Nursing expertise in palliative care is essential in providing pain relief to patients with chronic diseases. Examinations of the use of nonpharmacological therapies for chronic pain management in palliative care have revealed what nonpharmacological therapies have been used, but there is insufficient knowledge regarding nurses’ attitudes, views and experiences regarding pain therapies in this context.

Design

A qualitative descriptive design was chosen.

Methods

Data were collected through individual interviews in a purposive sample with 15 nurses to ensure maximum variation. The data were analysed using qualitative content analysis. This study aligns with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Results

The analysis yielded four categories, as follows: “building and sustaining favourable therapeutic relationships” involved the creation of trust and a solid relationship; in “recognising the diversity of patients’ needs,” person-centred care is expressed as being vital for individualised nonpharmacological pain management; “incorporating significant others” describes how nurses can help to ease the patient's pain by identifying positive encounters with family members or friends; and in “recognising the existence of barriers,” nurses highlight vulnerable groups such as children, for whom nurses require special education to enable optimal nonpharmacological pain management.

Conclusion

The unique knowledge that nurses gain about the patient through the nurse–patient relationship is central and crucial for successful nonpharmacological pain management.

Relevance to clinical practice

This study emphasises the need for nurses to get to know their patient and to be open and sensitive to patients’ descriptions of their unique life situations, as this provides the necessary knowledge for optimal care and pain management. Nurses should be encouraged and given the opportunity to attend specialised training in palliative care and pain management.

What does this paper contribute to the wider global clinical community?

Nurses view the nurse–patient relationship as central for nonpharmacological pain management in palliative care.
To provide nonpharmacological pain management successfully to palliative care patients, care must be individualised according to each patient's pain management needs.
Within palliative care, nurses are professionals who can identify and customise nonpharmacological pain management for patients.
Nurses are able to identify barriers that prevent or otherwise limit the effect of pain management for patients in palliative care.
Given the importance of the nurse–patient relationship to pain management, it is important for future studies to consider whether and how nurses might be able to lead pain management in palliative care.
Nurses should be encouraged and given the opportunity to attend specialised training.

1 INTRODUCTION

Pain is a common problem presented by patients to healthcare practitioners. Nurses’ understanding of patients’ pain is important in patient care, as nurses play a central role in patients’ pain management (Brorson, Plymoth, Ormon, & Bolmsjo, 2014). This role is vital, because pain negatively affects the quality of life of patients and can be a cause of morbidity (Bicek, 2004; Davies et al., 2013; Yates et al., 1998). In their quest to manage patients’ pain, nurses use nonpharmacological therapies, in addition to analgesic medication (Peng et al., 2013). Nurses’ experiences with nonpharmacological therapies to manage the chronic pain of their palliative care patients is critical, because such therapies play an essential function in reducing patients’ pain (Lynch, 2001; Mathew, Mathew, & Singhi, 2011; Yates et al., 2007). Thus, there is a need for a deeper understanding of the experiences and views of nurses concerning the use of nonpharmacological therapies of pain management for palliative care patients.

2 BACKGROUND

Chronic pain management in palliative care involves patients who have been diagnosed with a chronic illness (Zambia Ministry of Health, 2012) and who experience chronic pain lasting for more than 12 weeks (U.S. National Institutes of Health, 2011). Recently, nonmedication and nonsurgical interventions for pain treatment (Lin, Bohnert, Jannausch, Goesling, & Ilgen, 2018)—also known as nonpharmacological therapies—have become increasingly popular (Calenti et al., 2016) and can be useful in managing chronic pain in palliative care by meeting patients’ psychological, social and spiritual needs (Zambia Ministry of Health, 2012). Therefore, it is vital to understand nurses’ experiences with and views on nonpharmacological pain management therapies, because their attitudes regarding and knowledge of these therapies can affect their response to the way they manage the pain of their patients (Bicek, 2004).

