Despite important advances in its management,

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1 Oncology Nuring Society. Unauthorized reproduction, in part or in whole, i trictly prohibited. For permiion to photocopy, pot online, reprint, adapt, or otherwie reue any or all content from thi article, pubpermiion@on.org. To purchae high-quality reprint, reprint@on.org. Journal Club Article See page 49 for uggeted quetion to begin dicuion in your journal club. Downloaded on Single-uer licene only. Copyright 2018 by the Oncology Nuring Society. For permiion to pot online, reprint, adapt, or reue, pleae pubpermiion@on.org A Randomized, Clinical Trial of Education or Motivational-Interviewing Baed Coaching Compared to Uual Care to Improve Cancer Pain Management Mary Laudon Thoma, RN, MS, AOCN, Janette E. Elliott, RN-BC, MS, AOCN, Stephen M. Rao, PhD, Kathleen F. Fahey, RN, MS, CNS, Steven M. Paul, PhD, and Chritine Miakowki, RN, PhD, FAAN Depite important advance in it management, cancer pain remain a ignificant clinical problem (Apolone et al., 2009; McGuire, 2004; van den Beuken-van Everdingen et al., 2007). In a meta-analyi, cancer pain wa found in 64% of patient with metatatic dieae, 59% of patient receiving antineoplatic therapy, and 33% of patient who had received curative cancer treatment (van den Beukenvan Everdingen et al., 2007). Cancer pain alo ha a negative effect on patient functional tatu (Ferreira et al., 2008; Holen, Lyderen, Kleptad, Loge, & Kaa, 2008; Vallerand, Templin, Saenau, & Riley-Doucet, 2007) and i aociated with pychological ditre (Cohen et al., 2003; Vallerand, Haenau, Templin, & Collin-Bohler, 2005). The effect of cancer pain on an individual quality of life (QOL) can be ignificant and extend beyond diturbance in mood and phyical function (Burckhardt & Jone, 2005; Dahl, 2004; Fortner et al., 2003). Although advance in pain management can reduce cancer pain for a ignificant number of patient, numerou clinician, healthcare ytem, and ocietal barrier (e.g., knowledge deficit, reimburement and regulatory contraint, religiou or cultural view) contribute to ineffective pain management (Brockopp et al., 1998; Dahl, 2004; Hill, 1993; Sun et al., 2007). Attitudinal barrier held by patient can be a ubtantive factor in the inadequate treatment of cancer pain (Anderon et al., 2002; Ward et al., 2008). Thoe attitudinal barrier need to be addreed if cancer pain management i to be improved (Fahey et al., 2008). In a meta-analyi of the benefit of patient-baed pychoeducational intervention for cancer pain management, Bennett, Bagnall, and Clo (2009) concluded Purpoe/Objective: To tet the effectivene of two intervention compared to uual care in decreaing attitudinal barrier to cancer pain management, decreaing pain intenity, and improving functional tatu and quality of life (QOL). Deign: Randomized clinical trial. Setting: Six outpatient oncology clinic (three Veteran Affair [VA] facilitie, one county hopital, and one community-baed practice in California, and one VA clinic in New Jerey) Sample: 318 adult with variou type of cancer-related pain. Method: Patient were randomly aigned to one of three group: control, tandardized education, or coaching. Patient in the education and coaching group viewed a video and received a pamphlet on managing cancer pain. In addition, patient in the coaching group participated in four telephone eion with an advanced practice nure interventionit uing motivational interviewing technique to decreae attitudinal barrier to cancer pain management. Quetionnaire were completed at baeline and ix week after the final telephone call. Analyi of covariance wa ued to evaluate for difference in tudy outcome among the three group. Main Reearch Variable: Pain intenity, pain relief, pain interference, attitudinal barrier, functional tatu, and QOL. Finding: Attitudinal barrier core did not change over time among group. Patient randomized to the coaching group reported ignificant improvement in their rating of painrelated interference with function, a well a general health, vitality, and mental health. Concluion: Although additional evaluation i needed, coaching may be a ueful trategy to help patient decreae attitudinal barrier toward cancer pain management and to better manage their cancer pain. Implication for Nuring: By uing motivational interviewing technique, advanced practice oncology nure can help patient develop an appropriate plan of care to decreae pain and other ymptom. Oncology Nuring Forum Vol. 39, No. 1, January

