A pain education programme to improve patient satisfaction with
cancer pain management: a randomised control trial Pi-Ling Chou and Chia-Chin Lin Aim. The purpose of this study was (1) to evaluate the effectiveness of a pain education programme to increase the satisfaction of patients with cancer with regard to pain management and (2) to examine how patient satisfaction with pain management mediates the barriers to using analgesics and analgesic adherence. Background. The patients satisfaction with pain management is not merely an indicator, it is actually a contributor to med- ication adherence. However, very few studies investigate methods for improving patient satisfaction with pain management. Design. This study used an experimental and longitudinal design. Methods. A total of 61 patientfamily pairs (n = 122) were randomly assigned to either experimental or control groups. The instruments included the American Pain Society outcome questionnaire, the Barriers Questionnaire-Taiwan form, self-reporting evaluations of analgesic adherence and the Pain Education Booklet. The experimental group (n = 31) participated in a pain education programme, while those in the control group (n = 30) did not. The two groups were compared using generalised estimation equations after the second and fourth weeks. A Sobel test was used to examine the mediating relationships among patient satisfaction with pain management, barriers to using analgesics and analgesic adherence. Results. The experimental group showed a signicant improvement in the level of satisfaction they felt for physicians and nurses regarding pain management. For those in the experimental group, satisfaction with pain management was a signicant mediator between barriers to using analgesics and analgesic adherence. Conclusions. This research provides evidence supporting the effectiveness of a pain education programme for patients and their family members in increasing patient satisfaction with regard to the management of cancer pain. Relevance to clinical practice. It is important for health providers to consider patient satisfaction when attempting to improve adherence to pain management regimes in a clinical setting. Key words: barriers to pain management, cancer pain, mediator, nurses, nursing, pain education programme, pain management, patient satisfaction Accepted for publication: 9 January 2011 Introduction Cancer pain is a serious clinical problem and improving the means by which it is treated is an issue of critical importance (Gordon et al. 2002, Jain et al. 2008). Assuring the quality of cancer pain management by systematically evaluating the methods employed in such treatment can enhance the effec- tiveness of pain control in patients with cancer (Ward et al. 1998). The patients satisfaction with pain control is an essential indicator in assessing the quality of cancer pain management (Sterman et al. 2003, Panteli & Patistea 2007); however, very few researchers have adopted a longitudinal Authors: Pi-Ling Chou, MS, RN, Doctoral Student, Graduate Institute of Nursing, College of Nursing, Taipei Medical University; Chia-Chin Lin, PhD, RN, Professor and Director, School of Nursing, College of Nursing, Taipei Medical University and Wan-Fang Hospital, Taipei, Taiwan Correspondence: Chia-Chin Lin, Professor and Director, School of Nursing, College of Nursing, Taipei Medical University, No.250, Wuxing St., Taipei 11031, Taiwan. Telephone: + 886 2 2377 6229. E-mail: clin@tmu.edu.tw 1858 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 doi: 10.1111/j.1365-2702.2011.03740.x approach to studying pain education as it pertains to this issue. Patient satisfaction with pain control is not merely an important indicator. If patients are more satised with their pain management, they more likely to comply with the advice of health providers (Hirsh et al. 2005). Previous studies related to pain intervention have focused on barriers to changing analgesics and the resulting inuence on patient adherence to such treatment (Lin et al. 2006, Syrjala et al. 2008). Unfortunately, the means by which these barriers inuence adherence remains unclear. A deeper under- standing of the mechanisms involved in patient satisfaction that dissuade patients from adhering to the prescribed use of analgesics could prove extremely valuable in clinical practice. Background Patient satisfaction towards their treatment was dened by Lebow (1982) as the extent to which treatment graties the wants, wishes and desires of clients. Several studies have adopted the satisfaction that patients feel towards pain management as an indicator for assessing the effectiveness of pain management (de Wit et al. 2001, Jain et al. 2008). Merkouris et al. (1999) reported that patient satisfaction might provide the means to evaluate outcomes and act as a contributor to other outcomes (i.e. adherence), inuencing the process of recovery. Several researchers have discovered that patient satisfaction with medical management could be used to forecast medical outcomes, in addition to acting as an outcome indicator (Meakin & Weinman 2002). For instance, studies focusing on older patients suffering from coronary heart disease discovered that the degree to which patients adhere to the instructions they received regarding their medication improves proportionally to the patients satisfac- tion feel towards an increase in medical management from their