Studies have shown that nurses have experiences with using both pharmacological (Hartwig et al., 2014) and nonpharmacological therapies to manage the pain of their patients (Peng et al., 2013). However, some studies have shown that the effectiveness of pharmacological management for chronic pain is often limited (Mitchell & O’Donnell, 2013), and there is growing concern about the adverse effects of pharmacological pain management, including opioid dependence (Taylor et al., 2016). Therefore, nonpharmacological approaches to chronic pain may be an attractive alternative or adjunctive pain management (Taylor et al., 2016). While nonpharmacological therapies may not generally stand on their own, studies have shown that they are important because they can be used to overcome the limitations of pharmacological therapies in pain management (Mitchell & O’Donnell, 2013).

In addition, studies have identified inadequacies in the knowledge of chronic pain management among nurses (Desai & Chaturvedi, 2012), despite advancements in the treatment of both chronic and life-threatening diseases that have resulted in an increased demand for quality palliative care (Head et al., 2016). Although nursing expertise in palliative care is essential for the multidisciplinary team providing pain relief to patients suffering from chronic diseases (Ramanayake, Dilanka, & Premasiri, 2016), evidence shows that nurses are inadequately prepared to care for patients in chronic pain and have a greater orientation towards the biomedical dimension of chronic pain than the behavioural dimension (Prem et al., 2011).

Nonpharmacological measures are an important part of pain management in palliative care (Coelho, Parola, Cardoso, Bravo, & Apostolo, 2017), as medical intervention for chronic pain often cannot resolve the pain completely (Sturgeon, 2014). Thus, chronic pain management approaches that encompass and integrate physical and psychological approaches such as hypnosis, relaxation and massage have been proven useful (Gregoire & Frager, 2006). Furthermore, approaches such as the use of music therapy (Krishnaswamy & Nair, 2016), reassurance, physical activity, relaxation exercises (e.g. a cool draft of air such as from a handheld fan), physiotherapy and respiratory therapy have also been found to be useful (Bausewein & Simon, 2013). In addition, food provision and psychosocial support are key elements in the provision of nonpharmacological pain relief in palliative care patients (Herce et al., 2014).

Although nurses have been shown to have used nonpharmacological therapies of pain management in palliative care (Peng et al., 2013), most studies have only provided an understanding of what nonpharmacological therapies have been used and have provided insufficient information regarding the nurses’ views on nonpharmacological pain management for palliative care patients. Therefore, it is important to investigate the experiences and views of nurses in regards to nonpharmacological pain management for palliative care patients, as doing so will add to the knowledge of nonpharmacological therapies and of their role and importance in managing chronic pain in palliative care.

3 AIM

To explore the experiences and views of nurses regarding nonpharmacological therapies of chronic pain management in palliative care.

4 METHODS

4.1 Design

A qualitative exploratory descriptive design with narrative interviews (Mishler, 1986) and qualitative content analysis (Graneheim, Lindgren, & Lundman, 2017; Graneheim & Lundman, 2004) was chosen to explore nurses’ experiences and views regarding nonpharmacological pain management. This study aligns with the consolidated criteria for reporting qualitative research (COREQ) (Tong, Sainsbury, & Craig, 2007) (Appendix S1) and obtained approval from the national ethics board, which is required in Zambia.

4.2 Context

The study was conducted in Livingstone, Zambia, where nurses take care of palliative patients. In Zambia, the concept of palliative care is relatively new, and there is a large unmet need for palliative care services (Zambia Ministry of Health, 2012). In Livingstone, palliative care services are organised in a threefold manner. First, a multidisciplinary palliative care team at the hospital sees the patients and offers palliative care. Second, after patients are seen and treated at the hospital, the palliative care team refers some of them to the hospice for long-term care. Third, other patients who do not choose to be referred to the hospice are referred back home for home-based palliative care under the care of volunteer nurses and home-based care givers who assist the family to care for the patient. Although the palliative care team from the hospital follows up with some discharged patients, nurses at the hospice and volunteer nurses in the community play a prominent role in managing the pain of their patients.