2 that, compared to uual care, educational intervention improved knowledge and attitude and reduced average and wort pain intenity core. However, thoe intervention had no effect on medication adherence or in reducing pain level of interference with daily activitie. Bennett et al. (2009) uggeted that additional trial are warranted to tet different approache to cancer pain education and to clarify the exact relationhip between education and improved patient outcome. Many pychoeducational intervention tudie were conducted in the hopital etting (Chang, Chang, Chiou, Tou, & Lin, 2002; de Wit et al., 2001; Jahn et al., 2010) or in patient home (Given et al., 2002; Miakowki et al., 2004), which limited the generalizability of the finding to the outpatient clinic etting. In addition, although they achieved a poitive outcome, many of the tudie were labor-intenive, which alo limited their ability to be implemented in a buy oncology clinic (Given et al., 2002; Miakowki et al., 2004). Unfortunately, tudie uing le labor-intenive intervention were not a ucceful in decreaing cancer pain (Anderon et al., 2002; Oliver, Kravitz, Kaplan, & Meyer, 2001; Syrjala et al., 2008). Coaching i a ueful trategy to improve cancer pain management (Kalauokalani, Frank, Oliver, Meyer, & Kravitz, 2007; Miakowki et al., 2004). Incorporating principle of motivational interviewing into a coaching intervention afford a unique method of exploring peronal attitude, behavior, and belief that can interfere with effective cancer pain management (Fahey et al., 2008; Prochaka & DiClemente, 1984). Change theory, pecifically the Trantheoretical Model (Prochaka & DiClemente, 1984), i a ueful conceptual framework for coaching. In thi model, behavioral change i a function of a peron tate of readine or motivation to modify a particular behavior. Motivational interviewing i a nonauthoritarian couneling technique that can ait patient in recognizing and reolving ambivalence about making contructive behavioral change. It matche the patient readine to change and can motivate the patient to move through the tage of the Trantheoretical Model: precontemplation (unaware of need for change), contemplation (thinking about change), preparation (actively conidering change), action (engaging in changing behavior), and maintenance (maintaining a changed behavior) (Fahey et al., 2008; Prochaka & DiClemente, 1984). Given the limitation of previou intervention tudie, additional reearch i warranted uing approache that can be implemented in the outpatient etting. Therefore, the purpoe of thi randomized clinical trial were to tet the effectivene of two intervention compared to uual care in decreaing attitudinal barrier to cancer pain management, decreaing pain intenity, and improving pain relief, functional tatu, and QOL. The author hypotheized that the motivational-interviewing baed coaching group would demontrate greater benefit (i.e., decreaing attitudinal barrier; decreaing pain intenity; and improving pain relief, functional tatu, and QOL) than either the conventional education or uual care group. Method Sample and Setting A convenience ample wa obtained by recruiting patient from ix outpatient oncology clinic (three Veteran Affair [VA] facilitie, one county hopital, and one community-baed practice in California, and one VA clinic in New Jerey). Patient were eligible to participate if they were able to read and undertand the Englih language, had acce to a telephone, had a life expectancy longer than ix month, and had an average pain intenity core of 2 or higher a meaured on a 0 10 cale, with higher core indicating more pain. Patient were excluded if they had a concurrent cognitive or pychiatric condition or ubtance abue problem that would prevent adherence to the protocol, had evere pain unrelated to their cancer, or reided in a etting where the patient could not elf-adminiter pain medication (e.g., nuring home, board and care facility). The tudy wa approved by the intitutional review board and reearch committee at each of the ite. To tet the interaction of time (change in core from pre- to pottudy) by aignment to the three treatment group (i.e., control, education, or coaching), a ample ize of 240 wa needed to detect a medium effect (f = 0.25; h 2 = 6% of explained variance). A hown in Figure 1, of the 1,911 patient who were creened, 406 were eligible to participate, 322 provided written informed conent, and 289 completed baeline aement after being randomized to one of three group. Procedure Prior to beginning participant recruitment, all reearch team member were trained extenively o that the procedure for enrollment, data collection, and intervention were tandardized acro all clinic ite. Reearch aociate (RN or pychology intern) were trained in procedure for evaluating potential participant, approaching them, obtaining conent to participate, and adminitering the intrument and videotape. Importantly, the reearch aociate were trained in providing attention-control telephone call. The nure interventionit wa trained extenively in motivational interviewing and change theory by a cognitive behavioral pychologit and then in procedure related to the pecific coaching protocol. Detail of thi training are decribed in Fahey et al. (2008). Monthly team meeting were held throughout the tudy to enure procedural fidelity wa maintained. 40 Vol. 39, No. 1, January 2012 Oncology Nuring Forum