physicians and nurses (Rich et al. 1996, Rybacki 2002, Simpson et al. 2002). Similarly, if the adherence of patients increases with medical management, studies could more accurately predict the outcome of health care services. Most researchers recognise that patientprovider relationships and patient satisfaction with those relationships are important factors in adherence to treatment regimes (Cameron 1996, Bos et al. 2005). One study indicated that the more satised patients are with their pain management, the more they comply with the advice of health care providers (Hirsh et al. 2005). Another study on chronic pain in children revealed that the satisfaction of parents and children is signicantly correlated with patient adherence (Simons et al. 2010). Interventions that improve patient satisfaction could have a positive inuence on the outcome of treatment for cancer pain. Adherence to analgesic regimens has become one of the most signicant clinical problems in the management of cancer pain (Miaskowski et al. 2001). The lack of adher- ence to analgesics is a result of myths regarding their use (Tzeng et al. 2008, Valeberg et al. 2008). In the past few decades, promoting and maintaining adherence to prescribed analgesic regimens has become an important intervention in the treatment of patients with cancer (Agency for Healthcare Research and Quality 2001). As a result, many studies have developed strict guidelines to ameliorate misconceptions regarding pain and analgesics, and several of these interven- tions have signicantly increased patient adherence to the prescriptions of medical personnel (Ferrell et al. 1993, Lin et al. 2006, Syrjala et al. 2008). Patients who had been educated concerning pain intervention were less likely to self- terminate their medication when the pain decreased. Pain education programmes appear to be benecial in reducing patient misconceptions regarding analgesics and improving patient adherence to their analgesic regimens. The cancer patients satisfaction feel towards pain manage- ment programmes is a relatively new topic of discussion and many of the implications are scarcely understood (Alalo & Tselios 1996, Sherwood et al. 2000). Evaluating the level of patients satisfaction with the management of their cancer pain can provide a deeper understanding of their general satisfaction with the treatment they receive from their physicians and nurses. In a study by Sherwood et al. (2000), patients with cancer who were dissatised with their pain management perceived a lack of empathy among health care professionals, who were slow to respond to their complaints of pain. In addition, the same patients believed that health care professionals did not have sufcient knowl- edge or the skills required to properly manage their pain. Dissatisfaction with pain management may be a reection of poor pain management provided by health care professionals (Sherwood et al. 2000). Several studies have shown that interventions encourage patients with cancer to overcome the barriers preventing them from adhering to analgesics meant to reduce their pain. However, the mechanisms involved in the reduction of such barriers have never been explored. This study suggests that patient satisfaction with pain management regimes is a signicant factor inuencing medication adherence and fully exploring these underlying mechanisms is crucial. This study hypothesises that long-term education programmes address- ing the issue of cancer pain management for patients and their families would improve patient satisfaction. Patient satisfaction with pain management could be a signicant mediating factor among the various barriers to using anal- gesics and analgesic adherence. Pain management Pain education to improve pain management 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1859 Methods Participants and settings This study, part of which has been published elsewhere (Lin et al. 2006), is one component of a large randomised control study. It was conducted in the oncology outpatient clinics of two hospitals in Taipei, Taiwan. A purposive sample consisting of outpatients and their primary caregivers was recruited. Patientfamily pairs enrolled in the study were randomly assigned to the experimental group or control group using a computer-generated randomisation scheme developed by the researcher. Random allocation sequences and sealed, opaque envelopes were used to ensure security. Two participants in the experimental group and two partic- ipants in the control group discontinued involvement in the study during the second assessment and three participants stopped treatment after the third assessment. Sixty-one patientfamily pairs (n = 122) completed the analysis, of which 31 pairs were in the experimental group and 30 pairs were in the control group (Fig. 1). Participants had to meet the following criteria: (1) diagnosed with cancer; (2) expe- riencing pain due to cancer and currently taking oral analgesics; (3) over 18 years of age; and (4) ability to communicate in Mandarin or Taiwanese. Participants suffer- ing from cognitive impairment or brain metastasis were excluded from the study. This study used SSIZE SSIZE software (Hsieh 1991) to estimate the size of the sample from the pilot study. Scores regarding patient satisfaction were used as the primary outcome; with a r value of 005 and a test power of 85%. Satisfaction scores in the pretest were 