Applicability of the Nursing Outcomes Classification (Noc) to the Evaluation
of Cancer Patients with Acute or Chronic Pain in Palliative Care

Bruna S. Mello RN, MSN, Tânia M. Massutti RN, Vanessa K. Lon-

garay RN, Daniela F. Trevisan RN, Amália de F. Lucena RN, PhD

PII: S0897-1897(15)00085-3
DOI: doi: 10.1016/j.apnr.2015.04.001
Reference: YAPNR 50655

To appear in: Applied Nursing Research

Received date: 7 December 2014

Revised date: 31 March 2015
Accepted date: 10 April 2015

Please cite this article as: Mello, B.S., Massutti, T.M., Longaray, V.K., Trevisan, D.F.
& de F. Lucena, A., Applicability of the Nursing Outcomes Classification (Noc) to the
Evaluation of Cancer Patients with Acute or Chronic Pain in Palliative Care, Applied
Nursing Research (2015), doi: 10.1016/j.apnr.2015.04.001

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APPLICABILITY OF THE NURSING OUTCOMES CLASSIFICATION (NOC) TO

THE EVALUATION OF CANCER PATIENTS WITH ACUTE OR CHRONIC PAIN

IN PALLIATIVE CARE

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Bruna S. Mello , RN, MSNa,d, Tânia M. Massutti, RNb, Vanessa K. Longaray, RNb,

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Daniela F. Trevisan, RNd,, Amália de F. Lucena, RN, PhDa,c,d
a

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School of Nursing, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
b
Palliative Care Unit - Hospital de Clinicas of Porto Alegre, Brazil

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c
Nursing Process Committee - Hospital de Clinicas of Porto Alegre, Brazil
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Research and Study Group of Adult and Elderly Nursing (GEPECADI), Porto Alegre, Brazil
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Correspondence concerning this article should be addressed to Amália de F. Lucena,

School of Nursing, Federal University of Rio Grande do Sul, 963 São Manoel St., Rio
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Branco, Porto Alegre, RS,Brazil, 90620-110. Phone/fax: +55(51)335-98017 / +55(51)3359-

8657. E-mail: afatimalucena@gmail.com, alucena@hcpa.ufrgs.br.

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Introduction

The evaluation, management, and discomfort and suffering reliefs associated with

cancer-related pain are the major concerns for palliative care nurses (Waterkemper &

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Reibnitz, 2010). Cancer-related pain is present in 70 to 90% of those patients, and it is among

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the most common causes of disability in cancer patients (Minson et al., 2012). The cancer-

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related pain evaluation is a challenging task for nurses. Moreover, pain clinical presentation

and the need for familiarity with the use of instruments are complex. The use of these

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instruments provide accurate and reliable evaluation of patient status; thus, providing a basis

for nursing diagnoses and interventions. Hence, a precise, comprehensive, and systematic
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assessment of pain are crucial aspects of nursing care, but need further investigation in cancer

patient populations (Waterkemper & Reibnitz, 2010).

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The Nursing Outcomes Classification (NOC) has showed to be an important tool for

such investigations. Nursing outcomes (NO) allow states, behaviors, reactions, and feelings
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assessment observed in patients in response to nursing interventions (Moorhead et al., 2013).

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Although NOC (Moorhead et al., 2013) has been used in several studies in the literature, most

of these studies were performed in North-America and less than half evaluated the
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applicability of the outcomes in clinical practice (Garbin et al., 2009). Recent studies in

Brazil have found that NOC (Moorhead et al., 2013) is a useful tool for the evaluation and

identification of effective practices in nursing care (Lucena et al., 2013; Azzolin, 2011).

However, none of these studies have evaluated the applicability of the outcomes Acute

(00132) or Chronic Pain (00133) and their diagnostic indicators (Heardman & Kamitsuru,

2014) in palliative care units.

Therefore, the goal of this study was to verify the clinical applicability of the NOC

(Moorhead et al., 2013) to cancer patients with a diagnosis of Acute (00132) or Chronic Pain

(00133) (Heardman & Kamitsuru, 2014) in a palliative care unit.

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Background

Several complex interventions for the relief of physical, emotional, and spiritual

symptoms are involved in the nursing care of patients with advanced cancer (Goés et al.,

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2011). The major goal of palliative care is to improve quality of life and increase patient

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comfort through symptom prevention and relief; in addition to psychosocial, emotional, and

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spiritual support (WHO, 2013).

