Following professional concern in the Central Nottinghamshire Healthcare (NHS) Trust that cancer pain management 'could be better', a multidisciplinary group from primary and secondary care, chaired by the Hospice Medical Director, met to discuss the development of a clinical guideline for the management of cancer pain in adults.
The main aim of the group was to ensure that patients received a consistent approach to the effective management of their cancer pain, whether they were being cared for in the local hospice, in hospital, or in their own home.
Guidelines for Managing Cancer Pain in Adults,1 developed by the Working Party on Clinical Guidelines in Palliative Care, was used as a basis for the locally developed guideline. Reference was also made to work on morphine in cancer care undertaken by an expert working group of the European Association of Palliative Care.2
The guideline was developed for local use using the 10 steps outlined in the Royal College of Nursing document Clinical Guidelines What You Need to Know.3
Step 1 Developing a working group:
The group members were chosen to ensure that all professions who would be affected by, or involved in, the guideline were represented. These included: medical staff; palliative care, Macmillan, community and general ward nurses; pharmacists; two GPs; and clinical effectiveness staff from the Trust and health authority.
Step 2 Communicating and informing:
Before work on the guideline began, discussions were held with all staff who would be affected by the guideline. Awareness sessions were held at locations near to staff's place of work to encourage attendance.
The Hospice Medical Director also visited professional forums in the Trust to inform staff at all levels of the guideline development.
The team briefing process, and articles in staff newsletters, were also used to increase awareness.
Step 3 Development and adaptation:
As a nationally recognised guideline for the management of cancer pain in adults already existed, it was decided that this would be adapted for local use and supplemented by additional documentation, in the form of a patient pain assessment tool and guidance notes for staff.
One of the main advantages of adapting an existing guideline was that the time-consuming tasks of carrying out literature searches, undertaking critical appraisal of information, and testing reliability and validity had already been undertaken.
Step 4 Adoption, adaptation and assessment:
Although ownership is more readily achieved by active participation in guideline development, adapting available guidelines to local circumstances can be sufficient to stimulate acceptance.
This has been achieved by the use of a flow chart that summarises information on the assessment of pain and prescribing guidance (Figure 1). The flow chart is based on a guideline developed by The National Council for Hospice and Specialist Palliative Care Services.1
|Figure 1: Flow chart summarising information on the assessment of pain and prescribing guidance|
An additional measures chart provides pharmaceutical information and contact details for key local health professionals.
Step 5 Formatting:
To ensure that the guideline is used, the layout must be well designed and the information easy to read.
The cancer pain guideline combined the use of flow charts in A3 size for display on walls and pocket size (10cm x 15cm). Pain records were also in two formats; one laminated for repeated use and one designed for single use by community patients (Figure 2).
|Figure 2: Pain record designed for single use by community patients|
Information was also made available in Braille for people with visual impairment; this record is completed by the patient with assistance from staff.
A summary sheet is completed by nursing staff, based on the patient's pain record. This provides an ongoing record for medical staff to observe the effectiveness of the pain management overall, including patient satisfaction with pain relief. Guidance notes assist staff in completing the summary chart appropriately.
Step 6 Testing reliability and validity:
The guideline had been tested for reliability and validity by the original developers. The flow chart is based on the World Health Organization analgesic ladder.4 The pain assessment chart was adapted from several other well-validated assessment tools.
Step 7 Drafting:
All documentation relating to the guideline was piloted and amended following evaluation. This resulted in the development of notes for nursing staff to help patients complete the pain record.
Step 8 - Implementation:
Implementation requires changes in behaviour. Clinical audit, education and training were all used to promote the guideline. A staff nurse at the hospice was funded to provide awareness and training sessions, to help staff understand the importance of applying the guideline when caring for patients with cancer pain.
Feedback from these sessions provided the working group with useful information, resulting in changes to documentation and guidance notes. The awareness sessions also highlighted further training needs for staff, which have been communicated to the Trust's training and development department.
Step 9 Dissemination:
One of the many reasons why a guideline may not bring about change is that it does not reach the intended users. A subgroup was therefore established to develop a strategy for ensuring effective dissemination of the guideline.
Dissemination has been a time-consuming task, as all health professionals in both primary and secondary settings who care for adult patients with cancer pain needed to attend awareness sessions and have a copy of the guideline.
More than 3000 copies of the finished document were delivered by hand and explained to staff by members of the development group. This provided a further opportunity for problems relating to guideline content, documentation and staff compliance to be addressed.
Step 10 Audit:
The application of clinical guidelines should improve the quality of care provided to patients. However, concentrating on patient outcomes alone as a measure of the kuccess of the guideline is insufficient; the whole process development, dissemination and implementation needs to be evaluated.
For example, patient outcome may be unchanged because the target audience did not receive the guideline or the professional has not read or has forgotten the information contained in the guideline. Without assessment of each step, the inability to show effectiveness may lead to people not knowing which aspect of the guideline development is inadequate, and needs improving or changing.
An audit of the dissemination process has recently been carried out. This involved a short face-to-face or telephone interview with a random sample of staff from areas where the guideline had been implemented.
Initial findings showed that the majority of staff have received the documentation and are using the guideline.
In one area, the staff member who had received the guideline had not spoken to the remaining staff. This has now been followed up, and the details have been passed down to all appropriate members of the team in that area.
Some other staff requested further awareness sessions to qualify their use and completion of the documentation. These sessions are now being organised.
An audit to measure the care standards outlined in the guideline is currently being developed, and will be carried out later this year. Following this, a review of the guideline, based on the audit findings and any recent research evidence, will be carried out.
- Successful implementation and use of guidelines requires commitment and dedication of time to the development process.
- Make sure that all appropriate professionals and users of the service (where appropriate) are involved and consulted.
- Where national guidelines have already been developed, consider their adaptation for local use instead of starting from scratch. This saves time, particularly with literature searching, critical appraisal, and testing of validity and reliability.
- Pay particular attention to the presentation of information. Make it easy to read, eye catching and formatted in a style that is most appropriate to those who will be using it.
- Always pilot the guideline widely. In addition to highlighting any necessary changes, this increases awareness of the guideline,encourages local ownership by staff, and lessens the risk of problems following implementation.
- Use several methods of dissemination to highlight awareness. For example, attend professional meetings, use staff newsletters, fliers, and the local intranet.
- Ensure that you have an up-to-date mailing list. Where possible, do not send guidelines out deliver them personally.
- Do not assume that a guideline has reached all those for whom it was intended. Check that it has.
- Guideline implementation should improve patient care. Use the clinical audit process to measure the standards of care, and to highlight any changes required, both to patient care and to the guideline itself.
- Revisit the guideline. Ensure that the care it outlines remains up to date and relevant.
- Acknowledgement: See Letters, December 1999
- The documentation for the guideline was sponsored by a Boehringer Educational Grant.
- Working Party on Clinical Guidelines in Palliative Care. Guidelines for Managing Cancer Pain in Adults. National Council for Hospice and Specialist Palliative Care Services, 1999.
- Expert Working Group of the European Association for Palliative Care. Morphine in cancer pain: modes of administration. Br Med J 1996; 312: 823-6.
- Royal College of Nursing. Clinical Guidelines What You Need to Know. London: RCN, 1998.
- World Health Organization. Cancer Pain Relief and Palliative Care. Report of a WHO Expert Committee (WHO Technical Report Series, 804). Geneva, Switzerland: WHO, 1990: 1-75.