCH is an inpatient unit with 32 full-size rooms and one treatment room for short, transfusion-related stays. Eighty-six registered nurses, 10 physicians, and 6 advanced practice providers care for pediatric hematology, oncology, and solid organ transplant patients between 0 and 30 years of age. Patients receive chemotherapy, biotherapies, bone marrow, liver, and kidney transplants, and supportive care for solid tumors, blood cancers, SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 8 hematological disorders, and various genetic abnormalities. The length of stay for each patient varies from a day to months when their illness becomes particularly severe. Admitted patients frequently receive moderate to intense pain treatment that is too difficult to manage at home (K. McCurdy personal communication, April 15, 2021). Significance for Practice Reflective of Role-Specific Leadership This project relates explicitly to Essential II from the Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing, 2006). Organizational and systems leadership for quality improvement and systems thinking is crucial for advancing patient and healthcare outcomes. Sustainable changes to the culture of a hospital unit are challenging to create. This project will focus on quality improvement by teaching evidence-based pain relief techniques to nurses and creating sustainability by engaging stakeholders, evaluating outcomes, and changing course when necessary. The indirect population, pediatric oncology patients and their families, may benefit most from the implementation of this project. Literature Review This literature review aims to provide evidence to support nonpharmacological pain techniques in the pediatric population and identify barriers to their utilization. The following themes were identified: (a) there is a need for additional research regarding nonpharmacological pain techniques in the pediatric population, (b) evidence supports the use of guided imagery, cognitive behavioral therapy, and massage therapy as effective pain management techniques; and c) many barriers contribute to the underutilization of nonpharmacological techniques. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 9 Search Methods This project used search terms including “guided imagery,” “cognitive behavioral therapy,” “massage therapy,” “oncology,” “pediatric,” “children,” “cancer,” “nonpharmacologic,” “therapeutic touch,” “child life specialist,” “pain management,” “complementary therapies,” and “pain". Searched databases included CINAHL, EBSCO, and Google Scholar. Because research on this topic is limited, and to provide the most updated information, articles that were not peer-reviewed or more than 20 years old were excluded. Oncologic Pain Management Effective pain management in the pediatric population is crucial for quality care (Arnon et al., 2018; Vagnoli et al., 2019). Hainsworth & Jastrowski Mano (2021) identified ways acute pain experiences have lasting, life-long effects on children. These include altered future responses to pain and chronic pain syndrome development. They also found that untreated pain profoundly impacts physical, social, cognitive, and emotional functioning (Hainsworth & Jastrowski Mano, 2021). Currently, oncologic pain management centers around pharmacological interventions, including opioids and acetaminophen (Jacob, 2014). Opioids are the first-line treatment for moderate to severe cancer pain in children (Jacob, 2014). However, opioids require titration with extended use, and they cannot eliminate all pain (Caraceni et al., 2012). Renal and hepatotoxicity from cancer treatment can limit the number of pharmacological interventions patients can be given, indicating a need to investigate alternative therapies that do not contribute to toxicities. Finally, opioids have many side effects, including respiratory depression and constipation, and require a prescription, restricting patient access to adequate pain relief (Jacob, 2014). SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 10 Nonpharmacological pain management techniques are readily available without a prescription, can be used alone or in conjunction with medication, and are relatively easy to learn and utilize (Deng et al., 2009). Using alternative pain techniques does not negate the need for opioids or sedation but promotes optimal quality of life with little to no side effects (Arnon et al., 2018). Many of these therapies have the added benefit of improving fatigue and anxiety symptoms, even when used strictly for pain (Kwekkeboom et al., 2012). Nonpharmacologic therapies have been shown to improve patients’ treatment experiences due to a perceived increase in control over their pain and symptom management (Arnon et al., 2018; Vagnoli et al., 2019). Pediatric patients and their families experienced enhanced recovery and long-term emotional and behavioral benefits from relaxation-guided imagery pain management techniques (Vagnoli et al., 2019). Nonpharmacological Techniques Nonpharmacological pain modalities include environmental modification, mind-body therapies, massage, touch techniques, dance, music, and pet and art therapies (Deng et al., 2009; Radossi et al., 2018; Thrane, 2013). In 2013, Thrane published a systematic review discussing the effectiveness of integrative modalities in relieving pain and anxiety in the pediatric oncology population. The twelve studies included provided significant evidence that alternative methods have a positive effect on pain and stress. Nonpharmacological techniques are noninvasive and give the patient greater control over their care. Most reviewed modalities are easy to learn and within a nurse’s scope of practice to provide and teach, benefitting patients and their caregivers at home. In 2009, Deng et al. published guidelines recommending evidence-based nonpharmacological techniques for cancer pain management in conjunction with traditional SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 11 treatments. Specifically, mind-body modalities and massage therapy provide effective pain and anxiety relief (Deng et al., 2009). This review will focus on therapeutic massage and mind-body interventions, including cognitive-behavioral therapy and guided imagery. Massage Massage therapy requires physical manipulation of the body’s soft tissues using traction and pressure. Patients report decreased anxiety and stress levels and improved pain, nausea, and fatigue after treatment (Singh & Chaturvedi, 2015). In 2013, Thrane found that pediatric oncology patients experienced positive improvements physically, mentally, and emotionally after a therapeutic massage. These positive results lasted from a few hours to the rest of the day. Additionally, massage and healing touch help decrease anxiety and stress and improve depression (Greenlee et al., 2014). A systematic review by Radossi et al. (2017) reported a reduction in pain and anxiety in pediatric oncology patients using massage therapy in outpatient and inpatient settings. A recent pilot study in Canada found that therapeutic massage decreased acute pain and stress in pediatric cancer patients receiving palliative care (Genik et al., 2020). However, Deng et al. (2009) recommend avoiding deep massage over implanted medical devices, enlarged lymph nodes, recent surgical sites, and cancerous lesions. Mind-Body