4.3 Sampling and participants

This study included nurses who were involved in the provision of palliative care at Livingstone Central Hospital or at St Joseph's Hospice, as well as nurses who had retired but who provided palliative care in the community and had at least two years of experience working at a hospital or hospice in Africa. Written permission was obtained from the management of the hospice through the District Medical Office; similar permission was received from Livingstone Central Hospital.

Nurses at the hospital and the hospice were initially contacted by the hospice administrator and were provided with verbal and written information about the study. Volunteer nurses in the community were contacted individually and were given verbal and written information about the study by the first author (WM). These community volunteer nurses were identified and contacted through an organisation called St. Francis Home Based Care, which provides home-based care services to chronically ill patients in the community. A total of fifteen nurses were approached and invited to participate into the study, and they gave their written consent. These were invited through purposive sampling, whereby the researcher consciously selected participants for maximum variation, as shown in Table 1. To ensure a broader understanding of the phenomena under study (Graneheim & Lundman, 2004), nurses with varying levels of experience were chosen for the study. A total of 15 participants were included in this study, as no new information emerged after the thirteenth interview (Polkinghorne, 2005). The concern in this study was not how much data the researchers could gather, or from how many sources data could be collected, but rather whether the data collected would be sufficiently rich to bring refinement and clarity to an understanding of the experiences and views of nurses (Polkinghorne, 2005).

Table 1. Sociodemographic information of participants (n = 15)

Characteristics of participants	Descriptions	Numbers
Age range	26–64 years	15
Sex	Male	5
Sex	Female	10
Marital status	Married	4
	Never married	5
	Divorced/separated	4
	Widowed	2
Religion	Christian	14
Religion	Moslem	1
Highest educational level	Degree holder	3
	Diploma holder	8
	Certificate holder	4
Employment	Government sector	12
Employment	Self-employed	3
Years of service	2–10	3
	11–20	5
	21–30	2
	31–40	2
	Above 40	3
Institution	Livingstone Central Hospital	7
	St Joseph's Hospice	5
	Community volunteer nurses	3

4.4 Interviews

An interview guide was developed by the authors that comprised open-ended questions (Mishler, 1986) in order to explore various aspects of the nurses’ views on and experiences with nonpharmacological pain management. Two pilot interviews were conducted to test the interview guide. No major protocol revisions were made to the interview guide after the pilot interviews, so the pilot interviews were included in the study. Probing questions were used to obtain more information from the participants. For example, the question “tell me about your experience of nonpharmacological pain management” might be followed by a probing question such as “can you tell me more about why you think that?” For each nurse, the first author selected an appropriate location for the individual interview, depending on the preference of the participant. The interviews were conducted in English and lasted for 60–90 min and were audio taped and transcribed.

4.5 Data analysis

The data obtained were analysed using qualitative content analysis. The methodological challenges in this qualitative content analysis with a hermeneutic point of view strive to be close and connected to the participants and reveal meanings in the data (Graneheim et al., 2017; Graneheim & Lundman, 2004). The analysis was performed in several steps (Graneheim et al., 2017; Graneheim & Lundman, 2004). In the first step, the transcribed narrative text was read repeatedly in order to obtain a general sense of the overall meaning, and notes were written about the text while reading it. The second step involved the extraction of meaning units in the text that related to the views and experiences of nurses regarding nonpharmacological pain management. The third step involved revising the meaning units to ensure that they contained sufficient information. In the fourth step, the meaning units were condensed and coded. These steps were performed by the first author (WM) in discussion with the last author (CE). In the fifth step, similar codes were grouped into subcategories. This step was performed with discussion among all the authors. For examples of the analytical process, see Table 2. The categories are presented in the results section along with quotations that represent the range of ideas voiced, and participants are presented using codes within brackets to maintain confidentiality.