3 Control (n = 109) Completed T1 (n = 104) Completed T2 (n = 88) Aeed for eligibility (N = 1,911) Did not meet incluion criteria (n = 1,505) Declined to participate (n = 84) Stratify (N = 322) a Treatment (chemotherapy, radiation therapy, or none) Pain (low, medium, or high) Randomize into group (N = 318) a Education (n = 103) Completed T1 (n = 94) Completed T2 (n = 75) a Four patient withdrew before randomization, and one wa lot to follow-up before completing T1. Note. Reaon for lack of completion included being too ill, withdrawing, fatigue, being lot to follow-up, death, ineligibility, prolonged hopitalization, protocol violation, or other. Figure 1. Trial Participation at Baeline (T1) and Six Month (T2) Patient were identified by clinic taff and creened for eligibility by the reearch aociate, who then approached eligible patient, explained the tudy, and obtained written informed conent. Patient were tratified baed on pain intenity (i.e., low, medium, or high) and cancer treatment (i.e., chemotherapy or radiation therapy) to control for the confounding variable of pain intenity and the effect of cancer treatment. Stratifying by pain intenity account for the curvilinear relationhip between pain everity and functional tatu (e.g., change in pain intenity at the upper level of the cale have a different effect on functional tatu compared to change at the lower level of the cale). Stratification by cancer therapy wa ued to control for the effect of treatment in either decreaing pain from hrinking the tumor or increaing pain becaue of toxicity of treatment. Patient at each clinic ite then were randomized baed on the tratification criteria uing permuted block with variable ize into one of three group: uual care (control), education, or coaching. Thi method of randomization wa ued to enure balance acro the treatment group within each tratification cell. Patient and clinician at the tudy ite were blinded to the patient group aignment. At the time of enrollment, patient completed a demographic quetionnaire, the Karnofky Performance Statu (KPS) cale (Karnofky & Burchenal, 1949), the Brief Pain Inventory (Daut, Cleeland, & Flanery, 1983), the Barrier Quetionnaire (BQ) (Ward et al., 1993), the 36-Item Short Form Health Survey (SF- 36 ) (Ware & Sherbourne, 1992), and the Functional Aement of Cancer Therapy General (FACT-G) (Cella et al., 1993). Coaching (n = 105) The patient medical record were reviewed for dieae and treatment information. Completed T1 (n = 91) Patient in the uual care group viewed a video on cancer (American Cancer Society, 1994). Patient aigned to the education Completed coaching intervention (n = 74) group viewed a video on managing cancer pain that focued on Completed T2 (n = 64) overcoming attitudinal barrier (Syrjala, Abram, Du Pen, Nile, & Rupert, 1995) and received the Agency for Health Care Policy and Reearch (1994) pamphlet entitled, Managing Cancer Pain, Conumer Verion, Clinical Practice Guideline Number 9. To imulate the time contraint in many oncology outpatient clinic, no reinforcement of the material wa provided unle the patient ought additional information or aked quetion of the clinic taff. Patient aigned to the coaching group received the ame intervention a thoe aigned to the education group. In addition, they participated in four 30-minute telephone eion that explored belief about pain, ue of analgeic and nonpharmacologic pain management trategie, and communication about pain management. Thoe four call were conducted about every other week over a ix-week time period by the nure interventionit, a clinical nure pecialit trained in motivational interviewing technique. For a detailed decription of the coaching intervention, ee Fahey et al. (2008). Patient aigned to the uual care and education group alo received four telephone call (about every other week over a ix-week time period) from the reearch aitance for attention-control purpoe. Six week after the final telephone call (i.e., 12 week potrandomization), all patient completed the ame quetionnaire that were done at enrollment. Participant Oncology Nuring Forum Vol. 39, No. 1, January