Interventions Guided Imagery. Self-guided imagery focuses on pleasant images or scenes that distract from unpleasant sensations. Commonly used images include nature scenes where patients are encouraged to focus on specific details like the warmth of the sun or the smell of a cool breeze. Singh & Chaturvedi (2015) found imagery to be the most promising integrative therapy for cancer pain relief but noted that it requires adequate cognitive function and practice to become SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 12 proficient. In 2003, Kwekkeboom et al. conducted a pilot study that found guided imagery significantly decreased clinical pain symptoms in 90% of patients with various types of cancer. However, the researchers stressed the need for nurses to accurately assess whether patients can create and hold vivid mental images in their minds to ensure treatment effectiveness. Limited research regarding guided imagery for the pediatric population currently exists. However, Dobson & Byrne’s (2014) original study showed that pediatric patients who received adequate training for guided imagery techniques experienced improved pain management and effectively utilized these methods. Cognitive-Behavioral Therapy. Singh & Chaturvedi (2015) found that cognitive-behavioral therapy is the most frequently used alternative therapy for pain. They outlined three steps for treatment implementation. The first step involves educating the patient about pain and how it affects perceptions and responses. Second, the patient learns more coping skills, such as progressive relaxation or guided imagery. Finally, the patient is encouraged to practice and become proficient at these new skills. Deng et al. (2009) suggest patients experience less pain and anxiety when using these techniques, and there is little risk involved. Kwekkeboom et al. (2012) showed that cognitive-behavioral therapy manages multiple symptoms associated with advanced disease, including stress and fatigue. Windich-Biermeier et al. (2007) found that cognitive-behavioral interventions significantly reduce pain, fear, and anxiety in pediatric oncology patients during venous port access and intravenous catheter placement. Cognitive-behavioral therapy does not require a prescription, and there is no waiting period for the administration of pain relief. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 13 Barriers to Utilization of Nonpharmacological Techniques Evidence supports using these techniques, yet underutilization remains a problem in pediatric oncology (Kwekkeboom et al., 2012; Radossi et al., 2018; Thrane, 2013). Many factors contribute to this problem. Nurses cite a lack of time to learn and teach nonpharmacological techniques, while providers express concerns about efficacy (Arnon et al., 2018). Patients and families require adequate education and direction from reputable sources to aid in making decisions that benefit them most (Deng et al., 2009). Lack of Time and Value. Some caregivers, especially overworked nurses, express concerns about the time it would take to learn, implement or teach nonpharmacological techniques to their patients (Arnon et al., 2018). Despite contrary evidence, many caregivers express concerns about integrative therapies’ efficacy and believe there is insufficient literature to support their use in pain management. Arnon et al. (2018) found that caregivers must be shown the worth and efficacy of complementary and alternative therapies before they feel confident in providing them as patient options. After participating in a training program, nurses’ perceptions changed regarding their role in using integrative modalities for patient pain control. They believed alternative therapies improved patients' quality of life and saw positive results in their own families as they brought these techniques into their homes and communities. Thrane (2013) compiled multiple reputable studies that prove their effectiveness on acute and chronic pain and cluster symptoms such as anxiety and sleep disturbance. Evidence-Based Recommendations. According to Deng et al. (2009), many patients seek alternative therapies to avoid medication side effects and overuse pain medications but find disreputable sources that do not provide evidence-based recommendations. These may negatively interfere with their cancer treatment. Jacob (2014) discussed that pediatric cancer SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 14 families seek nonpharmacological pain treatments to decrease medication usage and side effects. Lee et al. (2020) found that parents with a knowledge of complementary pain techniques used fewer opioids in their child’s postoperative pain management and reported higher levels of education regarding pain management strategies. Guidelines developed by the Executive Committee for the Society of Integrative Oncology emphasize that providers must open-mindedly discuss complementary therapies with all patients and their families, regardless of where they are in their treatment trajectory. A significant barrier to implementing safe and effective alternative therapies is providers not asking about patients’ current or prior use of these therapies. Viable options with proven efficacy should be discussed and revisited with patients and families often. Caregivers should be familiar with available modalities, including ineffective ones, to better guide patient-centered cares (Deng et al., 2009). Solutions Education on evidence-based and available nonpharmacological treatment modalities for nurses, providers, administrators, patients, and families can provide a lasting solution to chronic and acute pain that traditional methods do not manage effectively. Klein & Guethlin (2018) identified that caregivers' lack of knowledge is one of the most extensive barriers to discussing alternative therapies with cancer patients and their families. Additionally, Klein & Guethlin (2018) indicate that training on these methods for nurses and providers can improve their utilization. Care Provider Education Providers require adequate knowledge regarding effective, evidence-based therapies to guide patients to those that will safely help them the most (Deng et al., 2009). Gustafsson & SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 15 Borglin (2013) illustrate how a short learning intervention can positively impact nursing knowledge regarding pain assessment and management in oncology patients. The time needed to learn the techniques was minimal and had lasting benefits for nurses and patients. In 2018, Arnon et al. conducted a qualitative study assessing the knowledge level of nurses regarding alternative therapies. They found that experienced nurses were less familiar with integrative techniques than new graduate nurses who had received training in their nursing programs. The researchers implemented a program to improve nursing knowledge of alternative methods, including appropriate use, and gave them resources to use in their clinical settings. Attitudes regarding these therapies greatly improved, and many nurses wanted to pursue a more in-depth education on the subject. The nurses also reported increased comfort when suggesting integrative therapies to patients and knew when a referral to a specialist was warranted. Kodama & Fukahori (2017) stress the importance of the nurse manager’s