Table 2. Example of the qualitative content analysis process involving meaning units, condensed meaning units, codes, subcategories and category

Meaning units	Condensed meaning units	Codes	Subcategories	Category
Nonpharmacological therapies are useful to the patient and also to the nurse… This is because they help the nurse to understand the patient better.	Enable the nurse to understand the patient better	Eliminates misconceptions about the patient	Spending time getting to know the patient	Building and sustaining favourable therapeutic relationships
My opinion is that to a large extent, the benefits of nonpharmacological pain management therapies for the patient depend on the approach of the nurse. If you do not find out what the patient is comfortable with, your intervention will not be helpful… Your good approach to patients can help to relieve their pain.	Patient–nurse relationship determines benefits of nonpharmacological therapies	Nurse–patient relationship needs to be cordial; otherwise, therapy is not beneficial	Building a mutual trustful relationship

4.6 Preunderstanding

The first author (WM) is a male and has context-specific knowledge about palliative care in Livingstone, while the second (KP) and third (CE) authors are female European researchers who had limited knowledge about palliative care in Zambia at the start of the study. The first author is a counsellor, whereas the second and third authors are registered nurses and thus could provide a nursing perspective on the research question in focus.

5 RESULTS

The results consisted of four categories that describe different aspects of the experiences and views of nurses regarding nonpharmacological therapies of pain management in palliative care. The following four categories represent the interactions and inter-relationships that influenced patients’ pain management: “building and sustaining favourable therapeutic relationships,” “recognising the diversity of patients’ needs,” “incorporating significant others” and “recognising the existence of barriers.” Each of these categories had subcategories as shown in Table 3.

Table 3. Overview of derived subcategories and categories

Subcategories	Categories
Spending time getting to know the patient Building a mutual trustful relationship	Building and sustaining favourable therapeutic relationships
Providing individualised pain management Recognising the roles of pharmacological and nonpharmacological therapies Depending on disease progression	Recognising the diversity of patients’ needs
Seeing patient's family as necessary partners Depending on close friends and the church	Incorporating significant others
Relying on training and availability of equipment Depending on economic factors Depending on patient's cooperation Accepting the role of patient's beliefs	Recognising the existence of barriers

5.1 Building and sustaining favourable therapeutic relationships

The respondents explained that the use of nonpharmacological therapies of chronic pain management for palliative care patients involved building and sustaining a favourable therapeutic relationship between the nurse and the patient.

The respondents explicitly mentioned spending more time with the patients while administering nonpharmacological therapies but also gaining a better understanding of how to best manage their pain. By talking with and observing the patient, the nurses obtained relevant information and feedback for their practice of nonpharmacological pain management. The nurses described how the time they spent with the patient built a relationship between the nurse and patient that improved their understanding of the patient, which was beneficial in pain management.

Moreover, with good interaction with the patient, you tend to know the patient better and you can even get more information about how the patient can be made more comfortable. (Participant 8)

The respondents expressed that the more time they spent with a patient, the more that patient opened up to them and cooperated with them. Their experience was that this cooperation between nurse and patient helped to make engaging with the patient much easier during the pain management process. The respondents described how a cordial interaction between the nurse and the patient worked to the advantage of the patient, as the presence of the nurse provided an opportunity for the patient to interact and share concerns with the nurse. By sharing the patient's concerns, the nurse was able to make better decisions regarding the appropriate option for pain management intervention.

At times, you may not be welcomed fully by the patient, but as you continue interacting through the provision of non-pharmacological therapies, they open up and believe that you can help them. (Participant 11)

The respondents expressed that their relationship with the palliative care patients developed and that as they became closer, they were more accepted by the patients. The nurses described an environment in which they could engage more with the patients on how to manage the patients’ pain better. The nurses explicitly spoke of how successful nonpharmacological pain management was only possible if the nurses were trusted by the patients. The nurse viewed the relationship as necessary for the provision nonpharmacological therapies and through the provision of nonpharmacological therapies the nurse–patient relationship is also strengthened.

