Thomas, M.L., Elliott, J.E., Rao, S.M., Fahey, K.F., Paul, S.M., & Miaskowski, C. (2012). A randomized, clinical trial of education or motivational-interviewing–based coaching compared to usual care to improve cancer pain management. Oncology Nursing Forum, 39(1), 39–49.

To test the effectiveness of two interventions, compared to usual care, in decreasing attitudinal barriers to cancer pain management, decreasing pain intensity, and improving functional status and quality of life (QoL)

Patients were randomly assigned to one of three groups: control, standardized education, or coaching. Patients in the education and coaching groups viewed a video and received a pamphlet about managing cancer pain. In addition, patients in the coaching group participated in four telephone sessions facilitated by an advanced practice nurse–interventionist who used motivational interviewing techniques to decrease attitudinal barriers to cancer pain management. Questionnaires were completed at baseline and at six weeks after the final telephone call. Authors used analysis of covariance to evaluate differences in study outcomes among the three groups.

• The sample was composed of 227 patients—that is, patients who completed the end-of-study evaluation.
• In the control group, average age was 58.7 years; in the education group, 62.5 years; in the coaching group, 61.8 years.
• Of all patients, 90.1% were male and 9.9% were female.
• In the sample the most common cancer types were lung, prostate, and head and neck cancers. Breast and colon cancers, myeloma, and mixed types made up the remainder of diagnoses.

• Multisite
• Six outpatient oncology clinics (four Veterans Affairs facilities, one county hospital, and one community-based practice)
   

• Phases of care: multiple phases of care
• Clnical applications: late effects and survivorship

Randomized clinical trial

• Attitudinal-barriers assessment: Authors chose the Barriers Questionnaire (BQ), a 27-item instrument, 0–5 scale, to measure barriers to cancer pain management. Barriers include concern about side effects, concern about tolerance, fear of addiction, fatalism, fear of disease progression, desire to be a good patient, fear of injections, and concern about distracting the physician from curing disease.
• Pain assessment: The study used the Brief Pain Inventory, a  0–10 scale self-report, to assess intensity and quality of pain, the extent to which pain relief was obtained, and the extent to which pain interferes with function.
• Functional status: The SF-36, a 0–100 scale, assessed eight health concepts (physical functioning, role limitations because of physical health problems, bodily pain, social functioning, role limitations because of emotional health problems, general mental health, vitality, and perception of general health). Higher scores reflect higher functioning.  
• QoL: The study measured four QoL domains (physical, social, emotional, and functional well-being) by means of the FACT-G, a five-point Likert-type scale, with each subscale summed to obtain a subscale score and all individual items summed to obtain a total score. Total score can range 0–112.
   

• Authors found no differences among the three groups in any of the subscale or total BQ scores.
• Assessment of measures at the second time point found no differences among the three groups in regard to pain intensity or pain relief. However, at the end of the study, authors noted significant differences in mean pain interference scores (p < 0.01).
• The SF-36 showed significant differences among the groups in general health, vitality, mental health, and the mental component (as measured by summary score). The coaching group had higher mental health component scores than did the control group.
• Authors noted no significant differences among groups in regard to any of the FACT-G subscales or total scores.
• Patients in the coaching group reported a statistically significant decrease in pain-related interference with function and improved ratings of vitality, mental health, and general health. Compared to standardized education, coaching was associated with clinical improvements in cancer pain management (decreased cancer pain intensity and improvement or stability in functional status and QoL).

Findings suggest that coaching may be beneficial to cancer pain management, especially as management relates to collaborative development of individualized care plans that decrease symptoms.

• The fact that more than 90% of the sample was male may be a limitation. 
• The study employed a convenience sample, a fact that may limit applicability to other oncology populations. 
• The study did not alter the amounts or types of analgesics prescribed. This fact may limit results.   
   

Focused sessions consisting of 30 minutes of motivational-interviewing coaching by an advanced practice nurse may improve the management of cancer pain and overall health outcomes.