Cancer patients often experience multiple types of pain, either constantly or

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intermittently. This experience is a result of factors, such as local or distant tumor invasion,

and reactions to invasive examinations (biopsy) or treatments (surgery, chemotherapy or

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radiotherapy) (Minson et al., 2012).

The NANDA-International© (Heardman & Kamitsuru, 2014) classification describes

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the nursing diagnoses (ND) of Acute Pain and Chronic Pain as follows: acute pain is “an

unpleasant sensory and emotional experience associated with actual or potential tissue
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damage, or described in terms of such damage (International Association for the Study of
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Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or

predictable end,” (p. 440). Chronic pain is defined as “an unpleasant sensory and emotional
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experience associated with actual or potential tissue damage, or described in terms of such

damage (International Association for the Study of Pain); sudden or slow onset of any

intensity from mild to severe, constant or recurring without an anticipated or predictable end

and a duration greater than three (>3) months” (p. 442).

If one of these ND is confirmed, nurses must prioritize the evaluation and relief of

painful symptoms. Each NOC outcome (Moorhead et al., 2013) contains a list of diagnostic

indicators which can increase the reliability of patient evaluation. The indicators

corresponding to each outcomes can be rated on a five-point Likert scale. The outcomes are
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stated as concepts that reflect the state, behavior, or perception of a patient, caregiver, family,

or community, rather than expected goals (Moorhead et al., 2013).

The 490 NOC outcomes are grouped into 32 classes and seven domains (Functional

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Health, Physiologic Health, Psychologic Health, Health Knowledge & Behavior, Perceived

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Health, Family Health and Community Health). The ability to identify nursing outcomes and

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determine appropriate interventions is crucial for nurses. For instance, nurses are faced with

the challenging task of constantly evaluate and detect patient status changes, and may also

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contribute to the quality of the care provided (Moorhead et al., 2013).

Research question
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The present study was guided by the following research question:

- Are NOC (Moorhead et al., 2013) outcomes and indicators associated with the
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nursing diagnoses Acute (00132) or Chronic Pain (00133) and are they applicable to clinical

practice in the palliative care of cancer patients?

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Method
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A longitudinal prospective study was performed. Participants were included if they

had at least two evaluations during their hospital stay. This approach was adopted in order to
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detect any patient status change over the course of treatment (Fletcher & Fletcher, 2006). The

study was performed in the palliative care unit of a Brazilian university hospital, which has

seven beds allocated to terminal cancer patients. Palliative treatment aims to ameliorate pain

and other symptoms through clinical interventions, as well as psychological, social and

spiritual support. These interventions seek to improve the quality of life of patients and their

families. At this unit, all patients have individual rooms, which provide privacy and

accommodation for family members.

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Sample

Inclusion criteria were adults with a diagnosis of cancer, whose records indicated

referral to palliative care, and had a ND of Acute (00132) or Chronic Pain (00133) during

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their stay in the palliative care unit. Patients who could not be evaluated within 24h of

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diagnosis were excluded due to the lack of a baseline measure. Eligible patients were

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identified by active surveillance performed by one of the researchers through daily telephone

contact with nurses in the unit. Therefore, this should be considered a convenience sample.

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The primary outcome for sample size calculation was the improvement in NOC

(Moorhead et al., 2013) scores corresponding to the ND of Acute (00132) or Chronic Pain
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(00133), as reported in previous study (Azzolin, 2011). A minimum sample size of 13

patients would be necessary to detect a one-point difference in NOC (Moorhead et al., 2013)
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scores with a statistical power of 90% and an alpha-error of 5%. A standard deviation of 1

and a correlation of 0.5 between scores on the first and last assessments were assumed.
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Procedures
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Data were collected between November 2013 and February 2014 using two

instruments. The first instrument was used to collect sociodemographic (age, race, gender,
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primary education, living with family and household income) and clinical (reason for

hospitalization, primary tumor site, metastasis, other palliative treatment and current

medication) data from patient records. The second instrument aimed to verify the

applicability of NOC (Moorhead et al., 2013) outcomes to patients with a ND of Acute

(00132) or Chronic Pain (00133).

