Validity and reliability of the Italian Constipation Assessment Scale.

Constipation is a common problem among oncology patients and requires careful assessment. Use of validated instruments is important to improving its management. The aim of this study was to validate the Italian translation of the Constipation Assessment Scale (CAS). To test construct validity, patients and apparently healthy adults were asked to complete the CAS. The results indicated that there was a significant difference between the median CAS of the patient group and that of the apparently healthy group. Test-retest reliability was very high (r=0.96; P=0.0001), and the internal consistency as assessed by Cronbach's alpha was 0.768. These findings suggest that the Italian CAS can be used in clinical practice to document the presence and severity of constipation in cancer patients. However, further studies should be conducted in a larger sample of patients to confirm the results.

Knowledge and attitudes of nurses in veterans hospitals about pain management in patients with cancer.

PURPOSE/OBJECTIVES: To assess nurses' knowledge and attitudes about pain management and patients in pain. DESIGN: Exploratory, descriptive. SETTING: Seven medical-surgical inpatient units in two large veterans hospitals in Southwest Florida. SAMPLE: A convenience self-select sample of 85 nurses (RNs and LPNs working on the target units on all shifts). METHODS: Staff nurses were approached at work and asked to complete the data collection forms. MAIN RESEARCH VARIABLES: Knowledge about pain management principles and attitudes toward pain management and patients in pain. FINDINGS: Areas of major knowledge deficits included physiology of pain and pharmacology of analgesics. Nurses were most knowledgeable about the importance of asking patients about their pain, around-the-clock scheduling, tolerance, and use of distraction. Patient behavior, age, and gender seemed to unduly influence nurses in their pain management decisions. Regarding attitudes about pain management, the majority of nurses did not agree that patients and their families should have the most control over analgesic scheduling and that a constant level of analgesic should be maintained in the blood. In fact, 82% indicated that around-the-clock analgesics increase the risk for sedation and respiratory depression. CONCLUSIONS: Years after the Agency for Health Care Policy and Research published pain guidelines, nurses in veterans hospitals continue to lack knowledge and have negative attitudes that may negatively affect pain management in patients with cancer. IMPLICATIONS FOR NURSING PRACTICE: Basic and continuing education for nurses needs to include intensive content about pain management. Continued research is needed to document improvements in pain management by nurses.

Management of pain and pain-related symptoms in hospitalized veterans with cancer.

Unrelieved pain continues to be a problem among hospitalized patients with cancer. The purpose of this study was to evaluate pain management outcomes in a group of veterans with cancer receiving inpatient care. The sample consisted of 90 veterans with cancer hospitalized in one of two large veterans medical centers in the southeastern United States. Daily pain was assessed by administering the visual analog scale (VAS) for pain three times in a 24-hour period and averaging these three scores. The Brief Pain Inventory (BPI) and Constipation Assessment Scale (CAS) were administered once. The charts were audited using the Chart Audit for Pain (CAP). The sample was predominantly male (93.3%) and white (82.8%). The length of time since diagnosis ranged from newly diagnosed during this hospitalization to 16 years. Average daily pain was 32.9 on the VAS and 4 on the BPI. However, approximately one-fourth of the patients reported average daily pain above the midpoint (VAS > 50), and some patients reported average daily pain to be as high as 98. Fewer than half of charts (42%) showed evidence that a pain rating scale was used. Other assessment data also were very limited. Patients reported that pain interfered with all activities on the BPI, with highest interference scores for walking and sleep (mean, 5.5). Although 80% of the patients reported some problem with constipation, the chart audit indicated that this was recorded in only 11 patient records. No patient records indicated a problem with sedation. The findings indicate that limited attempts were made to manage pain using nonpharmacologic methods. In addition, only one of the nine charts reporting these attempts showed evidence that results from the attempt were evaluated. It may be concluded that pain management continues to be less than ideal in these veterans hospitals. Study results indicate that nurses are not documenting careful assessment of pain, not documenting evaluation of approaches to pain management, and not attending to the constipation that is inevitable when opioids are administered. Continued emphasis on nursing education related to pain management is needed. Future research should be undertaken to evaluate these outcomes.