35 (slightly dissatised) and after two weeks 45 (somewhat satised). Each group had to be maintained at 30 samples with a difference of 1 between the two groups. Instruments The American Pain Society (APS) outcome questionnaire The APS outcome questionnaire was developed from qual- ity assurance studies, using identical tools for exploring patient satisfaction with regard to the treatment of cancer- related pain (Ward & Gordon 1994, Miaskowski et al. 1994). The standards proposed by the Quality Assurance Committee of the APS were adopted in the development of the questionnaire used in this study. In addition, the views of patients regarding the means by which their doctors and nurses managed their pain were also included (Max et al. 1991, Agency for Health Care Policy and Research 1994). The questionnaire was translated into Mandarin using a translation and back-translation method to ensure accuracy. This questionnaire included three parts: (1) a patient assessment of their satisfaction with the method of pain management employed by their physician(s); (2) a patient assessment of their satisfaction with the method of pain management employed by their nurse(s); (3) a patient assessment of their satisfaction with the overall treatment they received for the management of their pain. This study was scored on a six-point Likert scale ranging from 6 for very satised 1 for very dissatised to establish reli- ability and validity (Lin 2000, Panteli & Patistea 2007). The Barriers Questionnaire-Taiwan form (BQT) Ward and Colleagues proposed the Barriers Questionnaire (BQ), which was specically developed to measure barriers to the use of analgesics in patients with cancer (Ward et al. 1993). The BQT was translated and modied specically for Taiwanese participants. It comprises nine subscales with 34 items (Lin & Ward 1995). Based on the results of content analysis of the Taiwanese population, several items were added to the BQT. The subscale of fear of injection was dropped; and a three-item subscale labelled religious fatal- ism was added. Another three-item subscale labelled P.R.N. was also added. The nal BQT consisted of nine subscales, Declined participation (n = 19) Not interested (n = 10) Felt too burdensome (n = 4) Other reasons (n = 5) Randomised (n = 68) Allocated to the experimental group (n = 34) Allocated to the control group (n = 34) Completed assessment at T1 (n = 34) Complete follow up at T2 (n = 32) Too ill (n = 2) Completed assessment at T1 (n = 34) Complete follow up at T2 (n = 32) Transferred to hospice ward (n = 1) Did not wish to continue (n = 1) Complete follow up at T3 (n = 31) Did not wish to continue (n = 1) Complete follow up at T3 (n = 30) Died (n = 1) Missed because researcher was unavailable (n = 1) Assessed for eligibility (n = 87) Figure 1 Flow chart of the trial. P-L Chou and C-C Lin 1860 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 with 34 items (Lin 2001). These subscales included the fol- lowing: (1) addiction (three items); (2) disease progression (three items); (3) pain tolerance (three items); (4) fatalism (three items); (5) religious fatalism (three items); (6) P.R.N. or as needed (three items); (7) concern about side effects (10 items); (8) fear of distracting physicians (three items); and (9) a desire to be good (three items). The BQT asks patients to rate the extent to which they agree with each item on a scale from 0 (do not agree at all) 5 (agree very much). This study used both subscale scores and total score in the analyses. The reliability and validity of the BQT were previously estab- lished (Chang et al. 2002, Lin et al. 2006). The Taiwanese version of the Morisky Medication Adherence Measure (MMAM-T) A structured four-item self-reporting measure of analgesic adherence developed by Morisky et al. (1986) was adminis- tered to patients to measure their compliance with analgesics. The theory underlying this measure is that errors of drug omission can occur for any or all of the following reasons: forgetfulness, carelessness, cessation of the drug when feeling better and use of the drug when feeling worse. The sum of the yes answers provided a composite measure of non-adher- ence. The total score ranged from 04, with higher scores indicating a greater degree of adherence. The group showing a high degree of adherence received a total score of 4; the group with moderate adherence received a score of 23 and the group with low adherence received a score of 01. A Taiwanese sample with cancer pain veried the reliability and concurrent construct validity of this measure (Tzeng et al. 2008). Brief Pain Inventory-Chinese version (BPI-C) This study uses the BPI-C version to measure the intensity of pain and the degree to which pain interfered with daily activities (Wang et al. 1996). The rst part of the BPI com- prised the following four, single-item measures of pain intensity, with each item rated on a scale of 0 (no pain) 10 (the worst pain I can imagine): (1) worst pain, (2) least pain, (3) average pain and (4) pain now. A Taiwanese sample with cancer pain established the reliability and validity of this measure (Wang et al. 1996, Lin et al. 2006, Tsai et al. 2007). The Pain Education Booklet The primary researcher in this study developed the Pain Education Booklet using concise descriptions and illustra- tions to provide important information specic to Taiwanese patients with cancer and their family