From what I have seen in my nursing career, in any patient-nurse relationship, winning the trust of the patient is very important for beneficial non-pharmacological pain management. (Participant 10)

5.2 Recognising the diversity of patients’ needs

The respondents described how nonpharmacological pain management therapies involved recognising the diversity of patients’ needs, as patients are unique individuals who respond differently to nonpharmacological pain management therapies.

The respondents explicitly stated that nonpharmacological therapies must be tailored to meet individual patient's needs. The nurses described themselves as key players in understanding and identifying the diverse pain management needs of their patients and said that they use this understanding to provide appropriate pain management.

We cannot have a uniform way of managing the pain of our patients, because these patients respond to pain management differently… For example, not all patients need massage. (Participant 15)

The nurses considered that maximum pain management could only be provided if pharmacological therapy was combined with relevant nonpharmacological therapies that were appropriate for that particular patient. At times, it was necessary to use nonpharmacological therapies side by side with other nonpharmacological therapies in order to maximise pain management benefits.

I would describe pharmacological and non-pharmacological therapies as two sides of the same coin. I think we can use them hand in hand… This maximizes the benefits of pain management. (Participant 2)

Furthermore, nonpharmacological pain management was seen as depending on disease progression. Participants stated that the severity of the illness of the individual patient and the progression of that patient's disease along the continuum of palliative care determined the benefits of nonpharmacological pain management therapies.

In the nurses’ experience, the provision of appropriate nonpharmacological pain therapy was sometimes problematic when it was not possible to communicate with the patient. In these cases, the nurses described how they tried to meet the patients’ needs for nonpharmacological pain therapy based on previous experience. The nurses noted that this was the best they could do in situations with a noncommunicable patient and stated that it was important to stay with the patient and observe how the patient responded.

At times, it is very difficult to manage the pain of some patients… Patients who are too sick to communicate or suggest alternative care are difficult to manage. In such cases we stay with the patient and observe their responses, and manage their pain based on our previous experience. (Participant 7)

5.3 Incorporating significant others

The respondents described how others (e.g. close friends, the church and the patient's family) were necessary partners in pain management and played a vital role in pain management for palliative care patients.

The respondents described how patients who had contact with a church, or with friends who visited them or communicated with them regularly, responded much better to pain management than patients without such contact. The contacts made the patients feel accepted and respected and part of the social context despite their illness. The nurses found that caring was easier when friends of the patient from the community or church visited them and encouraged them or gave them hope.

The church has been so helpful. They visit and offer prayers to their members. This helps the patients to brighten up a bit and I think it gives them hope. (Participant 1)

If no one visited the patient, the burden of pain management on the nurse was heavier. The nurses considered that there were certain things that a patient might feel able to mention to friends or church members that they were not able to mention to the nurses. The participants also stated that patients need to be seen as a person as opposed to a patient with medical issues, which they always are reminded of in relationship with the nurse. Consequently, the nurses said that they encouraged friends and other visitors to be near the patient at times and made it possible for the patients to say what they felt without the nurses being present.

The nurses also considered that nonpharmacological therapy involved seeing the patient's family members as necessary partners, even though doing so could have both positive and negative outcomes for the patient's pain management. The nurses described how families played a key role in pain management through socialisation, and how the patient seemed to feel relieved as a result of the family members’ talk and touches. However, the nurses also described how families sometimes advocated for unconventional pain management therapies that conflicted with those provided by the nurse. The nurses commented on how they were sometimes hindered in providing the best nonpharmacological pain management to the patient by the continual presence of the family at the patient's bedside.

At times, the family may exercise authority over the patient and force him to do contrary to what the nurse has recommended. (Participant 12)

According to the nurses, whenever they encountered a situation where families’ preferences or beliefs for pain management contradicted those of the nurse, they called for counsellors to talk to the family to promote compliance.