4 received a $25 gift certificate after completing each et of quetionnaire. Intrument Attitudinal barrier were aeed with the BQ (Ward et al., 1993; Ward & Gatwood, 1994), a 27-item intrument that meaure eight barrier to cancer pain management (concern about ide effect, concern about tolerance, fear of addiction, fatalim, fear of dieae progreion, deire to be a good patient, fear of injection, and concern about ditracting the phyician from curing dieae). Each item i rated on a cale from 0 (not at all agree) to 5 (agree very much). Mean ubcale and total core were calculated for the BQ, with higher core reflecting tronger barrier. The BQ ha demontrated adequate validity and reliability (Ward et al., 1993; Ward & Gatwood, 1994). Pain wa aeed with the Brief Pain Inventory, a elf-report intrument deigned to ae the intenity and quality of pain, the extent to which pain relief wa obtained, and the extent to which pain interfere with function (Daut et al., 1983). Severity and interference are rated on a numeric core from 0 (doe not interfere) to 10 (completely interfere). A mean interference core wa calculated (Serlin, Mendoza, Nakamura, & Cleeland, 1995), with higher core reflecting greater pain intenity and greater interference with function. Functional tatu wa meaured with the SF-36 (Ware & Sherbourne, 1992). Eight health concept Table 1. Demographic and Clinical Characteritic by Study Group Control Education Coaching (N = 88) a (N = 75) b (N = 64) Characteritic Statitic Age (year) F(2, 223) = 2.54, p = 0.08 Education (year) F(2, 222) = 2.57, p = 0.08 Time ince diagnoi (month) F(2, 222) = 0.48, p = 0.62 Karnofky Performance Statu core c F(2, 222) = 3.53, p = 0.03* Characteritic n % n % n % Statitic Gender c 2 = 4; p = 0.13 Male Female Ethnicity c 2 = 13.4, p = 0.65 African American Caucaian Latino Other Marital tatu c 2 = 8.3, p = 0.61 Married or partnered Widowed, divorced, or eparated Never married Living arrangement c 2 = 6.4, p = 0.38 Alone With family or friend Other Employment c 2 = 10.1, p = 0.61 Full- or part-time Diability, leave of abence, or retired Unemployed Other Cancer diagnoi c 2 = 45.7, p = 0.72 Breat Colon Head and neck Lung Myeloma Protate Other (mixed type) * Education < coaching, p < 0.05 a Becaue patient could refue to complete item, N = 86 for ethnicity and employment. b Becaue patient could refue to complete item, N = 74 for ethnicity, marital tatu, and employment. c Score indicate functional tatu on a cale, with higher core reflecting higher function. Note. Becaue of rounding, not all percentage total Vol. 39, No. 1, January 2012 Oncology Nuring Forum

5 were aeed (phyical functioning, role limitation becaue of phyical health problem, bodily pain, ocial functioning, role limitation becaue of emotional health problem, general mental health, vitality, and perception of general health). In addition, phyical and mental component ummary core are obtained by combining core related to phyical and mental functioning, repectively. For each cale, core are revered (a needed o that higher core reflect better health tate), ummed, and linearly tranformed on a cale, with higher core reflecting higher functioning. The SF-36 ha been ued extenively and ha welletablihed validity and reliability (Given, Given, Azzouz, Stommel, & Kozachick, 2000; McHorney, Ware, & Raczek, 1993; Miakowki et al., 2007; Thong, Mol, Coebergh, Roukema, & van de Poll-Frane, 2009). QOL wa meaured with the FACT-G (Cella et al., 1993). Four QOL domain (phyical, ocial, emotional, and functional well-being) are meaured. Patient were aked to rate the extent to which they agreed with each item uing a five-point Likert-type cale that ranged from 0 (not at all) to 4 (very much). Score for item within each ubcale are ummed to obtain a ubcale core, and all of the individual item are ummed to obtain a total core, which can range from The FACT-G ha been ued in numerou tudie of patient with cancer (Elting et al., 2008; Wittmann, Vollmer, Schweiger, & Hiddemann, 2006; Zimmerman et al., 2010) and pecifically in tudie of patient with cancer-related pain (Chang, Hwang, & Kaimi, 2002; Harri et al., 2009). The FACT-G ha well-etablihed validity and reliability (Cella et al., 1993). Data Analyi Difference in demographic and clinical characteritic among the three group were evaluated uing analye of variance and chi-quare tet. Analye of covariance were performed to evaluate for difference in core on average and wort pain intenity, pain relief, mean pain interference, the BQ, the SF-36, and the FACT-G among the three patient group. That procedure allow for the evaluation of the end-of-tudy outcome while controlling for thoe ame outcome at baeline. The examination of difference among group in end-of-tudy outcome, with baeline meaurement of thoe outcome covaried out, often i a preferred method for examining change in outcome meaure from the beginning to the end of a tudy (Cohen, 1988). All calculation ued actual value. Adjutment were not made for miing data; therefore, the cohort for each analyi wa dependent on the larget et of data acro group. If the overall analyi of covariance for a particular outcome indicated difference among the three group, pairwie contrat were conducted to determine the location of the difference. The Bonferroni procedure wa ued to ditribute a family alpha of 0.05 acro the three pairwie contrat. All p value have been adjuted o that value lower than 0.05 