role in sustaining positive change. They discussed attributes associated with effective change processes, including having micro and macro-system perspectives, empathy, proactivity, and respect for one’s belief system. Nurse managers are vital stakeholders for change in a hospital unit. Therefore, they must be invested in the outcome to support the change process (Buckwalter et al., 2017). Patient and Family Education Parents are integral to treating cancer pain in children (Jacob, 2014). They know their child’s behavioral cues and can alert the staff when an intervention is necessary (Chng et al., 2015). In 2015, Chng et al. conducted a descriptive correlational study regarding parental knowledge, attitudes, and satisfaction about their child’s postoperative pain and pain management. The researchers found that the higher the parents’ knowledge scores, the more SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 16 positively they felt toward postoperative pain management. Higher knowledge scores correlated with greater use of pharmacological and nonpharmacological pain methods. In addition, they found that more positive attitudes toward pain management were associated with higher satisfaction levels regarding their child’s care. Alternative therapies can easily be taught to parents by nurses to use during their child’s pain episodes. Including parents in their child’s pain management plan helps them feel more control and gives them a sense of satisfaction in knowing they are involved in efforts to alleviate their child’s pain (Chng et al., 2015). Lee et al. (2020) determined that parental education on pain management strategies, terminology, and pediatric patient pain cues resulted in effective and appropriate pain management in pediatric patients post-tonsillectomy. Patients reported better pain control without overtreatment. Discussion Evidence supports nonpharmacological techniques for pain management in the pediatric oncology population. Pain is subjective and experienced differently in each patient (Hackett et al., 2016). It is difficult to quantify, and variation in self-reporting among pediatric patients leads to undertreatment of pain in this population (Hall-Million & Howard, 2015). Undertreated pediatric pain leads to lasting, devastating consequences contributing to decreased quality of life (Hainsworth & Jastrowski Mano, 2021). Guided imagery, cognitive behavioral therapy, and massage have proven efficacy for pain management in pediatric patients (Kwekkeboom et al., 2012; Thrane, 2013). Massage therapy requires a licensed professional with experience treating cancer patients making it more difficult to access and utilize in an outpatient setting (Deng et al., 2009). PCH has a licensed massage therapist available for appointments during business hours after a provider referral. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 17 Alternatively, mind-body interventions provide acute pain relief with or without provider or nurse involvement after assessing the patient’s ability and establishing the proper technique (Kwekkeboom et al., 2003; Dobson & Byrne, 2014). Nurses, providers, patients, and families are more likely to use nonpharmacological pain techniques if taught how to use them and shown evidence of their efficacy (Arnon et al., 2018). Parents are essential components in pediatric pain management and require education in management strategies, terminology, and pediatric pain cues (Jacob, 2014; Lee et al., 2020). Regarding the sustainability of nonpharmacological pain technique usage, it is essential to involve all stakeholders, especially unit managers, in the change process to effect unit-wide change (Buckwalter et al., 2017). Implications for Practice Because pain is a common symptom in the pediatric oncology population, caregivers must manage symptoms that decrease quality of life. At PCH, specialists in acupuncture, massage therapy, and aromatherapy teach patients and families techniques and give them tools to help them cope with the pain, anxiety, and nausea associated with their treatment. Providers submit a referral for these services, requiring no additional time from the nursing staff (J. Osteyee, personal communication, March 22, 2021). During business hours, child life specialists can readily teach coping and pain management techniques to families and patients in age-appropriate ways (K. McCurdy, personal communication, June 25, 2021). Bandstra et al. (2008) found that child life specialists teach nonpharmacological pain techniques and are receptive to receiving additional training in this area. Public applications such as YouTube are available on every smartphone and have many mind-body modality sessions for free. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 18 A hospital-wide survey conducted in April 2021 at PCH showed that nurses and providers in the immunocompromised and pediatric intensive care units were least likely to use nonpharmacological pain methods (S. Stokes, personal communication, June 26, 2021). Quality of care in the pediatric population is directly related to effective pain management. Nonpharmacological pain techniques provide evidence-based pain management in pediatric oncology patients after effective training programs (Arnon et al., 2018). Traditional pain treatments have dose-limiting toxicities and adverse effects that decrease quality of life (Jacob, 2014). Green et al. (2011) determined that unrelieved pain correlates to higher depression incidence, reduced function, and more cancer symptoms. Patients and their families report a sense of control and less frustration when utilizing guided imagery and cognitive behavior techniques, contributing to improved quality of life (Vagnoli et al., 2019). Framework This project follows the IOWA model and framework. Problem and knowledge-based triggers lie in each of the six steps. The first step is identifying the purpose of the change and stating a PICO (population, intervention, comparison, outcome) question to provide focus. This project aims to create sustainability among pediatric oncology nurses regarding nonpharmacologic pain techniques in pediatric oncology patients. The first step includes identifying if the topic is a priority to the organization. The second step requires forming an invested and passionate team about the change process. Team members may change throughout the implementation process and as adjustments are needed (Buckwalter et al., 2017). The third step involves assembling, appraising, and synthesizing evidence. It is crucial to determine if sufficient evidence supports the practice change. The fourth step incorporates designing the practice change with patients and families in mind while addressing resources, SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 19 constraints, and approvals. Pilot data helps the change team determine if the change will be practical and relevant to the implementation area. Integration and sustaining the practice change is the fifth step. This step requires engaging vital stakeholders and hardwiring the transition into the current system. Finally, results of the change process require dissemination with the goal of helping other systems make similar changes (Buckwalter et al., 2017). Project Plan Project Design Quality improvement is the primary focus of this project. The current