The latter instrument contained eight nursing outcomes and 19 indicators selected

from NOC (Moorhead et al., 2013) listings by nurses specialized in palliative care. The

following outcomes and indicators along with their respective numerical codes were

evaluated in the present study:

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 Pain Level (2102), and its indicators Reported pain (210201), Length of pain episodes

(210204), Facial expressions of pain (210206), Agitation (210222), and Irritability

(210223);

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 Comfort Status (2008), with its indicators Physical well-being (200801),

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Psychological well-being (200803), Social support from family (200806), and Ability

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to communicate needs (200812);

 Personal Well-Being (2002), with Social relationships (200203) as an indicator;

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 Client satisfaction: Pain Management (3016) with its indicators Pain level regularly

monitored (301602) and Actions taken to relieve pain (301604)/provide comfort

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(301605);

 Sleep (0004) with Sleep quality (000404) as an indicator;

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 Vital Signs (0802) with the indicators Respiratory rate (080204) and Systolic
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(080205)/Diastolic Blood Pressure (080206);

 Will to Live (1206) with Expression of determination to live (120601)/hope (120602)

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as an indicator; and

 Pain Control (1605) with the indicators Recognizes pain onset (160502), Describes
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causal factors (160501), and Use of non-analgesic relief measures (160504).

Each of the 19 indicators was operationally defined and adapted for use with a five-

point Likert scale ranging from 1= worst to 5=best scores (1=severely compromised;

2=substantially compromised; 3=moderately compromised; 4=mildly compromised; 5=not

compromised), as suggested by the NOC (Moorhead et al., 2013).

Two nurse researchers with experience in palliative care and prior training in the use

of the instrument evaluated included patients on a daily basis for a minimum of four and

maximum of five days. This procedure allowed an interobserver agreement for the
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investigation. Each patient was evaluated simultaneously, although independently, by the two

researchers. Each evaluator filled in their own copy of the instrument.

The present study followed all guidelines for ethical research involving human

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subjects, and the principles of autonomy, benevolence, nonmaleficence, justice and equity.

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All participants gave written informed consent prior to enrollment, and any vulnerable or

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incapacitated individuals were protected from harm (Conselho Nacional de Saúde, 2012). All

patients or legal guardians, in the case of incommunicable patients, were given a consent

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form in which the participant's anonymity was assured and individuals were informed that all

data would be used solely for research purposes. Additionally, the consent form specified that
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patients could withdraw from the study at any time. The study was approved by the

Institutional Review Board (#130229).

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Data Analysis

Data were analyzed using the Statistical Package for Social Sciences (SPSS), version
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18.0 (SPSS Inc., Chicago, USA). Continuous variables were expressed as mean and standard
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deviation, median, and interquartile range, depending on data normality. Categorical

variables were expressed as absolute frequencies and percentages. Student's t-test for paired
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samples was used to compare mean scores between researchers and assessments.

Interobserver agreement was calculated using the Bland-Altman method. A Generalized

Estimating Equation (GEE) Model was used to compare mean scores across assessments.

Then, a Least Significance Difference (LSD) post-hoc test was used to locate the differences

between means. Statistical significance was set at 5% (p≤0.05). The mean score of each

nursing outcome was calculated based on the mean indicator scores over the course of the

evaluation period.
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Results

Thirteen cancer patients in the palliative care unit received a diagnosis of Acute

(00132) or Chronic Pain (00133). Patients were evaluated for a minimum of four and a

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maximum of five consecutive days, totaling 62 evaluations. Ten of the patients were

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evaluated on five occasions, while just three underwent four evaluations due to death,

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hospital discharge, or withdrawal from participation, respectively.

The sample was predominantly male (53.8%) and had a mean age of 56.0±18.2 years.

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Most patients were hospitalized for dyspnea (38.5%) and pain (23.1%). Digestive system

cancer was the most common diagnosis in the sample (30.8%), followed by lung metastasis
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(23.1%). All patients were prescribed opioids and/or anti-inflammatory analgesics (Table 1).

Applicability of NOC Outcomes

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Statistical differences were demonstrated on the mean scores of four of the eight

nursing outcomes evaluated, as well as in five of the 19 NOC (Moorhead et al., 2013)
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indicators investigated in the present study (Table 2).

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In the Perceived Health domain, significant differences were observed in the Reported

pain (210201) and Length of pain episodes (210204) indicators. These indicators correspond
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to the Pain Level (2102) outcome. In addition, significant difference was found in the Social

relationships (200203) indicator of the Personal well-being (2002) outcome. Although no

differences were observed in the indicators pertaining to Comfort Status (2008) and Client

satisfaction: Pain Management (3016), the high scores on the latter suggest that patients were

generally satisfied with the treatment received in the unit.