are conidered tatitically ignificant. Reult Sample Of the 289 patient who enrolled, 227 completed the end-of-tudy evaluation. The length of time from cancer diagnoi to tudy enrollment averaged month. The mot common cancer type were lung, protate, and head and neck. Mot patient were men and middleaged, and about half of the ample wa married or partnered. No difference were found among the three group on any demographic or clinical characteritic except KPS core. Patient in the education group reported ignificantly lower KPS core than patient in the coaching group (p = 0.03) (ee Table 1). Intrument Score Barrier Quetionnaire: Barrier ubcale core were modet in all three group, with concern about addiction and dieae progreion rated higher than thoe related to fatalim or the need to be a good patient (data not hown). However, after controlling for each of the BQ core at baeline, no difference were found among the three group in any of the ubcale or total BQ core. Pain intenity, interference, and relief: After controlling for average pain at baeline, no difference were found among the three group in average pain intenity core at the end of the tudy (p = 0.08) (ee Figure 2). Similarly, nonignificant core were found among the three group in wort pain intenity core (data not hown). However, ignificant difference were found among the three group in mean pain interference core at the end of the tudy (p = 0.01) (ee Figure 3). Pot-hoc Average Pain Intenity Baeline Control Note. F = 2.58; p = 0.08 Education End of Study Figure 2. Change Over Time in Average Pain Intenity Score by Patient Group Coaching Oncology Nuring Forum Vol. 39, No. 1, January

6 Pain Interference Score a Pain Relief (%) b Baeline Baeline Control Education End of Study contrat demontrated that the coaching group had lower mean pain interference core at the end of the tudy compared to the education and control group (p = 0.03 and 0.02, repectively). After controlling for baeline pain relief core, no ignificant difference were found among the three group in the percentage of pain relief (p = 0.07) at the end of the tudy. Short-Form Health Survey: Table 2 lit the pre- and pot-tudy SF-36 ubcale and component core for the three group. After controlling for each of the baeline SF-36 ubcale and component core, no ignificant difference were found among the group in ocial functioning, phyical or emotional role functioning, bodily pain, or phyical component core. However, after controlling for each of the ubcale core at baeline, ignificant difference were found among the group in general health, vitality, mental health, and the mental component ummary core. Pot-hoc contrat demontrated that the coaching group had higher mental health component core compared to the control group. All other pot-hoc comparion were not ignificant. End of Study Coaching a F = 4.53, p = 0.01; coaching > control, p = 0.02; coaching > education, p = 0.03 b F = 2.63, p = 0.07 Note. All value are plotted a mean and tandard deviation of the mean. Figure 3. Change Over Time in Mean Pain Interference and Pain Relief Score by Group Functional Aement of Cancer Therapy General: Table 3 lit the pre- and pot-tudy ubcale and total QOL core for the three group. Score for all four ubcale remained table over time. After controlling for each of the FACT-G core at baeline, no ignificant difference were found among the group on any of the ubcale or total core. Dicuion Educational intervention have demontrated poitive outcome in decreaing cancer pain (Clotfelter, 1999; Dalton, Keefe, Carlon, & Youngblood, 2004; de Wit et al., 2001; Syrjala et al., 2008; Ward et al., 2008; Yate et al., 2004). Coaching ha been teted le frequently a a pain management intervention, but it reulted in poitive outcome in three tudie (Kalauokalani et al., 2007; Miakowki et al., 2004; Oliver et al., 2001). Although ucceful, the labor-intenive nature of thoe intervention may limit their ue in clinical practice. The current tudy teted the effect of two intervention (tandardized education and coaching) that were feaible for implementation in an outpatient oncology clinic etting. The coaching intervention wa deigned to afford flexibility for both the patient and the nure interventionit to enhance it utility in clinical practice. Patient aigned to the coaching group reported a tatitically ignificant decreae in pain interference with function and improved rating of vitality, mental health, and general health. Compared to tandardized education, coaching alo wa aociated with clinical improvement in cancer pain management (i.e., decreaed cancer pain intenity and improvement or tability in functional tatu and quality of life). However, mot of the improvement were not tatitically ignificant. Several poible explanation exit for the lack of tatitical ignificance for mot of the outcome meaure. The current tudy wa unique in