Cancer/Transplant unit process provides limited visibility of nonpharmacological pain techniques among nurses or pediatric oncology patients. Newly diagnosed patients and nurses lack information about the nonpharmacological options available at the hospital. This project aims to promote and expand the usage of nonpharmacological pain techniques available at Primary Children’s Hospital to improve and supplement pain management through a short educational intervention provided to the nurses in the Cancer/Transplant Unit. Needs Assessment From 2013 to 2017, the Utah Department of Health (2020) reported 975 new pediatric cancer diagnoses in patients ages 0-19. The American Cancer Society (2018) shows the national incidence rate for all pediatric cancers, over five years, in ages 0-19 years, is 18.9 per 100,000. Schulte et al. (2021) recently found that 4.3% to 75% of pediatric cancer survivors suffer from chronic pain due to their treatment. Jody Osteyee DNP, APRN, CPNP, a pediatric clinical nurse specialist and aromatherapist at Primary Children’s Hospital, believes one of the most significant needs in the hospital is the sustainable education of staff members regarding nonpharmacologic SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 20 pain and relaxation techniques for managing pain in the inpatient and home setting (personal communication, February 1, 2021). Parental social determinants of health significantly impact pediatric patients. Many of these families cannot afford their treatment due to the rising costs of healthcare coupled with a lack of financial support. Inpatient hospital stays require numerous healthcare resources, which increases the money needed to pay for treatment. Pediatric oncology patients only receive 4 percent of government funding for cancer research (ALSF, 2021). Every pediatric cancer requires a different treatment regimen to achieve remission (Jacob, 2014). Most current treatment options are from research used to treat adult cancers in the 1960s, representing a significant health inequity for this population (NPCF, 2021). These patients do not have a voice to advocate for themselves. They are not eligible to vote; therefore, they cannot petition the government for more funding to find pediatric-focused treatment options. Nonpharmacological pain techniques are cost-effective in improving pain control and quality of life in pediatric oncology patients, which benefits all stakeholders. These include pediatric oncology patients, family members, Cancer/Transplant unit staff, and PCH. Pediatric oncology nurses are the only participants included in the learning intervention. Cost Analysis and Sustainability Most of the cost of this project involves printing supplies with the minimal paid time required from support staff. Unit charge nurses must provide educational updates to their team and attend leadership meetings where the initial training took place. Training for the nurses occurred on regularly scheduled shifts. Because of this, the learning intervention incurred no additional cost to the unit. The costs associated with printing supplies are already within the unit SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 21 budget. The unit administrative assistant replaces old printed materials with new ones as the old ones are depleted. Appendix A contains a comprehensive cost analysis. Creating sustainability is a vital component of this project. Improving visibility and discussion of nonpharmacological techniques through various methods may increase their usage among pediatric oncology patients and families. Continuing education for pediatric oncology nurses on nonpharmacological techniques with modification of patient handouts and teaching outlines may provide the exposure needed to sustain this unit culture change. Project Outcomes The over-arching goal of this project is to improve pain management in pediatric oncology patients through using nonpharmacological pain techniques in conjunction with traditional pain relief methods. Short-term outcomes involve improving nursing knowledge and comfort in providing nonpharmacological pain techniques to pediatric oncology patients through a short, in-service learning intervention. The long-term result of this project is creating sustainability three months post-learning intervention and incorporating nonpharmacological pain techniques into routine care. Consent Procedures and Ethical Considerations The nurse’s voluntary participation in the pre-evaluation survey obtained consent for this project. The Institutional Review Boards at Weber State University and PCH granted project approval. The project creator and faculty advisor completed human subjects research training through the Collaborative Institutional Training Initiative. All project data was stored on one password-protected computer with no patient identifiers included in the data collection. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 22 Measuring Intervention Effectiveness The instrument used to evaluate this project was a survey to assess nursing familiarity and comfort with nonpharmacological pain techniques given before project implementation and three months after (See Appendix B). It consists of questions using a rating scale and open-ended questions that require a free-text response. Stephanie Stokes, a survey specialist employed at PCH, developed the survey. Project Implementation A short learning intervention was provided via PowerPoint (Appendix F), outlining the nonpharmacological treatment options available and orienting the nurses to the charting and teaching outline changes. Project implementation was complete when all the nurses in the Cancer/Transplant Unit at PCH willing to participate (N=54) received the intervention. New nurses and patients will continue to receive the training upon hire and diagnosis. Project Intervention Every charge nurse received nonpharmacological pain management training from the project creator, and the charge nurses were identified as super users. The initial plan was that these super users would train the staff nurses; however, that plan was revised when it became apparent the charge nurses were not completing this task due to staffing limitations. The DNP student provided the training in its entirety via PowerPoint to all the staff nurses during safety huddles before the start of multiple weekly shifts over 2 months. The PowerPoint (Appendix F) outlined the course content and presented the following information: • Discussion of nonpharmacological pain survey results was briefly addressed. An evidence table was introduced (Appendix D), and the efficacy of nonpharmacological pain techniques was presented for discussion. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 23 • The updated Pain and Comfort Menu patient handout (Appendix G) that lists the nonpharmacological pain techniques available at the hospital and the requirements for their use with the patients was introduced. Methods that require provider referral were listed last. The Pain and Comfort Menu handout will be given to all patients upon admission to make them aware of their nonpharmacological and pharmacological pain options and increase the visibility of nonpharmacological modalities. • Two of Intermountain Healthcare’s Let’s Talk About patient teaching handouts (Appendix E) were presented to illustrate the resources available for nurses to teach the pain and comfort menu techniques and show how little time these interventions require. • Screenshots of where to locate nonpharmacological pain techniques in iCentra, Intermountain Healthcare’s patient charting system, were included. Nurses were encouraged to discuss these with patients every admission and address them in shift handoff reports. The presentation concluded with a brief discussion about adding nonpharmacological pain techniques to new diagnosis patient teaching outlines and new nurse orientation checklists, which are designed to aid in the sustainability of this project. At the end of the training, the post-intervention evaluation survey was completed and collected. Project Timeline The project proposal was submitted in May 2021, and IRB approval was obtained from Weber State University and Intermountain Healthcare by December 2021. The in-service learning intervention was developed and completed in January 2022. Project implementation SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 24 began in February 2022 and concluded in June of the same year. The evaluation was completed in July, and project dissemination will end in December 2022. A comprehensive project timeline is found in Appendix C. Project Evaluation The evaluation tool (Appendix B) was part of a hospital-wide assessment completed at PCH by Intermountain Healthcare. The outcomes measured included nursing knowledge and comfort in providing nonpharmacological pain techniques to pediatric oncology patients after participation in the short learning intervention. Data Maintenance/Security All project data were stored on a single password-protected computer. No identifiable personal information was collected from participants, and all email communication took place through password-protected accounts within Intermountain Healthcare’s email system. Only the survey specialist, project creator, project mentor, and Weber State University faculty received the deidentified survey results. Data Collection and Analysis The evaluated participants were all hematology/oncology registered nurses employed in the Cancer-Transplant unit at Primary Children’s Hospital. All participants had a Bachelor’s Degree or higher and between 0-28 years of experience as registered nurses. Only 3.8 percent of the participants identify as male, while 96.2 percent identify as female. All participants were between the ages of 21 and 60 (See Table 1.). Table 1: Participants that Received the Educational Intervention Demographics N=26 Sex • Male • Female • 1 • 25 Age 21-60 years SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 25 Position Registered Nurse Years experience 0-28 years The post-class evaluation survey was completed by all 26 participants and utilized a 5-point Likert scale to evaluate the effectiveness of the training (Appendix G). Approximately 73.1 percent of the participants felt the learning intervention was beneficial, and 69.2 percent thought that the time for the intervention was adequate. When asked what improvements would be helpful for future project improvement, many participants voiced their enthusiasm for the number of options available at the hospital, the importance of introducing these techniques as options for patients, and expressed a desire to start using them immediately. One participant stated, “Some of the suggested nonpharm(acological) pain management tools/treatments should be obvious, but I didn’t think about it until I saw the PowerPoint.” Another participant stressed the importance of having this training available upon hire to give registered nurses all available tools before using them on the floor. Table 2 illustrates the results of the post-class evaluation survey. Table 2: Education Intervention Evaluation Post-Intervention Survey N=26 Questions 1 (Strongly Disagree) 2 3 (Somewhat agree) 4 5 (Strongly Agree) Training was beneficial 0 (0%) 0 (0%) 3 (11.5%) 4 (15.4%) 19 (73.1%) Time was adequate 0 (0%) 0 (0%) 2 (7.7%) 6 (23.1%) 18 (69.2%) Quantitative Results Twenty-eight participants took the pre-intervention survey, and 26 received the training and the post-class evaluation survey. The other 2 participants stopped working on the unit during project implementation. Only 15 participants took the post-intervention survey. Acupressure/acupuncture (pre: 19%, post: 13.3%), imagery techniques (pre: 7%, post: 0%), SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 26 massage therapy (pre: 4%, post: 0%), and thought-replacement techniques (pre: 19%, post: 0%) all showed an increase in nursing knowledge of their availability. Because nurses reported previous awareness of breathing techniques, essential oils, and heat/cold therapy, there was no change in knowledge from the intervention. Hand and foot massage (pre: 7%, post: 13.3%) and progressive muscle relaxation (pre: 11%, post: 20%) decreased nursing knowledge after the learning intervention was implemented. Many techniques showed an improvement in sometime usage after the learning intervention. These include acupuncture/acupressure (pre: 4%, post: 6.7%), hand and foot massage (pre: 22%, post: 33.3%), imagery techniques (pre: 7%, post: 46.7%), and thought replacement techniques (pre: 11%, post: 28.6%). Breathing techniques (pre: 39%, post: 53.3%), essential oils (pre: 36%, post: 60%), hand and foot massage (pre: 4%, post: 13.3%), massage therapy (pre: 12%, post: 20%), progressive muscle relaxation (pre: 4%, post: 13.3%), and thought replacement techniques (pre: 4%, post: 7.1%) all showed an improvement in the often category. Breathing techniques (pre: 4%, post: 6.7%), essential oils (pre: 4%, post: 20%), and heat/cold therapy (pre: 29%, post: 53.3%) all showed an improvement in the always category. Counterintuitively, post-intervention, consideration of nonpharmacological techniques as often as pharmacological options decreased among the participants (pre: 54%, post: 46.7%). All quantitative survey results are included in Table 3. Qualitative Results The pre-intervention survey showed that concerns about efficacy, patient preference, and lack of nursing knowledge regarding nonpharmacological interventions contributed to the lack of utilization in the Cancer-Transplant unit. Acupuncture, massage therapy, and more knowledge about available techniques were common themes when asked about “wish-list” interventions. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 27 Participants identified unit culture, patient preference, and lack of nursing knowledge as barriers to implementing nonpharmacological techniques more often. Most participants reported no concerns about alternative therapies but wanted more education on how they work. The post-intervention survey showed that many nurses feel that pharmacological methods are more accessible and effective for relieving pain than nonpharmacological techniques. Massage therapy and acupuncture were identified as techniques nurses wish they had increased access to, especially on the night shift. Most participants had no concerns about using nonpharmacological methods but felt that time and patient preference were barriers to utilizing them more. Table 3: Pre- and Post- Education Survey Data Q.1 How often do you use the following nonpharmacological pain treatments for your patients? Treatments Never Rarely Sometimes Often Always Didn’t know was available Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Acupressure/ Acupuncture 44% 40% 33% 40% 4% 6.7% 0% 0% 0% 0% 19% 13.3% Breathing techniques 7% 0% 11% 13.3% 39% 26.7% 39% 53.3% 4% 6.7% 0% 0% Essential oils 4% 0% 21% 6.7% 36% 13.3% 36% 60% 4% 20% 0% 0% Hand and foot massage 33% 20% 33% 20% 22% 33.3% 4% 13.3% 0% 0% 7% 13.3% Heat/Cold therapy 0% 0% 0% 0% 4% 0% 68% 46.7% 29% 53.3% 0% 0% Imagery techniques 29% 20% 43% 33.3% 7% 46.7% 14% 0% 0% 0% 7% 0% Massage therapy 12% 26.7% 23% 6.7% 46% 46.7% 12% 20% 4% 0% 4% 0% Progressive muscle relaxation 32% 20% 46% 46.7% 4% 0% 4% 13.3% 4% 0% 11% 20% SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 28 Thought replacement techniques 26% 28.6% 37% 35.7% 11% 28.6% 4% 7.1% 4% 0% 19% 0% Q.2 When considering how to treat a patient’s pain, do you think about nonpharmacological treatment options as often as pharmacological treatment options? Yes Pre: 54% Post: 46.7% No Pre: 46% Post: 53.3% Note. Pre-survey N=28; Post-survey N=15 Findings Nursing knowledge of specific nonpharmacological techniques increased as well as the utilization of some methods, addressing both outcomes of increasing nursing knowledge and improving the utilization of available methods. One nurse offered guided imagery to an 8-year-old patient after all pharmacological interventions had been exhausted and found it very effective. The nurse shared how surprised she was seeing its efficacy where medications had failed. The education intervention was well-received, and most participants saw the value in increasing the utilization of these techniques. Qualitative findings indicate a culture change and further education for patients and families may be needed to increase nurses’ willingness to try nonpharmacological methods as often as pharmacological ones. Strengths Strengths of this project include using a reliable instrument to measure project outcomes. The survey was developed by a survey specialist employed by Intermountain Healthcare. Evaluation of survey data was completed using Qualtrics. The learning intervention was created with the help of Jody Osteyee, a certified aromatherapist and Doctor of Nursing Practice, and included only evidence-based information. The project creator taught the intervention to all participants in its entirety, ensuring consistency. Finally, the large number of sustainability interventions add to the strength of this project. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 29 Weaknesses Project adjustment required the DNP student to provide education to each staff member rather than the charge nurse “super-users.” This decreased time for utilization. Post-intervention survey participation was low, potentially due to significant nurse burnout from the COVID-19 pandemic and understaffing (Galanis et al., 2021; Shapiro et al., 2022). Discussion This DNP project focused on assessing and improving nursing knowledge of available nonpharmacologic pain techniques. Increasing the utilization of these techniques and improving pain control in the pediatric oncology patient population may enhance their quality of life. Most participants were receptive to the training, and post-class evaluation survey results found nonpharmacological pain techniques applicable and beneficial for their practice. Translation of Evidence into Practice This project highlighted the effectiveness of a short learning intervention on nursing knowledge and comfort in providing nonpharmacological pain techniques to pediatric oncology patients. It showed how nurses’ perceptions could change when evidence-based research is presented for consideration. One nurse found that guided imagery was effective after all available pharmacological interventions had failed. It also showed that organizational and unit support is crucial for sustainability. This project also illustrated how problematic implementing a quality improvement project can be when nurses are experiencing significant staffing shortages and burnout. Future quality improvement projects on this topic should be done after addressing these barriers to facilitate increased participation for a broader evaluation. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 30 Implications For Practice and Future Scholarship PCH is currently applying for Magnet status, a worldwide designation indicating that nursing leaders align their goals to improving patient outcomes within their organizations (American Nurses Association, n.d.). This project was selected to support that application after the Magnet representative for PCH heard about it at a hospital-wide nursing town hall. The nonpharmacological pain team at PCH is developing a quality improvement project patterned after this DNP project to be implemented in all hospital units. Recommendations to improve the outcomes of this project should include future research on additional nonpharmacological pain relief modalities for pediatric oncology patients. Research with the patients and families as the direct population to assess pain relief and satisfaction achieved with nonpharmacological modalities would also be beneficial. Additionally, staffing shortages and nurse burnout must be addressed. Shapiro et al. (2022) found that nurse burnout contributes to higher turnover rates, leading to higher patient-nurse ratios and increased burnout. Galanis et al. (2021) determined that increased workload, decreased confidence in protection, and fear during the COVID-19 pandemic also increase burnout and lack of personal achievement in nurses. Future research and intervention on this topic may improve participation and enthusiasm for quality improvement projects. Sustainability The unit administrative assistant, educators, hospital-wide nonpharmacological pain team, nursing staff, and pain lead will sustain the program structure. Training will be supported and overseen by the unit educators. The administrative assistant will supervise the ordering and printing of the new diagnosis patient teaching and Pain and Comfort Menu handouts. The nonpharmacological pain team at PCH will provide updated education on available techniques SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 31 for the pain lead in the Cancer/Transplant Unit. The pain lead will be a resource for staff when hospital-wide changes occur regarding the availability of nonpharmacological options. The nursing staff is the primary source for sustaining this unit culture change because they introduce and discuss the options with the patients and families. Dissemination Dissemination of this project began with a presentation at Intermountain Healthcare’s Nursing Town Hall. The nursing executive leadership was present and expressed enthusiasm for implementing this project in additional hospital units within the healthcare system. The nonpharmacological pain team at PCH has begun gathering evidence to support this change. The project creator plans to publish this study in a peer-reviewed journal to encourage further discussion and research on this topic. Finally, this project will be presented at the Western Institute of Nursing in the Spring of 2023. Conclusion This DNP project highlighted the need for effective pain management in the pediatric oncology population and illustrated that nonpharmacological methods are evidence-based and effective for this