In the Physiological Health domain, significant changes were observed in the

Respiratory rate (080204) indicator from the Vital Signs (0802) outcome.
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In the Health Knowledge & Behavior domain, significant differences were observed

in the Describes causal factors (160501) indicator from the Pain control (1605) nursing

outcome.

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In the Functional Health domain, no significant differences were observed on the

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indicator corresponding to the outcome Sleep (0004). However, low scores on this measure -

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which remained at approximately three - suggest poor sleep quality in the sample.

In the Psychological Health domain, mean scores on Will to Live (1206) indicators

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remained at approximately four, and did not differ over the course of the study.

It is important to note that all patients were receiving pain relief treatments in addition
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to psychological and spiritual support, which also included interventions directed to patient

families. These interventions were described in nursing records and implemented to patient
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care. These actions are linked to the ND of Acute (00132) or Chronic Pain (00133) according

to institutional guidelines and protocols.

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Interobserver agreement
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Scores from the nursing outcomes Pain Level (2102), Comfort Status (2008), Personal

Well-Being (2002), Client satisfaction: Pain Management (3016), and Sleep (1206) showed
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high interobserver agreement. However, significant differences were observed between raters

on the nursing outcomes Pain Control (1605) (p≤0.05) and Will to Live (1206) (p≤0.05). This

difference may be attributed to the high sensitivity of the paired-samples t-test. According to

the Bland-Altman method, the raters achieved agreement of at least 88.9% in all outcome

measures, suggesting excellent interobserver agreement. Since the Vital Signs (0802) domain

is based solely on objective clinical data, no interobserver variability was observed on this

measure. According to the t-test results, rater scores difference only exceeded one point in the

nursing outcome Will to Live (1206) (Table 3).

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Discussion

This was the first Brazilian study performed in a clinical environment with the aim of

assessing the applicability of the NOC (Moorhead et al., 2013) for the assessment of the

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clinical evolution of palliative care patients with ND of Acute (00132) and Chronic Pain

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(00133). These findings allowed to answer the research question, since there was

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applicability of the selected outcomes for nursing evaluation of patients with Acute (00132)

and Chronic Pain (00133) in palliative care.

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The present study evaluated eight nursing outcomes in the following domains:

Functional Health (I), Physiologic Health (II), Psychological Health (III), Perceived Health
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(V), Health Knowledge & Behavior (IV) (Moorhead et al., 2013). A specifically designed

instrument was used to evaluate these outcomes in 13 patients for at least four consecutive
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days, totaling 62 evaluations.

In the Pain Level (2102) outcome, a subcategory of the Perceived Health domain,
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scores on Reported pain (210201) (p≤0.05) indicators and Length of pain episodes (210204)
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(p≤0.05) differed significantly between evaluations. These findings suggest that patient’s

reports contributed substantially to the assessment of pain. Moreover, pain severity improved
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significantly over the course of the study. However, despite the importance of Reported pain

(210201) scores for patient evaluation, it is important to note that some critically ill patients

were unable to respond to this item on some of the evaluations, which underscores the need

for additional indicators of pain (Haslam et al., 2011). Therefore, in the case of palliative care

patients with cancer-related pain, such as those in the present sample, reported pain cannot

always be used as the sole indicator of patient discomfort, and must be accompanied by

additional measures of this variable. The improvement in Reported pain (210201) scores

illustrates the effectiveness of the treatment and nursing care received by patients. An

example is the adoption of the NIC intervention Pain management (1400) (Bulechek et al.,
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2013), which includes monitoring patient comfort and administering prescribed analgesics.

Significant differences were also observed on mean scores in the Length of pain episode

(210204) indicator, suggesting an improvement in pain intensity, regardless of the continued

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presence of some degree of pain. This finding is mostly attributable to the nature of chronic

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pain in cancer patients, whose disease progression often prevents total pain relief (Rangel &

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Telles, 2012).