Comparison of Florida Hispanic and non-Hispanic Caucasian women in their health beliefs related to breast cancer and health locus of control.

PURPOSE/OBJECTIVES: To compare Florida Hispanic and non-Hispanic Caucasian women in their health beliefs about breast cancer and health locus of control (LOC). DESIGN: Exploratory, comparative. SETTING: A variety of healthcare settings in an urban area in Florida. SAMPLE: Hispanic (n = 113) and non-Hispanic (n = 197) Caucasian women who could read and understand either English or Spanish. METHODS: The Health Screening Questionnaire, which assesses health beliefs and health LOC, was administered in either Spanish or English, and the results were analyzed. MAIN RESEARCH VARIABLES: Attitudes about health in general, perceptions about susceptibility to cancer, beliefs about benefits of early diagnosis, and perceptions about the seriousness of cancer; LOC. FINDINGS: Florida Hispanic women are better educated than the Mexican American Hispanic women described in the literature. Hispanic and non-Hispanic women were significantly different in their health beliefs and LOC. With age and education controlled statistically, these differences remained. Hispanic women who preferred to speak/read English were more like the non-Hispanic women in their responses than were the women who preferred Spanish. CONCLUSIONS: Cultural differences exist between Hispanic and non-Hispanic women; however, differences also exist between groups of Hispanic women in Florida versus Hispanics in the southwestern United States. IMPLICATIONS FOR NURSING PRACTICE: Outreach programs for cancer screening should be culturally relevant and may need to be different for subgroups of Hispanics in the United States.

How problematic are various aspects of quality of life in patients with cancer at the end of life?

PURPOSE/OBJECTIVES: To identify aspects of quality of life (QOL) in patients receiving end-of-life care that are most and least problematic for patients. DESIGN: Descriptive using secondary analysis of data from an earlier QOL study. SETTING: A large not-for-profit hospice that primarily provides home care in southwest Florida. SAMPLE: 231 homecare hospice patients with cancer. METHODS: Item analysis of items on the Hospice Quality-of-Life Index. MAIN RESEARCH VARIABLES: Psychophysiologic, functional, and social/spiritual well-being. FINDINGS: Patients had the most problems in the area of functional well-being and the least problems with social/spiritual well-being. Most common physical problems included constipation and dyspnea. CONCLUSIONS: Patients with end-stage cancer are able to maintain their relationships with God and with family and friends even in the face of marked functional difficulties and troublesome physical symptoms. IMPLICATIONS FOR NURSING PRACTICE: A continued focus on the patient and family by the interdisciplinary healthcare team is warranted.

Instruments for assessing quality of life in palliative care settings.

Quality of life is an outcome that is particularly important during palliative care. However, in order to measure this outcome, it is necessary to have a valid and reliable measure. The purpose of the article was to identify and describe quality of life measures that are appropriate for use in palliative care settings. Characteristics that are believed to be critical for quality of life instruments include the following. The instrument should: (1) be multidimensional; (2) provide self-report data; (3) be useful in the setting in which it is to be used; (4) be valid and reliable for use in palliative care settings. The five scales described measure a variety of dimensions including physical, psychological, social, spiritual, existential, support, symptoms and functional aspects of quality of life. All but one are self-report instruments. All have evidence of validity and reliability for use with palliative care populations.

The Caregiver Quality of Life Index-Cancer (CQOLC) Scale: revalidation in a home hospice setting.

Hospices provide palliative care to persons who are dying and supportive care to their family caregivers. As death approaches, these family caregivers become increasingly responsible for providing the majority of daily care. Although research has documented their distress, little work has evaluated the broader impact of caregiving on quality of life (QOL). This study reevaluates the internal consistency and validity of the Caregiver Quality of Life Index-Cancer (CQOLC). 239 family caregivers of hospice patients with a variety of cancer diagnoses participated. Internal consistency for the instrument was 0.87. There were moderate correlations with overall mental health (r = 0.68) and low correlations with overall physical health (r = 0.01). Low correlations were observed with patient's performance status (r = 0.09). The CQOLC appears to possess adequate validity and internal consistency in this revalidation sample.