5.4 Recognising the existence of barriers

The respondents described how some patients in the community were excluded from accessing necessary nonpharmacological pain management therapies due to a lack of nurses with specialist training, a lack of resources and the patients’ own attitudes.

The respondents described how the lack of specialised training in paediatrics and psychiatric nursing prevented these groups of patients from enjoying the full benefits of nonpharmacological therapies. The nurses also expressed concern that some nurses had limited knowledge of how to use some of the therapies to help manage the pain of chronically ill patients.

My view is that children in many cases are ignored by palliative care services because very few nurses are trained in pediatric nursing. (Participant 3)

The nurses considered that nonpharmacological pain management was also limited by a lack of equipment such as televisions and radios, especially when there was a need for diversion therapy.

And there is a lack of equipment like radio, video, and television. Because of this, we can’t do much to help some of the palliative care patients who require non-pharmacological therapies. (Participant 8)

The respondents described how managing the pain of patients with insufficient financial resources was particular challenging for the nurses in the community—especially volunteer nurses—when patients were cared for in their own homes. Food and painkillers might be lacking, and the care provided was sometimes performed under primitive conditions.

The benefits of non-pharmacological therapies of pain management are minimal for poor patients in the community. A nurse can counsel them or use other methods like touch, but if they have no food, it won’t work. (Participant 11)

The respondents stated that the use of nonpharmacological therapies was dependent on the patient's attitude. The nurses said that if the patient is not willing to cooperate, it limits the nurse's opportunities to provide nonpharmacological therapies; as a result, the benefits of the nonpharmacological therapies are limited or even negligible for such a patient. The nurses commented that it was even more worrying when a patient did not accept his or her illness but remained in the denial stage, as such a patient was generally unmotivated to receive nonpharmacological pain therapy. It was the nurses’ experience that in order for them to effectively carry out their tasks in the pain management of palliative care patients, they needed additional skills in their nursing practice, such as counselling and negotiation.

It is difficult for us as nurses… some [patients] even refuse to be talked to if they know that they have cancer. (Participant 6)

The respondents stated that the beliefs of the patients influenced the provision of nonpharmacological pain management. The nurses experienced difficulties in managing the pain of patients who had traditional beliefs that did not support pain management, whether pharmacological or nonpharmacological pain therapy. The nurses recounted how certain traditional beliefs that attributed sickness to works of witchcraft made it difficult for some patients to cooperate with and respond to the nurse's pain management therapies.

6 DISCUSSION

The aim of this study was to explore the experiences and views of nurses regarding the use of nonpharmacological therapies for chronic pain management in palliative care patients. This study revealed various views and experiences on the part of the nurses, which fell into the following four categories: “building and sustaining favourable therapeutic relationships,” “recognising the diversity of patients’ needs,” “incorporating significant others” and “recognising the existence of barriers.” The various experiences and views of nurses regarding the use of nonpharmacological pain management therapies revealed the interactions and inter-relationships that influenced patients’ pain management.

This study found that interpersonal relationships are important for the success of nonpharmacological pain management for palliative care patients and that the nurse–patient relationship appears to be central in nonpharmacological pain management in palliative care. The results show that the maximum benefits from the use of nonpharmacological pain management therapies can be obtained when a favourable therapeutic relationship between the nurse and patient is built and sustained. This finding aligns with the social model of health where one's health is influenced by a wide range of individual, interpersonal, organisational, social, environmental, political and economic factors (Yuill, Crinson, & Duncan, 2010) and the results of other studies on nonpharmacological pain management interventions. The studies by Butow and Sharpe (2013) and Linse, Aust, Joos, and Hermann (2018) revealed that good communication, as well as warm and friendly relationships between healthcare providers and patients, improved health outcomes such as pain management.