On the other hand, the indicators Facial expressions of pain (210206), Agitation

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(210222), and Irritability (210223) can be evaluated based on the nurses' observations and do

not depend on patient reports. However, these measure scores did not change over the course
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of the study, remaining in the mild to none range, and showing a slight improvement on the

fifth assessment day. Moreover, severe disease, such as that presented by the palliative care
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patients evaluated in the present study, is usually associated with fatigue, prostration, and

some degree of drowsiness induced by analgesics such as opioids (De La Cruz et al., 2014).
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No significant differences were observed in the indicators pertaining to the Comfort

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Status (2008) outcome from the Perceived Health domain. Mean scores on this measure were

indicative of mild impairment, and were of approximately 3. However, scores on the Physical
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well-being (210801) indicator decreased over the course of the study. This finding may have

been caused by the impaired physical mobility, discomfort, altered respiratory patterns,

fatigue, loss of appetite, nausea, and vomiting associated with terminal cancer. For instance,

cancer symptoms are difficult to manage and have a significant impact on physical well-

being, compromising patient stability (De La Cruz et al., 2014). The indicators Psychological

well-being (200803) (p>0,05) and Social support from family (200806) (p>0,05) are also

important measures of psychosocial processes associated with the disease. In the present

sample, scores on these measures did not change significantly over the course of the study,

remaining in the mildly compromised to not compromised range. These findings suggest that,
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although patients may be experiencing some degree of psychological distress, they also feel

supported. Social and psychological support interventions provided in the palliative care unit

may have contributed significantly to the improvement of painful symptoms, even with

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patient awareness of the progression of their disease (Kawi, 2014). These findings

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corroborate with a recent study of pain and quality of life in cancer patients receiving home

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palliative care. Authors reported that decreased pain severity is associated with increased

patient satisfaction and leads to higher self-esteem and spirituality, and greater satisfaction

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with the self and one's physical appearance (Mendes et al, 2014). Scores on the Ability to

communicate needs (200812) (p>0.005) indicator showed a slight, but not significant,
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increase on the fourth and fifth assessments. Communication is a major facet of human

behavior and permeates all aspects of human functioning. Furthermore, communication is an

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important aspect of palliative nursing, since it allows practitioners to identify and empathize

what are the needs of patients and their families. This understanding results in more
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comprehensive and humanized interventions (Andrade, Costa & Lopes, 2013).

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Patient satisfaction scores in the Perceived Health domain increased significantly over

the course of study, especially in the Social relationships (200203) (p≤0.05) indicator from
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the Personal Well-being (2002) outcome. Scores on this measure were already indicative of

satisfaction with social relationships at the time of the first evaluation, and increased even

further over the remainder of the study. However, the previously mentioned study of pain and

quality of life in cancer patients receiving home palliative care yielded contrasting results.

The study in question found that advanced cancer patients with no possibility of cure had

difficulty maintaining personal relationships, even in the absence of cancer-related pain

(Mendes et al, 2014). This discrepancy may be associated with the setting where each study

was performed, since the present study evaluated patient relationships during hospitalization,

while Mendes et al. (2014) focused on patient relationships at home.

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These findings emphasize the importance of the environment in which the present

study was conducted. A unit dedicated specifically to patients beyond cure, where a

multidisciplinary team offers palliative treatment, aimed at improving the quality of life of

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patients and their families (Kruse et al., 2007). We believe that our treatment approach had a

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positive effect on the Social relationships (200203) indicator. Nursing interventions

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implemented in the unit involve encouraging family participation in care and restoring family

relationships, which result in a positive effect both on relationship satisfaction and general

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well-being.

Scores on the Client satisfaction: Pain Management (3016) outcome and its indicators,
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such as Pain level regularly monitored (301602) (p>0.05) and Actions taken to relieve pain

(301604)/provide comfort (301605) (p>0.05), did not change between assessments. However,
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the high scores on these measures (from 4.78 to 5.0) suggested that patients were satisfied

with the pain management received throughout the study period. A previous study of patient
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satisfaction with pharmacological treatment in a palliative care unit found that pain relief was
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possible even in cancer patients with a mean of 7 to 11 symptoms (Barbosa, 2011).

Nonetheless, both patient and family must receive detailed information regarding the
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treatment strategies implemented in clear and understandable language, especially when

patients or family members have low education levels, as in the present study. In the unit

where the present study was performed, nurses inform both the patient and its family of the

pain management strategies available. This approach increases patient satisfaction, facilitates

symptom control, and promotes patient comfort.

The nursing outcome Sleep (0004) in the Physiologic Health domain was measured

using the Sleep quality (000404) indicator (p>0.05). These indicator scores did not change

over the course of the study and remained relatively low (from 3.33 to 3.80), showing only a

slight improvement on the fifth evaluation day. This finding corroborates with previous
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literature regarding sleep alterations in cancer patients caused by depression and cancer-

related pain (Stepanski et al., 2009).