that the coaching intervention ued principle of motivational interviewing and wa baed on the Trantheoretical Model of change theory. Thoe baic principle involve addreing iue of greatet importance from the patient perpective and aeing the individual readine to change a particular behavior. Some patient in the coaching group exhibited peritent reluctance to conider changing a given attitude or behavior that might reult in improving their cancer pain management. More commonly, the iue of prioritie had a ignificant effect on the nure interventionit ability to addre attitudinal barrier that might affect cancer pain management. Cancer pain doe not exit in a vacuum. Other iue, relatedor notto cancer and it treatment, often were more preing from the patient perpective. True to the theoretical underpinning of the intervention, the nure interventionit, in turn, focued on thoe more preing iue. That adaptation poed challenge in adhering to the attitudinal content within the 44 Vol. 39, No. 1, January 2012 Oncology Nuring Forum

7 Table 2. Short-Form Health Survey Score by Study Group Subcale Control (N = 88) coaching protocol, but addreed the unique need preented by the patient. Although the variation wa viewed very poitively by patient in their tudy exit interview, it effect on decreaing cancer pain likely wa reduced. Similarly, the reearcher had difficulty maintaining the attention-control telephone call for their intended purpoe (i.e., to control for the attention received by thoe in the coaching group). A ubtantial number of patient (aigned to either the education or control group) voiced ignificant problem or concern to the reearch aociate during thoe call, which required the reearch aociate to notify the patient clinician. Although uch notification wa important from a clinical and ethical tandpoint, the patient did not eek intervention on their own, but rather waited for upport and aitance from the reearch aociate beyond that offered from the attention control deign, which may have blunted the effect of the coaching intervention. Another poible explanation for the current finding i that the coaching intervention yielded a poitive benefit, but the benefit wa not utainable. The Education (N = 75) Coaching (N = 64) Statitic Phyical functioning F = 1.179, p = Pretudy Pot-tudy Body pain F = 2.817, p = Pretudy Pot-tudy General health F = 4.249, p = a Pretudy Pot-tudy Vitality F = 3.963, p = 0.02 b Pretudy Pot-tudy Mental health F = 3.207, p = c Pretudy Pot-tudy Mental component F = 3.397, p = d Pretudy Pot-tudy a Coaching > education, p = b Coaching > education, p = 0.02 c Coaching > control, p = 0.089; coaching > education, p = 0.07 d Coaching > control, p = tudy deign wa modified at the requet of the peer reviewer to delay the pot-tet to ix week after the coaching intervention wa completed. In hindight, another meaurement hould have been made immediately after the coaching intervention wa completed (ix week after baeline), with a third meaurement at 12 week after baeline. The additional meaurement would have allowed for an aement of the immediate effect of the intervention, particularly with patient who were able to complete the intervention, but died or were too ill to complete the quetionnaire at 12 week. If a more ignificant effect wa een immediately after completing the intervention, but wa not utained, an argument could then be made for providing ome brief ongoing eion to reinforce the coaching intervention. In iolation, a behavioral intervention to decreae cancer pain likely will demontrate a mall effect ize. Therefore, the lack of tatitical ignificance may imply be a reflection of inadequate ample ize. The ample ize alo wa affected by a high attrition rate (30% of thoe who enrolled to participate), often becaue of death or dieae progreion, which could have contributed to the lack of tatitical ignificance in many of the outcome Table 3. Functional Aement of Cancer Therapy General Score by Study Group Subcale Control (N = 88) Education (N = 75) Coaching (N = 64) Statitic Phyical well-being F = 1.373, p = 0.26 Pretudy Pot-tudy Social well-being F = 0.465, p = 0.63 Pretudy Pot-tudy Emotional well-being F = 2.41, p = 0.09 Pretudy Pot-tudy Functional well-being F = 1.382, p = 0.25 Pretudy Pot-tudy Total core F = 2.164, p = 0.12 Pretudy Pot-tudy Oncology Nuring Forum Vol. 39, No. 1, January