caregivers, addressing concerns of reporting pain and using analgesics. This pocket- sized booklet is 16 pages long and addresses nine common concerns. A panel of experts validated the content of the Pain Education Booklet. Further modications to the content of this booklet were made according to comments from patients and experts. Cancer outpatients previously used this booklet in a pain education programme (Chang et al. 2002, Lin et al. 2006). Karnofsky Performance Status (KPS) This study used the KPS to assess the performance status of patients. The KPS is rated on a scale of 1100, in steps of 10. The KPS has demonstrated a high level of predictive validity (Buccheri et al. 1996). Procedure A research assistant approached patientfamily groups to describe the study and obtain informed consent. On the day of the rst interview, the patients in the experimental group lled out the APS outcome questionnaire, the BQT, the BPI-C and the self-reported measure of analgesics. They also ll out a demographic questionnaire. After the patients had completed the questionnaire, the research assistant provided a pain education intervention session for patients and family caregiv- ers, using the Pain Education Booklet. Researchers conducted the session in a private room at the outpatient unit, to avoid interruptions. The research assistant discussed all of the content covered by the booklet and encouraged patients and family caregivers to ask questions. The pain education session took approximately 3040 minutes to complete. Patients and family caregivers were encouraged to call phone numbers included the booklet, following the education session, if they required answers to any questions. Each participant received a copy of the pain education booklet. The second and third interviews were conducted two and four weeks after the pain education session, respectively. At each interview, the patients were asked to complete the questionnaire again. Researchers took the chance to answer any questions the patients or family caregivers had and reviewed the information on pain educa- tion. Patients and their family caregivers in the control group received conventional care. Patients in the control group individually and independently completed the questionnaires on pain and demographic data during the rst interview. They complete the questionnaires during the two- and four-week follow-up interviews. The control group did not receive an education programme. The research assistant only answered questions asked by patients or family caregivers. If the interviewer observed that a patient appears to be in pain or distress, or if a patient verbalised pain or distress, the assessment or follow-up would cease until the patient was relieved fromthese symptoms. Noadverse events or side effects resulted from the intervention. Pain management Pain education to improve pain management 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1861 Data analysis This study used complete analysis to interpret the collected data. The generalised estimating equations (GEE) analyses the effects of the pain education programme on patient satisfaction, and the Sobel test under the SAS SAS system (version 8.2; SAS Institute Inc., Cary, NC, USA) assesses the mediating role on the barriers to using analgesics and analgesic adher- ence. To account for repeated measurement dependence that might occur at the two- and four-week intervals (Liang & Zeger 1986, Zeger & Liang 1992, Lin et al. 2006), GEE were used to analyse whether the pain education programme improved patient satisfaction with nurses and physicians. The GEE analysis compensated for the baseline heterogeneity (differences existing before the intervention) between the experimental and control groups and the effects of maturation (changes in outcome variables resulting from the passage of time). To control for the effect of pain intensity on patient satisfaction, this study factored the mean pain intensity (worst pain + average pain + least pain + painnow/4) intothe analytic model. As hypothesised in this study, patients in the experi- mental group displayed a greater degree of satisfaction regard- ing pain management. The patients satisfaction with regard to pain management was a signicant mediator between barriers to using analgesics and analgesic adherence. The Sobel test described by Baron and Kenny (1986) and Preacher and Hayes (2004) was used to examine the mediating effects of variables. In this manner, we were able to estimate the direct, indirect and total effects of the causal relationships involving this mediating variable. In this study, the Sobel test under the SAS SAS system (version 8.2) was used to assess the mediating role of patient satisfaction on barriers to using analgesics and analgesic adherence. Ethical approval This study obtained approval from the Human Subject Committee of the hospital. All subjects signed written informed consent forms. Results Demographic information The participants in this study suffered from various forms of cancer, including nasopharyngeal (21%), breast (18%), oral (16%), liver (13%), lung (6%), colorectal (6%) and various others (20%). In the experimental group, 61% of the participants were women. The mean age was 55 (SD 1438). The mean years of education were 774 (SD 423). The mean KPS score was 81 (SD 138). The mean pain intensity score was 331 (SD 137) before intervention. Among these