The Vital Signs (0802) indicators Respiratory rate (080204) and Systolic (080205)/

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Diastolic Blood Pressure (080206), are from the Physiologic Health domain of NOC

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(Moorhead et al., 2013). These indicators are important aspects of pain assessment, since

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both parameters may be influenced by the presence of pain (Biasi et al., 2011). Although

mean Systolic (080205)/Diastolic Blood Pressure (080206) scores did not differ throughout

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the study period (p>0.05), this was not the case for Respiratory rate (080204) scores (p≤0.05).

Given the unique, subjective and challenging nature of pain assessment in cancer patients, to
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monitor quantitative variables, such as vital signs, may have especially important

contributions to this area (Biasi et al., 2011). However, in patients with chronic pain, such as
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the majority of the patients in this study sample, pain management and relief may be

especially difficult. This difficulty may lead patients to habituate to this symptom and its
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ramifications, and to result in a greater stability of vital signs for patients with chronic pain
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than patients with acute pain. Although neurovegetative symptoms, such as tachycardia and

elevated BP, are among the main repercussions of acute pain, chronic pain is not associated
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with sudden or prolonged changes in vital signs (Sallum et al., 2012).

The nursing outcome Will to Live (1206) was evaluated using the Expression of

determination to live (120601)/hope (120602) indicator (p>0.05). These scores showed no

significant changes over the course of the study. In fact, scores on this measure varied quite

little (from 3.83 to 4.22), ranging from mildly to moderately compromised. Although most

patients showed prostration or discouragement at some point, they were mostly hopeful and

accepting treatment, as well as visits from family and friends. The literature shows that

despite the presence of terminal illness and suffering, cancer patients may still maintain a

sense of hope and have the will to live; thus, agreeing to spend time with their families and
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receive palliative care. A study of the association between support interventions and

depression, reported by cancer patients, found that psychological interventions led to

improvements in over 50% of cases (Rhondali et al., 2014).

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The Pain Control (1605) (p>0.05) outcome in the Health Knowledge & Behavior

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domain was evaluated approximately three times throughout the study. The outcome did not

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appear to change over the course of the study period. However, scores on the Describes

causal factors (160501) (p≤0.05) indicator did improve on the fifth day of assessment.

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Systematic nursing interventions are performed in the study unit and include provision of

information and clarifications regarding the disease and its progression. As a result, most of
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the patients were able to determine the cause of their pain and able to understand the events

experienced during the hospitalization. Scores on the Recognizes pain onset indicator
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remained constant at 5. This finding suggests that patients “consistently demonstrated” the

onset of pain, although a p-value could not be calculated for this variable. All included
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patients with effective communication were able to report the onset and location of pain.
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Scores on the Use of non-analgesic relief measures (160504) (p>0.05) indicator

remained stable and low (1.49 and 1.89) throughout the study. Findings suggest that patients
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used few non-pharmacological treatments for pain relief. The ethical principle of autonomy,

which states that the patient must be involved in their pain management, must always be a

guiding principle for palliative care workers (Mateus et al., 2008). Additionally, non-

pharmacological pain relief strategies must be incorporated into conventional care. Non-

pharmacological strategies have the potential to increase analgesia and, consequently,

improve patient well-being (Abreu et al., 2009).

Findings from this study suggested that the selected nursing outcomes were applicable

to the assessment of the presence, decrease, or increase of cancer-related pain in patients in a

palliative care unit. The variability, or lack thereof, in indicator scores provided an evaluation
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of both patient status and treatment strategies implemented. This evaluation identify the need

to initiate or adjust treatments to achieve better pain management.

Limitations of this study are the fact that operational definitions were adopted for the

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indicators and were developed by the researchers considering the study setting. Moreover,

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findings might not be generalized for other settings, considering the high specificity of the

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setting where the patients were evaluated. Another limitation was the difficulty in data

collection, which used a relatively long instrument for patients in palliative care. These

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patients have unique health conditions, and sometimes could not or did not have motivation

to answer to the research questions.