Family caregiver quality of life: differences between curative and palliative cancer treatment settings.

To compare the impact of cancer caregiving in curative and palliative settings on family caregiver quality of life (QOL), 267 family caregivers of cancer patients receiving curative treatment were compared to 134 family caregivers of cancer patients receiving palliative treatment through hospice. Both groups completed a demographic profile in addition to two self-report QOL questionnaires. Patient performance status and disease site were also recorded. Family caregivers of patients receiving palliative care had significantly lower QOL scores and lower scores on physical health. Hierarchical multiple regressions showed that after accounting for patient performance status, treatment status accounted for no additional significant variability in QOL scores. After accounting for caregiver level of education, treatment status accounted for no additional significant variability in physical health. These results suggest that the lower QOL scores of caregivers in the palliative setting are a reflection of the patients' poorer performance status. The lower physical health scores of caregivers in the palliative setting appear to be a reflection of their lower educational level. Additional research is needed to evaluate the influence of specific demands of caregiving and emotional distress of the caregiver on caregiver QOL.

Revising the blueprint for the AOCN Examination using a role delineation study for advanced practice oncology nursing.

PURPOSE/OBJECTIVES: To conduct a role delineation study of advanced oncology nursing practice as a basis for the blueprint for the Advanced Oncology Certified Nurse (AOCN) Examination. DESIGN: Descriptive and comparative. SAMPLE: A group of 802 Oncology Nursing Society members comprised of 258 oncology nurse practitioners (NPs), 235 oncology clinical nurse specialists (CNSs), and 309 baccalaureate-prepared oncology nurses. METHODS: A pilot survey was mailed to a small group to allow refinement of the survey instrument. The survey then was mailed to a total sample of 2,400. MAIN RESEARCH VARIABLES: Frequency and importance to practice of 121 survey items as well as whether each item reflected an entry-level skill. Survey items were divided into five major domains: (a) Direct Caregiver, (b) Consultant, (c) Administrator/Coordinator, (d) Researcher and (e) Educator. FINDINGS: Direct Caregiver domain was weighted most heavily (63%), followed by Educator (18%), Consultant (10%), Administrator/Coordinator (5%), and Researcher (4%). Most of the items were identified as entry-level skills, and fewer than 10% of the items differentiated between CNS and NP respondents. CONCLUSION: The blueprint for the AOCN Examination reflects entry-level advanced practice oncology nursing and is appropriate for both CNSs and NPs in oncology. IMPLICATIONS FOR NURSING PRACTICE: Examinees, consumers, and employers can have confidence that the AOCN Examination will be based on a blueprint that was revised to reflect current oncology nursing practice and, therefore, is valid for its purpose.

Improving pain outcomes of hospice patients with cancer.

PURPOSE/OBJECTIVES: To evaluate the success of a multifaceted, hospicewide, nurse-focused pain-management intervention for improving patient pain outcomes. DESIGN: Comparative, descriptive. SETTING: A large, nonprofit hospice that primarily provides home care. SAMPLE: Two samples were included in the study. One sample (n = 47) was from a study completed in 1995 before the intervention, and one (n = 255) was from a study completed in 1997 after the intervention. All patients had been diagnosed with cancer and were alert and able to self-report. METHODS: Secondary analysis of data that were collected as part of two quality-of-life studies. The four-part intervention included intensive pain-management education for the nurses, development and implementation of pain-management policies and procedures, changes in pain assessment and management documentation, and development and use of quality assurance monitors by the nursing staff. MAIN RESEARCH VARIABLES: Pain at its worst, pain relief, and quality of life. FINDINGS: Adjusted mean pain-relief scores were significantly lower in 1995 (X = 5.8) than in 1997 (X = 8.4). In 1995, 43% of patients reported pain relief at a level of 5 or less (on a 0-10 scale). This number dropped to 10% by 1997. Adjusted mean pain-at-its-worst scores were significantly lower in 1997 (X = 6.1) than in 1995 (X = 6.7). Pain relief was found to be positively correlated (r = 0.41-0.51) with quality of life in both samples. CONCLUSIONS: The hospicewide pain-management intervention was effective. IMPLICATIONS FOR NURSING PRACTICE: Through careful study and multifaceted nurse-focused interventions, pain outcomes of hospice patients with cancer can be improved.