participants in the experimental group, the cancer identied in 77% of the test subjects had metastasised. In the control group, 60% of the patients were women. The mean age was 59 (SD 1660). The mean years of education were 857 (SD 488). The mean KPS score was 85 (SD 114). The mean pain intensity score was 376 (SD 194) before intervention. Among these participants in the control group, the cancer identied in 70% of the test subjects had metastasised. No signicant difference was displayed be- tween the two groups regarding the prescriptions (ex: NSAID, codeine/tramadol, morphine, fentanyl, adjuvant drugs) provided by physicians. No signicant demographic differences were noted between the two groups, with the exception of treatment status (i.e. patients who received chemotherapy or radiotherapy vs. those who received neither), which reached signicance (p = 002). Determining whether the pain education programme improved patient satisfaction with the pain management provided by nurses There was no signicant difference at baseline (p = 01065) in patients satisfaction levels between the two groups. The control group showed a signicant maturation effect in the second and fourth weeks (p = 00027 and p = 00073). However, the elevation slope of the experimental group was signicantly higher than that of the control group in both the second (p < 00001) and fourth weeks (p = 00002), after adjusting for the effects of treatment and mean pain intensity. Clearly, the pain education programme signicantly increased patient satisfaction with the nurses. The satisfac- tion felt by the experimental group regarding the pain management of nurses increased signicantly from 395 during the pretest to 518 by the fourth week. On the contrary, the satisfaction felt by the control group was 428 during the pretest and 472 by the fourth week. Although both groups displayed a signicant elevation in satisfaction levels from the pretest to the fourth week, only a minimal increase in patient satisfaction was observed between the second week and the fourth week (Fig. 2; Table 1). Determining whether the pain education programme improved patient satisfaction with pain management conducted by physicians The baseline scores of the experimental group were signi- cantly lower than the control group with regard to satisfac- tion with the pain management conducted by physicians P-L Chou and C-C Lin 1862 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 (p = 00002). The control group showed signicant matura- tion in the second week (p = 00415). However, the elevation slope of the experimental group was signicantly greater than the control group in both the second (p < 00001) and the fourth weeks (p < 00001) after adjusting for baseline heterogeneity, the effect of treatment and mean pain inten- sity. The pain education programme signicantly improved patient satisfaction with physicians. The satisfaction felt by the experimental group regarding the pain management of physicians increased signicantly from 454 during the pretest to 564 by fourth week. In contrast, the satisfaction felt by the control group was 511 during the pretest and 545 by the fourth week. Despite the signicant improvement in satisfac- tion in both groups between the pretest and the fourth week, only a slight improvement was observed in patient satisfac- tion between the second week and the fourth week (Fig. 3; Table 2). Determining the mediating role of patient satisfaction with nurses to barriers in using analgesics and adherence to the prescribed use of analgesics One of the objectives of this study was to determine whether patient satisfaction with nurses was a mediating factor between barriers to using analgesics and adherence to the prescribed use of analgesics. The results revealed that in the experimental group, patient satisfaction with pain manage- ment was a mediator between barriers to using analgesics and adherence to the prescribed use of analgesics (p < 00001), accounting for 4773% of the observed mediation (Table 3). However, no mediation relationship was observed in the control group. Figure 4 shows a path analytic model of the relationships related to patient satisfaction with nurses, barriers to analgesic use and adherence to the prescribed use of analgesics. Determining the mediating role of patient satisfaction with physicians on barriers to the use of analgesics and adherence to the prescribed use of analgesics This study examined patient satisfaction with physicians to determine whether a mediating relationship existed between satisfaction and barriers to the use of analgesics and adherence to the prescribed use of analgesics. The results showed that in the experimental group, patient satisfaction with pain management was a mediator between barriers to using analgesics and adherence to the prescribed use of analgesics (p < 00001), accounting for 4556% of the mediation (Table 3). However, no mediating relationship Patients satisfaction with nurses (n = 61) 1 2 3 1 2 3 0 1 2 3 4 5 6 Test time S c o r e