Therefore, according to the findings of the two studies above, good relationship between the nurse and the patient can itself be viewed as a nonpharmacological pain management method. In addition, a qualitative study by Schoenthaler, Basile, West, and Kalet (2018) also reported that communication styles can either facilitate or hinder pain management. Thus, the successful use of nonpharmacological pain management interventions depends on the patient–nurse relationship being one in which the patient can open up and speak freely. In view of the above studies, it can be suggested that the ability of the nurse to provide nonpharmacological pain management therapies is not the only thing that matters; the relationship that is created between the patient and the nurse is also essential in determining the benefits of pain management. Thus, in order to obtain the maximum benefits from nonpharmacological pain management therapies, nurses must create and sustain a favourable therapeutic relationship with the patient. Creating a friendly atmosphere, that is spending time with the patient, communicating in a friendly manner and developing close bonds will allow the patient to open up to the nurse and will facilitate the provision of appropriate nonpharmacological therapies.

This study found that nurses’ experiences with nonpharmacological therapies involved recognising the diversity of patients’ needs, which is in line with a key concept of the social model of health (Yuill et al., 2010). Each patient is unique in terms of, for example, family situation, financial conditions and acceptance of illness; other unique qualities that may affect pain management care include being a child or having a mental illness. Consequently, patients have various pain management needs that cannot be met uniformly. Moreover, patients at various stages of disease progression along the continuum of palliative care may have different pain management needs; thus, pain management therapies can only be relevant if they align with the specific needs of patients. This fact emphasises the importance of the nurse having sufficient knowledge and skills to individualise pain treatment. Nurses’ lack of specialist training regarding pain management is known to be a barrier to effective pain management (Alzqhoul & Abdullah, 2015; Prem et al., 2011).

According to Taylor et al. (2016), some patients’ pain can be managed through nonpharmacological therapies as an alternative to pharmacological therapies, while others may need nonpharmacological therapies to augment and complement pharmacologic treatments (Chang, Fillingim, Hurley, & Scgumidst, 2015; Mitchell & O’Donnell, 2013; Nestler, Gnass, & Schuler, 2015). It has been found that a combination of pain management approaches such as hypnosis, relaxation and massage transfers the patients’ attention from their painful experience to a more pleasant alternative (Kuttner, 2006). However, it seems more likely that a collaborative relationship between pharmacological and nonpharmacological pain management therapies provides the maximum pain management benefit for patients. Nevertheless, it is of the utmost importance for nurses to have an understanding of the pain management needs of the patient, to explore available alternative nonpharmacological therapies and then to choose the best suitable combination for each individual patient. For this to be possible, nurses need access to specialist training in both palliative care and caring for special patient groups (i.e. paediatrics and psychiatry).

This study reports on the necessity of incorporating significant others into patient care, which is in line with the results of other studies. In a qualitative study of end-of-life home care, Jack, O’Brien, and Groves (2014) acknowledged that the family carer plays a vital role in end-of-life care. Similarly, studies by Chew, Carpenter, and Haase (2018) and Bar Sela, Bentur, Rei Koren, and Schultz (2017) recognised the significance of social relationships in patient care. The present study identified another aspect related to incorporating significant others in patient care; namely, significant others can be an obstacle if there is poor or no cooperation—which is a problem, as the nurse is dependent on the participation of significant others. This finding is supported by other studies that have shown that parents’ participation in pain management in paediatric care—and the child's ability to cooperate—are factors that promote the use of nonpharmacological pain management strategies (Paczkowska, Kopciuch, Nowakowska, Hoffmann, & Bryl, 2016; Pölkki, Laukkala, Vehviläinen-Julkunen, & Pietilä, 2003) .