Quality of life in cancer patients: use of a revised Hospice Index.

PURPOSE: Improving or maintaining the quality of life for persons with cancer is a major goal of end-of-life care; however, to measure quality-of-life outcomes, a valid and reliable measure is needed. The purpose of this project was to report the psychometric properties of the revised Hospice Quality of Life Index (HQLI), including validity and reliability for hospice patients with cancer. DESCRIPTION: Data were collected from home care hospice patients with cancer (n = 255) and a group of apparently healthy adults in the community (n = 32). The revised HQLI is a 28-item self-report instrument that includes three subscales: Psychophysiological Well-being, Functional Well-being, and Social/Spiritual Well-being. RESULTS: Evidence for validity was provided in three ways. First, factor analysis confirmed the three subscales (Psychophysiological, Functional, and Social/Spiritual Well-being). Second, a weak significant correlation was found between the Easterm Cooperative Oncology Group Performance Status Rating scores and HQLI scores (r = .26; P = .00). Third, the HQLI was able to discriminate between hospice patients with cancer and apparently healthy adults (lambda = .34; P = .00). In addition, the mean scores of these two groups were significantly different (t = 6.64; P = .00). However, only a minimal difference in scores was found on the Social/Spiritual Well-being subscale between the cancer and healthy groups. Reliability for the revised HQLI was high for both the total scale (alpha = .88) and the subscales (alpha =.82-.85). CLINICAL IMPLICATIONS: Emphasis has been placed recently on understanding quality of life from the patient's perspective. The development of a valid and reliable tool can guide care givers in providing meaningful quality-of-life care. The HQLI provides patients the opportunity to express beliefs about quality-of-life issues and to maintain direction over a critical aspect of their care. Of note from this study, the significant difference between groups in functional well-being and minimal difference in social/spiritual well-being suggest that patients are able to appraise their functional abilities realistically and still maintain their social network and spiritual beliefs. Indeed, it may be that patients give family relationships and spiritual beliefs greater focus during a terminal illness.

A study of the role of the generalist oncology nurse as a basis for revision of the blueprint for certification.

PURPOSE/OBJECTIVES: To delineate the current role of the generalist oncology nurse as a basis for revision of the blueprint for the OCN Exam. DESIGN: Survey of generalist oncology nurses. SAMPLE: 1,200 oncology nurses randomly chosen from the general membership of the Oncology Nursing Society who completed and returned surveys. METHODS: Surveys developed by subject matter experts and mailed by American College Testing. MAIN RESEARCH VARIABLES: Frequency and importance of 201 oncology nursing activities previously identified by a group of experts in oncology nursing. FINDINGS: Highest ranked items for combined frequency and importance pertained to comfort, information, protective mechanisms, and coping. Lowest ranked items pertained to prevention, detection, research, and sexuality. CONCLUSIONS: The blueprint was redesigned to include eight domains of practice: quality of life (27%), gastrointestinal and urinary function (15%), protective mechanisms (15%), scientific basis for practice (12%), cardiopulmonary function (10%), health promotion (8%), oncologic emergencies (7%), and professional performance (6%). IMPLICATIONS FOR NURSING PRACTICE: Because oncology nursing is changing, it is necessary to reconfirm and update the blueprint for the certification exam. Certification exams for the generalist nurse beginning in May 1996 were based on this updated blueprint.

Genetically linked cancers: prevention, detection, and treatment.