purpose. It also showed that a short learning intervention can improve pediatric oncology nurses’ awareness and comfort in providing these techniques to patients. Evaluation data showed mixed results with increased knowledge for some methods and decreased knowledge for others. Low participation in the post-intervention survey may have impacted the project findings. Overall, pediatric oncology nurses at PCH felt that nonpharmacological pain techniques were useful and practical. Many valued having additional options to manage their patient’s pain. By using all avenues of pain management, caregivers at PCH can improve the SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 32 quality of care provided without interfering with traditional cancer treatments. Improving care contributes to improved quality of life, which every pediatric oncology patient deserves. SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 33 References ALSF. (2021, June 10). Childhood cancer facts: By the numbers. Alex's Lemonade Stand Foundation for Childhood Cancer. https://www.alexslemonade.org/childhood-cancer/about-childhood-cancer/facts. American Association of Colleges of Nursing. (2006). 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Journal of Pediatric Oncology Nursing, 24(1), 8-19. https://doi.org/10.1177/1043454206296018 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 40 Appendix A Line-Item Budget New Diagnosis Patient Teaching Outlines Year 1 Paper $15 Ink $167 Total $182 New Nurse Orientation Change Year 1 Paper $15 Ink $167 Total $182 Changes to Nursing Handoff Tool Year 1 Paper $63 Ink $167 Total $230 Creation of New Patient Handout Year 1 Paper $21 Ink $167 Total $188 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 41 Appendix B Needs Assessment of Nonpharmacological Pain Treatment at Primary Children's Detailed Results for the Immunocompromised Unit Strategic Research How often do you use the following nonpharmacological pain treatments for your patients? Acupressure/Acupuncture Never Rarely Sometimes Often Always Didn't know was available Breathing techniques Never Rarely Sometimes Often Always Didn't know was available Essential oils Never Rarely Sometimes Often Always Didn't know was available Hand and foot massage Never Rarely Sometimes Often Always Didn't know was available Heat/Cold therapy Never Rarely Sometimes Often Always SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 42 Didn't know was available Imagery techniques Never Rarely Sometimes Often Always Didn't know was available Massage therapy Never Rarely Sometimes Often Always Didn't know was available Progressive muscle relaxation Never Rarely Sometimes Often Always Didn't know was available Thought replacement techniques Never Rarely Sometimes Often Always Didn't know was available Q2. When considering how to treat a patient's pain, do you think about nonpharmacological treatment options as often as pharmacological treatments? Why not? Q3. What nonpharmacological pain treatments do you wish you had access to? Q4. What gets in the way of you using nonpharmacological pain treatments? SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 43 Appendix C DNP Project Timeline Task Completion Complete project proposal 15-May-2021 Gather info about patient and nurse surveys 1-Jun-2021 Build a project team 1-Jun-2021 Meet with department manager 1-Jun-2021 Collaborate with project consultant for peer buy-in options 1-Jun-2021 Complete Section I of DNP project paper 1-Jun-2021 Complete Section II of DNP project paper 1-Jul-2021 Obtain IRB approval for project 1-Dec-2021 Complete pre-implementation survey for nonpharmacological pain technique use (nursing) 8-Feb-2022 Create an evidence table 1-Jul-2021 Create in-service education module for nurses 1-Jan-2022 Schedule class times for in-service education 1-Mar-2022 Complete in-service education classes 30-May-2022 Complete post-implementation survey (nursing and patients) 13-Jun-2022 Complete Section III of DNP project paper 7-Feb-2022 Complete Section IV of DNP project paper 28-Feb-2022 Complete project evaluation 1-Jul-2022 Complete project dissemination 1-Dec-2022 Complete Section V of DNP project paper 20-Jun-2022 Complete Section VI of DNP project paper 18-Jul-2022 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 44 Appendix D Author(s), Publication Date & Title Research Question/Purpose Study Design Study Findings/Recommendations Strength of Evidence (I-V)/Quality of Evidence (A-C) Thrane, S. (2013). Effectiveness of Integrative Modalities for Pain and Anxiety in Children and Adolescents with Cancer: A Systematic Review Determine which integrative modalities have proven effectiveness for reducing pain and anxiety in children and adolescents with cancer. Systematic Review There is good evidence that integrative modalities can help pediatric oncology patients during painful procedures and general treatment for cancer. IB Deng et al. (2019). Evidence-Based Clinical Practice Guidelines for Integrative Oncology: Complimentary Therapies and Botanicals Address principles for clinical encounters, followed by individual classes of integrative treatment modalities with recommendations. Clinical Practice Guidelines Recommendations are made for each therapy based on the strength of evidence to support it. Many therapies are considered safe and effective to use in conjunction with traditional treatments. IVA Dobson, C. E. & Byrne, M. W. (2014). Original Research: Using Guided Imagery to Manage Pain in Young Children with Sickle Cell Disease Test the effects of guided imagery training on school-age children who had been diagnosed with sickle cell disease. Quasi-Experimental After training in the use of guided imagery, participants reported significant increases in self-efficacy, reductions in pain intensity, and decreased usage of analgesics. IIB SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 45 Evidence Levels Quality Ratings Level I • Experimental study, randomized controlled trial (RCT) • Explanatory mixed method design that includes only a level I quantitative study • Systematic review of RCTs, with or without meta- analysis Research: Quantitative Studies A. High quality: Consistent, generalizable results; sufficient sample size for the study design; adequate control; definitive conclusions; consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence. B. Good quality: Reasonably consistent results; sufficient sample size for the study design; some control, fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence. C. Low quality or major flaws: Little evidence with inconsistent results; insufficient sample size for the study design; conclusions cannot be drawn. Level II • Quasi-experimental study • Explanatory mixed method design that includes only a level II quantitative study • Systematic review of a combination of RCTs and quasi-experimental studies, or quasi-experimental studies only, with or without meta-analysis SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 46 Level III • Nonexperimental study • Systematic review of a combination of RCTs, quasi-experimental and nonexperimental studies, or nonexperimental studies only, with or without meta-analysis • Exploratory, convergent, or multiphasic mixed methods studies • Explanatory mixed method design that includes only a level III quantitative study • Qualitative study Meta-synthesis Research: Qualitative Studies No commonly agreed-on principles exist for judging the quality of qualitative studies. It is a subjective process based on the extent to which study data contributes to synthesis and how much information is known about the researchers’ efforts to meet the appraisal criteria. For meta-synthesis, there is preliminary agreement that quality assessments of individual studies should be made before synthesis to screen out poor-quality studies1. A/B High/Good quality is used for single studies and meta-syntheses. • The report discusses efforts to enhance or evaluate the quality of the data and the overall inquiry in sufficient detail; and it describes the specific techniques used to enhance the quality of the inquiry. Evidence of some or all of the following is found in the report: • Transparency: Describes how information was documented to justify decisions, how data were reviewed by others, and how themes and categories were formulated. • Diligence: Reads and rereads data to check interpretations; seeks opportunity to find multiple sources to corroborate evidence. • Verification: The process of checking, confirming, and ensuring methodologic coherence. • Self-reflection and scrutiny: Being continuously aware of how a researcher’s experiences, background, or prejudices might shape and bias analysis and interpretations. • Participant-driven inquiry: Participants shape the scope and breadth of questions; analysis and interpretation give voice to those who participated. • Insightful interpretation: Data and knowledge are linked in meaningful ways to relevant literature. C Low quality studies contribute little to the overall review of findings and have few, if any, of the features listed for high/good quality. Level IV Opinion of respected authorities and/or nationally recognized expert committees or consensus panels based on scientific evidence Includes: • Clinical practice guidelines • Consensus panels/position statements Non-research Evidence A. High quality: Material officially sponsored by a professional, public, or private organization or a government agency; documentation of a systematic literature search strategy; consistent results with sufficient numbers of well-designed studies; criteria-based evaluation of overall scientific strength and quality of included studies and definitive conclusions; national expertise clearly evident; developed or revised within the past five years B. Good quality: Material officially sponsored by a professional, public, or private organization or a government agency; reasonably thorough and appropriate systematic literature search strategy; reasonably consistent results, sufficient numbers of well-designed studies; evaluation of strengths and limitations of included studies with fairly definitive conclusions; national expertise clearly evident; developed or revised within the past five years SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 47 C. Low quality or major flaws: Material not sponsored by an official organization or agency; undefined, poorly defined, or limited literature search strategy; no evaluation of strengths and limitations of included studies, insufficient evidence with inconsistent results, conclusions cannot be drawn; not revised within the past five years Level V Based on experiential and non-research evidence Includes: • Integrative reviews • Literature reviews • Quality improvement, program, or financial evaluation • Case reports • Opinion of nationally recognized expert(s) based on experiential evidence Organizational experience (quality improvement, program or financial evaluation) A. High quality: Clear aims and objectives; consistent results across multiple settings; formal quality improvement, financial, or program evaluation methods used; definitive conclusions; consistent recommendations with thorough reference to scientific evidence B. Good quality: Clear aims and objectives; consistent results in a single setting; formal quality improvement, financial, or program evaluation methods used; reasonably consistent recommendations with some reference to scientific evidence C. Low quality or major flaws: Unclear or missing aims and objectives; inconsistent results; poorly defined quality improvement, financial, or program evaluation methods; recommendations cannot be made Integrative Review, Literature Review, Expert Opinion, Case Report, Community Standard, Clinician Experience, Consumer Preference A. High quality: Expertise is clearly evident; draws definitive conclusions; provides scientific rationale; thought leader(s) in the field B. Good quality: Expertise appears to be credible; draws fairly definitive conclusions; provides logical argument for opinions C. Low quality or major flaws: Expertise is not discernable or is dubious; conclusions cannot be drawn https://www.york.ac.uk/crd/SysRev/!SSL!/WebHelp/6_4_ASSESSMENT_OF_QUALITATIVE_RESEARCH.htm 2 Adapted from Polit & Beck (2017). © 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 48 Appendix E SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 49 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 50 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 51 Appendix F SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 52 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 53 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 54 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 55 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 56 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 57 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 58 Arnon, Z., Steinberger, D., Attias, S., rimberg, O., Peterfreund, I., Schiff, E., & Keshet, Y. (201 ). Nurses as boundary actors: Promoting integrative medicine in hospital wards. o le e ta T e a es l al a t e , 9 10 . doi:10.101 / .ctcp.201 .01.01 Deng, . E., Frenkel, M., Cohen, L., Cassileth, B. R., Abrams, D. I., Capodice, J. L., Courneya, K. S., Dryden, T., Hanser, S., Kumar, N., Labriola, D., Wardell, D. W., & Sagar, S. (2009). Evidence based clinical practice guidelines for integrative oncology: Complementary therapies and botanicals. ou al o t e o et o te at e olo ( ), 5 120. doi: 10.2 10/7200.2009.0019Jacob, E. (201 ). Pain. In N. Kline (Ed.), sse t als o e at e atolo o olo u s A o e u ulu ( thed., pp 2 252). Association of Pediatric Hematology/Oncology NursesRadossi, A. L., Taromina, K., Mar errison, S., Diorio, C. J., Similio, R., N uguna, F., Afungchwi, . M., & Ladas, E. J. (201 ).A systematic review of integrative clinical trials for supportive care in pediatric oncology: A report from the International Society of Pediatric Oncology, T&CM collaborative. u o t a e a e , 75 91. https://doi.org/10.1007/s00520 017 90 0Thrane, S. (201 ). Effectiveness of integrative modalities for pain and anxiety in children and adolescents with cancer: A systematic review. ou al o e at olo u s ( ), 20 2. doi: 10.1177/10 5 21 5115 SUSTAINABLE USE OF NONPHARMACOLOGICAL PAIN TECHNIQUES 59 Appendix G Post-Class Evaluation Survey Do you feel this training was beneficial? 1 2 3 4 5 Not Beneficial Somewhat Beneficial Very Beneficial Do you feel the time required for this training was adequate? 1 2 3 4 5 Not Adequate Very Adequate Please share any constructive comments you may have to improve this training for future use.