Experimental group Control group Experimental 395 507 518 Control 428 47 472 1 2 3 Figure 2 Patients satisfaction score with nurses of Experimental Group and Control Group (1 = pretest, 2 = second week, 3 = fourth week). Note: Score was estimated with a generalised estimating equations model of the patient satisfaction with nurses. Table 1 Generalised estimating equations model of the patient satisfaction with nurses (n = 61) Variable Regression coefcient Standard deviation Z p Intercept 42817 02391 1791 <00001 Experimental vs. control group 02321 01438 161 01065 Second week vs. pretest 04204 01401 300 00027* Fourth week vs. pretest 04358 01624 268 00073* Interaction between second week and group 06991 01561 448 <0001* Interaction between fourth week and group 07895 02134 370 00002* Treatment status (yes vs. no) 02535 01539 165 00995 Mean pain intensity (worst pain + average pain + least pain + pain now/4) 00646 00421 153 01248 Interaction between second week and group shows the difference between the experimental and control groups in change between pretest and second week. Interaction between fourth week and group shows the difference between experimental and control groups in change from pretest to fourth week. The change in the experimental group is represented by the change in the control group plus the interaction term. *p < 005. Pain management Pain education to improve pain management 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1863 was evident in the control group. Figure 5 displays a path analytic model of the relationships between patient satisfac- tion with physicians, barriers to analgesic use and adherence to the prescribed use of analgesics. Discussion Very few studies have examined the effectiveness of inter- vention on patient satisfaction with pain management. Even fewer studies have shown signicant improvements in patient satisfaction with pain management, despite implementing educational interventions. One long-term study (de Wit et al. 1997) conducted in the Netherlands in 1997 focused on 313 homecare patients with cancer. During hospitalisation, health care professionals conducted face-to-face pain education followed by a telephone-delivered reiteration of pain educa- tion on the third and seventh days following discharge. The researchers found no signicant improvement in satisfaction with pain control, despite a reduction in pain intensity (de Wit et al. 1997). Yates et al. (2004) conducted a pain education programme with 189 homecare patients with cancer. During the return visit, the health care professionals administered a pain education session with the patients and conducted a telephone interview one week after the visit. Although the programme enhanced the perception of control in the minds of patients, no signicant difference in patient satisfaction with pain management was observed between the rst week and second month following the intervention (Yates et al. 2004). This may be attributed to the fact that the interviews on pain education were conducted over the telephone without face-to-face contact between patients and medical staff. In addition, the education did not involve any family members. In this study, however, pain education consisted of an extended, face-to-face intervention involving patients and family caregivers. Previous studies have revealed that the level of patient satisfaction with pain control might be inuenced by multiple factors. Sherwood identied three factors inuencing the patients satisfaction feel regarding pain management. These factors included previous experience with pain (affecting beliefs and attitudes regarding pain management and expec- tations about pain); patient appraisals of health care profes- sionals (if the health care professionals managed pain with empathy, care, sufcient knowledge and technique); and personal experience managing pain (such as the involvement of family caregivers in the treatment plan and the develop- ment of effective strategies to cope with pain) (Sherwood et al. 2000). Studies have also investigated the satisfaction felt by patients with terminal cancer regarding pain manage- ment using phenomenology. These studies revealed three 1 2 3 1 2 3 0 1 2 3 4 5 6 Test time S c o r e Experimental group Control group Experimental group 454 552 564 Control group 511 541 545 1 2 3 Patients satisfaction physicians (n = 61) Figure 3 Patient satisfaction with physicians in the Experimental and Control Groups (1 = pretest, 2 = second week, 3 = fourth week). Score was estimated by generalised estimating equations model of patient satisfaction with physicians. Table 2 Generalised estimating equations model of patients satisfaction with physicians (n = 61) Variable Regression coefcient Standard deviation Z p Intercept 51124 01894 270 <00001 Experimental vs. control group 05722 01535 373 00002* Second week vs. pretest 02970 01457 204 00415* Fourth week vs. pretest 03396 01853 183 00069* Interaction between second week and group 06812 01579 431 <00001* Interaction between fourth week and group 07566 01953 387 00001* Treatment status (yes vs. no) 00359 00875 041 06817 Mean pain intensity (worst pain + average pain + least pain + pain now/4) 01437 00371 387 00001 Interaction between second week and group shows the difference between the experimental and control groups in change between pretest and second week. Interaction between fourth week and group shows the difference between experimental and control groups in change from pretest to fourth week. The change in the experimental group is represented by the change in the control group plus the interaction term. *p < 005. P-L Chou and C-C Lin 1864 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 themes inuencing patient satisfaction with pain manage- ment: communication, planning and