Although they are influenced by genetics, most human cancers are not inherited. However, genetic changes in cells are now believed to be the primary initiating factors that lead to cancer development. Although scientists have an increasingly better understanding of the relationship between genetics and cancer, nurses are not as well informed. There is now great potential to improve early detection and treatment of cancer; morbidity and mortality also will decrease as a result. However, this newly gained knowledge is not without its problems. Ethical dilemmas for both society and individuals are likely to arise. Becoming well-informed individuals will help to prepare nurses for cancer care in the future.

The quality of life of patients with cancer receiving hospice care.

PURPOSE/OBJECTIVES: To evaluate the outcomes of hospice services and explore factors that affect the quality of life (QOL) of patients with cancer receiving hospice care. DESIGN: Descriptive. SETTING: Two homecare hospices in the southeastern United States. SAMPLE: Convenience sample of 118 hospice patients with a diagnosis of cancer and their primary caregivers. METHODS: The Hospice Quality of Life Index (HQLI) was administered to patients and caregivers within 48 hours of admission and after three weeks of hospice care. MAIN RESEARCH VARIABLE: QOL. FINDINGS: HQLI scores could range from a low of 25 to a high of 250. Mean HQLI scores of the patients ranged from 168-173.7; the caregivers' means ranged from 157-158. Factor analysis confirmed four subscales: physical/functional, social/spiritual, psychological, and financial well-being. The social/spiritual subscale resulted in the highest mean scores (74.9), and the physical/functional subscale had the lowest (23.9). Correlations between patient and caregiver HQLI scores were only moderate (r = 0.51-0.55) CONCLUSIONS: Overall QOL remained stable during the study period when measured by an apparently valid and reliable instrument. QOL is characterized by multidimensionality and subjectivity. IMPLICATIONS FOR NURSING PRACTICE: Nurses need to design interventions to support the QOL of people who are terminally ill, with a particular focus on the physical/functional aspects of care. QOL assessment data should be collected from patients whenever possible, and outcomes of care should continue to be studied using valid and reliable tools.

Pain and pain relief experienced by hospice patients with cancer.

The purpose of this descriptive study was to explore the pain intensity and pain relief experienced by hospice patients with cancer and the variables that might be associated with that pain. The sample consisted of 118 consenting patients and their primary caregivers receiving hospice care in their homes. Methods involved a secondary analysis of data from a study of quality of life. The Hospice Quality of Life Index (HQLI), used in the study, assesses multidimensional aspects of quality of life including pain relief. Each item is assessed on a 1 (worst) to 10 (best) scale. To eliminate pain-free patients from the analysis, an additional item asks how severe pain is when it is at its worst. Both patients and caregivers were asked to evaluate the patient's quality of life on admission and after 3 weeks of hospice care. Relationships were sought among items on the HQLI and between pain and demographic characteristics. Results revealed that most patients experience pain (82%) but that caregivers were not able to accurately estimate that pain. Pain relief, even after 3 weeks of hospice care, was less than optimal, with many patients (42%) reporting pain relief at a level of 5 or less. A significant difference in pain at its worst was found by type of cancer. Although there were differences by gender, these were not significant. Pain was found to be weakly related to enjoyable activity, sleeping, fatigue, physical care, hope, and anger. Results support the idea that pain is important to overall quality of life, but despite its importance, pain in hospice patients with cancer still is not well managed.

Quality of life of primary caregivers of hospice patients with cancer.

PURPOSE: The purpose of this study was to evaluate the quality of life of a group of adults who were serving as primary caregivers for 118 hospice patients with cancer who were receiving hospice home care in west central Florida. DESCRIPTION OF STUDY: The Caregiver Quality of Life Index, used in the study, includes items related to physical, emotional, social, and financial well-being. The Caregiver Quality of Life Index was administered within 48 hours of admission to hospice and after 3 weeks of hospice care (during week 4). RESULTS: Quality of life scores remained stable from admission to week 4. Item scores were highest for social well-being (74.7 and 69.7) and lowest for physical well-being (60.6 and 63.7). No significant differences were found in item scores from admission to week 4. CLINICAL IMPLICATIONS: Quality of life of primary caregivers is negatively affected by caregiving, but the support provided by hospice care may help to ameliorate these effects. Health providers who are alert to caregiver needs and knowledgeable about the work of the multidisciplinary hospice team will be more likely to refer patients and caregivers to appropriate hospice care.