8 meaure. In addition, more patient aigned to the coaching group were unable to complete the end-oftudy meaure. Another poible explanation for the lack of tatitical ignificance on many of the outcome meaure i that the intrument ued were not enitive enough to detect change. A a group, the ample cored low on each barrier ubcale and total core; the core were imilar to thoe reported in other tudie (Ward et al., 2008). Although participant in the coaching group achieved an improvement in each ubcale (except fear of injection) that wa greater than the improvement in the other two group, the difference were not ignificant. Given the low baeline core and maller number of patient aigned to the coaching group, the ability to improve thoe core would be extremely difficult. More importantly, during the coaching telephone call, unique barrier were identified by the patient and dicued that were not alway reflected in the core on the BQ (Fahey et al., 2008). The trength of uch belief or barrier may be o great that four coaching call may have been inadequate to overcome that enduring attitude. In addition, motivational interviewing i baed on change theory, in which an individual readine to change behavior i crucial to the ucce of a behavioral intervention (Prochaka & DiClemente, 1984). The current tudy did not ae, nor tratify for, an individual readine to change a priori, which alo could be a contributing factor to thoe finding. At baeline, the FACT-G ubcale and total core in the current tudy were markedly lower than in the general population, particularly the phyical and functional well-being ubcale core (Holzner et al., 2004). Similarly, functional well-being core were lower than thoe previouly reported by patient with cancer (Burckhardt & Jone, 2005; Sherman, Simonton, Latif, Plante, & Anaiie, 2009). However, baeline core for all FACT-G ubcale were imilar to thoe obtained in another tudy of U.S. Veteran with cancer pain (Chang et al., 2002). QOL core did not change ubtantially over time in any group, which ugget that cancer pain wa not a ignificant factor in the QOL of thoe patient. An alternative explanation i that the tability of core may reflect the inability of the FACT-G to detect ubtle change in QOL. Niv and Kreitler (2001) acknowledge that pain can be an important factor in one QOL, but alo uggeted that it may not alway be the mot important. Therefore, focuing olely on managing pain may not necearily have a ignificant effect on QOL. Thi view wa ubtantiated in the coaching group, in which other iue that affected the patient QOL often took precedence over cancer pain (e.g., thoe related to cancer treatment, family, or economic hardhip). The SF-36 core reported by patient in the current tudy were lower than thoe reported by the general U.S. population (Miakowki et al., 2007; Wening, Vingerhoet, & Grol, 2001) and other ample of patient with cancer (Boini, Briançon, Guillemin, Galan, & Hercberg, 2004; Miakowki et al., 2007; Mol, Coebergh, & van de Poll-Frane, 2007; Wening et al., 2001). Perhap reflective of the upportive and alliance-building nature of the intervention, core related to mental health, mental component ummary core, and even vitality and ocial function improved from baeline in the coaching group. In contrat, thoe core declined in the other two group. A expected, phyical functioning and general health declined over time in the control and education group, yet urpriingly remained table in the coaching group. Although bodily pain core improved in the coaching group (p = 0.06), attempt to improve cancer pain management are unlikely to fully explain all of thoe difference. However, the improvement may better reflect the nure interventionit willingne to adapt to more preing iue facing the patient during the coaching telephone call. That action i conitent with motivational interviewing, but not captured by tandardized intrument. Finally, the current tudy wa not deigned to alter the amount and type of analgeic precribed. The type and amount of opioid precribed and taken varied widely among referral ite (Thoma, Anni, & Hwang, 2004). Interetingly, in thi ubanalyi, the amount of opioid precribed or taken did not appear to affect pain intenity rating, pain relief, or atifaction with pain management. Although intervention that focu on medication ue alone alo have not been conitently effective in controlling cancer pain, integrating pharmacologic intervention with cognitive-behavioral intervention might produce reult that are more ignificant. Thi tudy highlight the challenge of teting intervention that focu on clinical procee regarding provider advice, communication, and education in a everely ill patient population. Thoe clinical procee often are complex, and everal interacting component may account for the outcome. A a reult, the author encourage the ue of deign methodologie and outcome meaure that addre the complexitie of clinical tranlational tudie and ue of nonpharmacologic intervention. Future tudie hould compare a coaching intervention with different type of control to enure that the pecific effect of the intervention can be better ditinguihed from thoe of other controlled factor, uch a time, attention, motivation, expectation, and experience (Bennett, 2010; Bennett et al., 2009). Concluion and Implication for Nuring Practice Finding from the current tudy did not upport the ue of ma-produced educational material a an 46 Vol. 39, No. 1, January 2012 Oncology Nuring Forum