trust. Patients expect health care professionals to communicate in an open and honest manner regarding pain management. After physi- cians and nurses gain the trust of patients, patients show an increased willingness to participate in the pain management plan (Bostrom et al. 2004). Other factors that may con- tribute to patient satisfaction with pain management include a greater degree of social support (Jamison et al. 1993) and the physicianpatient relationship, manifesting itself as an awareness of empathy and condence in physicians and nurses (Jamison et al. 1993), such that patients trust their health care providers (McCracken et al. 1997, Jensen et al. 2004). In addition, a recent study revealed the four main factors inuencing satisfaction with the quality of pain management. These included adminis- tering treatment in a respectful manner, the provision of a safety net, the efcacy of pain management and the involvement of the patient as a partner. Among the four factors, a collaborative relationship between patients and health care professionals was the most important factor in pain management determining the degree of control per- ceived by patients (Beck et al. 2010). In this study, several factors may explain how providing pain education contributes to improving patient satisfaction with pain management. Long-term engagements consisting of multiple face-to-face visits with systematic pain education provided patients with the opportunity to discuss how pain management ought to be implemented. Such discussions provided the opportunity to describe pain symptoms, evaluate the effectiveness of medication and discuss the pain manage- ment plan with physicians and nurses during every clinical visit. In addition, researchers encouraged patients to take an active role in their pain treatment and health care BQT score Adherence 049* 085* Without mediation: 087* With mediation: 046* Patient satisfaction with nurses Figure 4 The mediation relationship of patient satisfaction with nurses on the Barriers Questionnaire-Taiwan form score and anal- gesic adherence in the experimental group. *p < 005. BQT score Adherence 047* 084* Without mediation: 087* With mediation: 047* Patient satisfaction with physicians Figure 5 The mediation relationship of patient satisfaction with physicians on the Barriers Questionnaire-Taiwan form score and analgesic adherence in the experimental group. *p < 005. Table 3 Sobel test for the mediation effects of patient satisfaction with nurses and physicians on the barriers adherence relationship in the experimental group Std b SE p-value Test of mediation pathway of patient satisfaction with nurses Barriers (predictor) adherence (outcome) 087 014 <00001 Barriers (predictor) satisfaction (mediator) 049 008 <00001 Satisfaction (mediator) adherence (outcome) 085 016 <00001 Barriers (predictor) adherence (outcome) with mediator 046 015 00028 Mediation results Per cent of the total effect that is mediated: 4743% Test statistic: 393 p-value: <00001 Test of mediation pathway of patient satisfaction with physicians Barriers (predictor) adherence (outcome) 087 014 <00001 Barriers (predictor) satisfaction (mediator) 047 008 <00001 Satisfaction (mediator) adherence (outcome) 084 017 <00001 Barriers (predictor) adherence (outcome) with mediator 047 015 00022 Mediation results Per cent of the total effect that is mediated: 4556% Test statistic: 382 p-value: 00001 p-value at 005 level. Std b, standardised beta coefcient; SE, standard error. Pain management Pain education to improve pain management 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 1865 professionals were expected to keep lines of communication open regarding the outcomes of pain management interven- tion. When patients experience care and empathy delivered in a consistent manner, they perceive their relationship with health care professionals as collaborative. These factors may contribute to improving perceptions of pain management. The factors that inuence adherence are multidimensional. Several scholars have taken a socio-psychological perspective in suggesting several factors that inuence patient adherence, including the physicianpatient relationship, the communi- cative skills of physicians, the provision of information and social support (Cameron 1996, Ryan 1999, Lowe et al. 2000). The behaviour and attitudes displayed by health care professionals can positively or negatively inuence the adherence of patients (Cameron 1996). One important factor contributing to the under-treatment of cancer pain is a lack of adherence to the therapeutic regimen (Lin et al. 2006, Tzeng et al. 2008, Valeberg et al. 2008). In previous studies, pain interventions signicantly increased patients knowledge of pain, but did not improve their adherence to taking analgesics (Wells et al. 2003, Miaskowski et al. 2004). These results indicate that merely enhancing patient knowledge with regard to medication does not signicantly improve adher- ence to taking prescribed medication. Patient adherence is inuenced by multidimensional elements, such as socio- psychological perspectives, which health care professionals must consider when attempting to break down barriers that prevent patients with cancer from taking analgesics. Such considerations could be far more effective than merely focusing on enhancing patient knowledge. Improving patient satisfaction with medical care is another way