The results also show that a patient's beliefs can counter pain management initiatives and that patients with insufficient financial resources have limited possibilities of receiving the best possible pain relief. These findings align with the results of a study by Herce et al. (2014), which reported that financial support and food provision were vital elements in the provision of nonpharmacological pain management for palliative care patients. In addition, a study by Feierabend, Walter, Kalff, and Reichart (2017) on chronic pain and poverty found a correlation between the two. These studies seem to indicate that patients who are disadvantaged by their economic condition may be barred from enjoying the full benefits of nonpharmacological pain management. Hence, barriers such as the beliefs of the patient or the patient's economic situation illustrate the need for collaboration with other health professionals such as counsellors in order to explore the possibility of financial support.

7 METHODOLOGICAL CONSIDERATIONS

The application of purposeful sampling was very limited in terms of the volunteer nurses in the community due to the fact that there were very few of such nurses, and it took some time to contact them. Therefore, there were not many options from which to choose regarding whom to include in the sample, as the few nurses who were available were automatically included. This limitation may have narrowed the breadth of views from community volunteer nurses. However, the delay in accessing the community volunteer nurses did not affect the dependability of the study; as data were collected in the same period of time, there was consistency in the manner in which data were collected. During the analytic phase in which categories were created, it was a challenge to decide which codes and supporting quotes from the original text should be included in each category. However, the matter of dependability was addressed by including more than one researcher/author in the analysis (i.e. WM, KP and CE). This is known to be a way of establishing dependability, as researchers’ interpretative repertoires can vary (Graneheim et al., 2017). The analysis process was stopped when consensus was achieved among the researchers. In addition, in order to ensure transferability, this study provides a clear description of the context in which the research occurred, along with clarity regarding how the sample was selected, the characteristics of the participants and how the data were collected and analysed. Moreover, the results are presented with participants’ quotations. Considering the universal character of the categories in this study, the results of this research are transferable to more or less any nursing context in chronic and palliative care that involves pain management and nonpharmacological therapies.

8 CONCLUSION

This study reveals nurses’ perspectives on nonpharmacological therapies for chronic pain management in palliative care. The findings of this study clearly show that nurses view the nurse–patient relationship as central and crucial for successful nonpharmacological pain management and for unique knowledge regarding what will ease an individual patient's pain the most. By building and sustaining favourable therapeutic relationships with patients, the nurse can recognise the diversity of patients’ needs, incorporate significant others into patient care and recognise the existence of barriers in order to optimise pain management for each individual patient. From the nurses’ perspective, the nurse–patient relationship can itself be viewed as a nonpharmacological pain management method. Further research is needed to gain depth and concreteness regarding the influence and importance of the nurse–patient relationship in pain management in daily care. It is also essential to gain further knowledge on patients' perspective, and on whether a close nurse–patient relationship can be a reason for nurses to lead pain management.

9 RELEVANCE TO CLINICAL PRACTICE

In clinical practice, nurses’ attention, engagement and dialogue are essential in order to gain extensive and varied knowledge about the needs and life situations of individual patients. This study emphasises the need for nurses to get to know their patients—that is, to be open and sensitive to the patients’ descriptions of their unique life situations. This individualised approach has benefits for nursing practice and can provide the knowledge that is needed for optimal care and pain management for the patient. Furthermore, opportunities for continuing education should be offered regularly to nurses working in palliative care, regardless of the type of employment.

ACKNOWLEDGEMENTS

We sincerely thank the nurses who willingly and freely shared their experiences with nonpharmacological pain management.

CONFLICTS OF INTEREST

The authors declare that there is no conflict of interest.

AUTHOR CONTRIBUTIONS

(a) The idea and conception for this research came from Author 1. The design, analysis and interpretation of the data were performed through collaboration among all three authors. (b) All three authors contributed to drafting, writing and revising the manuscript. (c) All three authors have approved this version for publication.

Supporting Information

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Citing Literature

Volume29, Issue9-10

May 2020

Pages 1643-1652

Nurses’ experiences of providing nonpharmacological pain management in palliative care: A qualitative study

Abstract

Aim and objectives

Background