9 effective mean of managing cancer pain. However, in the buy clinic etting, too often thi approach i all a patient with cancer in pain may receive. Symptom including cancer pain may not be carefully aeed, nor intervention carefully elected, implemented, and dicued. Advanced practice nure (APN) provide comprehenive aement of ymptom and problem faced by patient with cancer. Uing motivational interviewing, APN and patient can jointly develop an appropriate plan of care to decreae thoe ymptom. Motivational interviewing i a kill that can be matered by an APN with ufficient training. In working with patient over time, the ue of motivational interviewing can yield poitive outcome that extend beyond traditional cancer pain management. Indeed, the ue of motivational interviewing i becoming more popular a a mechanim to increae patient adherence with medical treatment. Cancer pain management need to be addreed from an integrated biopychoocial approach (e.g., pharmacologic, cognitive, behavioral, motivational, educational) for it effectivene to be achieved fully. The author gratefully acknowledge Marilyn (Marty) Dougla, DNSc, RN, FAAN, who wa coprincipal invetigator of thi tudy. They alo gratefully acknowledge the time and commitment on the part of the patient who participated in thi tudy. Mary Laudon Thoma, RN, MS, AOCN, i a hematology clinical nure pecialit and Janette E. Elliott, RN-BC, MS, AOCN, i a pain management clinical nure pecialit, both at the Veteran Adminitration Palo Alto Healthcare Sytem in California; Stephen M. Rao, PhD, i the health behavior coordinator and director of the Training Pychology Potdoctoral Fellowhip Program at the San Francico Veteran Adminitration Healthcare Sytem in California; Kathleen F. Fahey, RN, MS, CNS, i the palliative care coordinator at El Camino Hopital in Mountain View, CA; and Steven M. Paul, PhD, i the principal tatitician and Chritine Miakowki, RN, PhD, FAAN, i a profeor and aociate dean for Academic Affair, both in the Department of Nuring at the Univerity of California, San Francico. Thi reearch wa upported by the Department of Veteran Affair, Veteran Health Adminitration, Health Service Reearch and Development Service (Project Number NRI-97026). The view expreed in thi article are thoe of the author and do not necearily repreent the view of the Department of Veteran Affair. Thoma can be reached at mary.thoma4@va.gov, with copy to editor at ONFEditor@on.org. (Submitted July Accepted for publication May 17, 2011.) Digital Object Identifier: /12.ONF Reference Agency for Health Care Policy and Reearch. (1994). Managing cancer pain, conumer verion, clinical practice guideline number 9. Rockville, MD: U.S. Department of Health and Human Service. American Cancer Society. (1994). The cancer experience: Living with treatment [Videotape]. 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11 The relation between the experience of time and pychological ditre in patient with hematological malignancie. Palliative and Supportive Care, 4, doi: /s Yate, P., Edward, H., Nah, R., Aranda, S., Purdie, D., Najman, J.,... Walh, A. (2004). A randomized controlled trial of a nureadminitered educational intervention for improving cancer pain management in ambulatory etting. Patient Education and Couneling, 53, doi: /s (03) Zimmerman, C., Burman, D., Swami, N., Krzyzanowka, M.K., Leighl, N., Moore, M.,... Tannock, I. (2010). Determinant of quality of life in patient with advanced cancer. Supportive Care in Cancer, 19, doi: / For Further Exploration Ue Thi Article in Your Next Journal Club Meeting Journal club program can help to increae your ability to evaluate the literature and tranlate thoe reearch finding to clinical practice, education, adminitration, and reearch. Ue the following quetion to tart the dicuion at your next journal club meeting. At the end of the meeting, take time to recap the dicuion and make plan to follow through with uggeted trategie. 1. What i motivational interviewing? 2. How doe motivational interviewing differ from couneling? 3. What i the purpoe of having a control group? What wa the intervention for the control group? 4. What i tratification and why wa it important to tratify participant in thi tudy baed on (a) pain and (b) cancer therapy? 5. In the dicuion ection of the article, the author tate, Cancer pain doe not exit in a vacuum. What do you think thi mean? How doe thi concept affect the effort of the nure to manage cancer pain? 6. In our practice, what type of nonpharmacologic reource do we provide to help patient manage cancer pain? Do you feel thee reource are effective? Why or why not? Viit for detail on creating and participating in a journal club. Photocopying of thi article for dicuion purpoe i permitted. Oncology Nuring Forum Vol. 39, No. 1, January