to increase adherence to prescribed analgesic use, thereby improving the management of cancer pain. Results of this study indicate that the implementation of pain education noticeably increased satisfaction scores dur- ing the second- and fourth-week follow-ups, compared with the satisfaction scores in the pretest. Nevertheless, the scores of the experimental group regarding satisfaction with pain management provided by nurses signicantly improved from 507 in the second week to 518 by fourth week. In addition, satisfaction with the pain management provided by physi- cians increased from 552564 by the fourth week. How- ever, this incremental improvement was insufcient to achieve statistical signicance. This study adopted a Likert six-point scale for the satisfaction questionnaire. Patients satisfaction felt towards the pain management provided by nurses was 395 during the pretest, which was between somewhat unsatised and somewhat satised. In the second week, the level of satisfaction signicantly increased to display a score between satised and extremely satised. On the other hand, patient satisfaction with their physician was between somewhat satised and satised with a score of 454 during the pretest, signicantly improving to a point between satised and extremely satised by the second week. The above results reveal that patients felt satised to extremely satised by the second week of pain education. However, no signicant difference in the change of satisfac- tion felt by patients was observed during the fourth week. Because this study only tracked patient satisfaction for four weeks, no demonstrable change in follow-up satisfaction was observed. This study suggests several possible explanations for the lack of signicant changes in satisfaction between the second and fourth weeks. First, the score regarding the satisfaction of pain management displayed extremely right- skewed distribution. Owing to the inuence of ceiling effect, the margin of improvement was limited. In addition, long- term follow-up investigation regarding the ongoing commu- nication between cancer outpatients and physicians revealed that dimensions such as interest/engagement or friendliness/ warmth were signicantly correlated with the patients satisfaction felt towards physicians one week or three - months after outpatient visits. In addition, the correlation coefcient showed nearly no change, suggesting that there were no signicant changes in patient satisfaction with physicians over the short-term or the long-term (Ong et al. 2000). Other studies have also mentioned that testretest reliability related to satisfaction with physicians was moder- ately correlated after four weeks (r = 041) (Lam et al. 2005). Meanwhile, the testretest coefcient regarding patient satisfaction adopted by the consultation satisfaction ques- tionnaire was 082 within three weeks (Baker & Whiteld 1992). These studies revealed that patient satisfaction regarding physicians is relatively stable correlated across time. Additionally, we must not exclude the degree to which subsequent interaction with other staff members or patients cloud these relationships. Because this study only collected follow-up data for four weeks, we were unable to investigate long-term changes with regard to satisfaction. Therefore, we suggest a future study including long-term follow-ups to gauge changes in the level of patient satisfaction with pain management. This study was limited by several factors. First, it was not a double-blind study. Second, patient satisfaction with physi- cians or nurses accounted for 45564773% of the mediation effect on barriers to using analgesics and adherence to the prescribed use of analgesics. Other factors, such as social circumstances or medication side effects may have inuenced these relationships, but remain unexplored. Third, the sample size used to conduct the Sobel test used to estimate the mediation effect was small. P-L Chou and C-C Lin 1866 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 18581869 This is the rst study investigating pain education as a way to improve the long-term patient satisfaction feel towards pain management, with an examination of the mediating effect of patient satisfaction on pain control. This study found that systematic, face-to-face pain education involving multiple visits with patients and family caregivers can result in the long-term enhancement of patient satisfaction with pain management. Conclusions This study veried that patient satisfaction is a mediator with regard to the barriers to using analgesics and analgesic adherence. The outcome of the study not only supports the efcacy of pain education programmes among patients, family caregivers and medical personnel to improve patient satisfaction but also emphasises the important role of patient satisfaction in improving analgesic adherence in patients with cancer. This change in behaviour could ultimately result in improvements in the management of cancer pain. Relevance to clinical practice Patient satisfaction with physicians and nurses operates partially as a mediating factor and cannot be discounted when attempting to improve adherence to the prescribed use of analgesics. The results of this study show that with respect to the control of cancer pain, the enhancement of patient satisfaction can signicantly improve patient adherence. 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