Validity and reliability of an oncology critical care patient acuity tool.

PURPOSE/OBJECTIVES: To test the reliability and validity of a patient acuity tool for use on a critical care oncology unit. DESIGN: Prototype classification system using therapeutic indicators to describe a patient's acuity. SETTING: Intensive care unit of a research and academic oncology hospital in the Southeastern United States. SAMPLE: Critical care nursing staff including management-level personnel at the research site. METHODS: An acuity tool for critical care was developed using the Johns Hopkins Oncology Center's patient classification system as a model. Content validity indexes were calculated based on ratings of nurse experts. interrater reliability was calculated based on two independent raters: a staff nurse and a patient care manager. MAIN RESEARCH VARIABLES: Appropriateness of language and categorization of therapeutic indicators developed for the tool. FINDINGS: The content validity index of the entire tool was 0.85; 24/25 indicators were retained. Reliability was r = 0.84. CONCLUSIONS: The tool is reliable and valid. IMPLICATIONS FOR NURSING PRACTICE: Acuity tools can be used to calculate unit productivity and assist with determination of staffing needs. In this age of healthcare reform, it is imperative that personpower needs in all care settings be accurately determined to provide cost-effective and safe care levels.

A descriptive study of the management of pain and pain-related side effects in a cancer center and a hospice.

The purpose of this study was to describe the pain and pain-related symptoms experienced by persons receiving treatment in a cancer center or a hospice and to describe the nurses' responses to these problems. The sample consisted of 25 hospice and 19 cancer center patients who were being treated for pain. Pain was assessed three times in a 24-hour period using a visual analogue scale (VAS). Constipation was assessed using the Constipation Assessment Scale. Sedation was assessed on a 0 (fully alert) to 4 (comatose) scale. The nurses' documentation was assessed using the Chart Audit for Pain. Results showed that patients in the cancer center and hospice continued to experience pain (VAS M = 38.6 and 29.7 respectively) in spite of their pain management regimens. The cancer center patients were given an average of 38% of the maximum ordered dose of analgesic while the hospice patients self-administered 93% of the ordered dose. The cancer center nurses documented the efficacy of the analgesics in only 26% of cases while hospice nurses recorded this information in 96% of the charts. Sedation was not found to be a problem. Constipation was reported by 100% of cancer center patients and 84% of hospice patients but was rarely documented by nurses in either setting. It appears that nurses need to do more thorough assessment of patient symptoms and more consistent follow-up evaluation and documentation.

Advanced practice in oncology nursing: a role delineation study.

PURPOSE: To identify the elements that comprise the role of the advanced practice oncology nurse. DESIGN: Survey. SETTING: National. SAMPLE: 637 master's-prepared nurses in oncology clinical practice and 619 baccalaureate nurses who were in their first four years of certification as oncology nurses. METHODS: Using a 190-item survey composed of five subscales (Direct Caregiver, Consultant, Administrator/Coordinator, Researcher, and Educator) listing advanced practice behaviors, respondents were asked to indicate the frequency with which they performed each behavior and the importance of each behavior to their practice. MAIN RESEARCH VARIABLES: The elements of the advanced practice role differentiated from those elements of the role of the nurse who is practicing at the generalist level (i.e., non-master's-prepared). FINDINGS: The majority of items showed a significant difference between the the two groups with the greatest similarities in the area of Direct Caregiver and the greatest differences in the areas of Consultant and Researcher. Advanced practice nurses indicated that they performed the behaviors on the Direct Caregiver and Educator subscales most frequently and believed these behaviors to be most important to their practice. CONCLUSION: Significant differences exist between the roles of nurses in basic and advanced oncology nursing practice. IMPLICATIONS FOR NURSING PRACTICE: The results of the role delineation study have been used to design the blueprint for the Advanced Oncology Nursing Certification Test, to be administered for the first time in April 1995.