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Conclusions

Statistical differences were observed between the first and last assessment in the
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following indicators and outcomes: Reported pain (210201), and Length of pain episodes

(210204) in the Pain Level (2102) outcome; Social relationships (200203) in the Personal
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Well-Being (2002) outcome; Respirator rate (080204) in the Vital Signs (0802) outcome; and
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Describes causal factors (160501) in the Pain control (1605) outcome.

It is important to note that Comfort Status (2008) and Sleep (0004) remained
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moderately compromised throughout the study period. These outcome and indicator scores

did not change over the course of the study, likely because they are affected by the severity of

patient illness. Although our focus was on pain and symptom reliefs, these symptoms in more

severe patients could not always be completely controlled. On the other hand, scores on the

Client satisfaction: Pain Management (3016) and Will to Live (1605) outcomes were

consistently elevated throughout the study. Findings showed that patients and their families

were satisfied with the nursing interventions provided to manage patient pain and to promote

physical and psychological well-being.

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Therefore, findings showed that NOC (Moorhead et al., 2013) outcomes and

indicators are applicable to the assessment of the clinical evolution of cancer patients with

acute or chronic pain in palliative care units. However, caution must be considered to ensure

T
that the selected NOC (Moorhead et al., 2013) outcomes are able to provide reliable

P
RI
evaluations of the patient status. In conclusion, we believe that the present study may be

SC
helpful to palliative care nurses. This study provides orientations regarding the most adequate

methods of evaluating cancer-related pain and minimizing patient suffering through effective

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pain management strategies.

Acknowledgments
MA
This study was supported by FIPE-HCPA (Research Incentive Fund of the Hospital de

Clinicas of Porto Alegre).

ED

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Table 1 – Sociodemographic and clinical characteristics of cancer patients in a palliative care

unit. Porto Alegre/RS, 2014
Variables n=13
Age, years * 56.0 ± 18.2
White† 9 (69.2)

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Male gender† 7 (53.8)
Primary education†

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9 (69.2)
Living with family† 13 (100)

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Household income of two minimum wages† 6 (46.2)
Reason for hospitalization†

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Dyspnea 5 (38.5)
Pain 3 (23.1)
Hyperthermia 3 (23.1)
Gastrointestinal bleeding 1 (7.7)

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Diarrhea 1 (7.7)
Primary tumor site†
Digestive cancer 4 (30.8)
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Kidney cancer 2 (15.4)
Lymph node cancer 2 (15.4)
Gynecological cancer 2 (15.4)
Head and neck cancer 1 (7.7)
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Reproductive system cancer 1 (7.7)

Respiratory cancer 1 (7.7)
Metastasis†
Lung 3 (23.1)
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Bone 2 (15.4)
Liver 1 (7.7)
Axillary lymph nodes 1 (7.7)
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Unknown 6 (46.2)
Other palliative treatment†
Radiotherapy 3 (23.1)
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Chemotherapy 2 (15.4)
Other 1(7.7)
None 7 (53.8)
Current medication†
Opioids 13 (100)
Anti-inflammatory analgesics 13 (100)
Adjuvants
Antidepressants 8 (61.5)
Anticonvulsants 5 (38.5)
Anxiolytics 3 (23.1)
Corticoids 3 (23.1)
Neuroleptics 3 (23.1)
GABA Agonists 1 (7.7)
Source: Research data
*mean ± standard deviation; † n (%)
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Table 2 – Mean score obtained for nursing outcomes and corresponding indicators in cancer
patient hospitalized for palliative care. Porto Alegre/RS, 2014
NOC Outcomes/ Day 1 Day 2 Day 3 Day 4 Day 5 P
Indicators (n=13) (n=13) (n=13) (n=13) (n=10)
Pain Level (2102) * 4.33 (0.20) 4.37 (0.18) 4.23 (0.17) 4.15 (0.21) 4.55 (0.18) 0.361

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Reported pain* 3.45 (0.47)a 3.71 (0.40)ab 3.30 (0.47)a 3.58 (0.38)ab 4.39 (0.31)b 0.003
Length of pain episodes* 3.70 (0.38)ab 3.50 (0.52)ab 3.25 (0.43)a 3.00 (0.44)a 3.88 (0.51)b 0.041

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Facial expressions of 4.00 (0.39) 4.58 (0.20) 4.27 (0.28) 4.08 (0.40) 4.35 (0.37) 0.639
pain*

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Agitation* 4.92 (0.05) 4.77 (0.16) 4.62 (0.19) 4.96 (0.04) 4.95 (0.05) 0.166
Irritability* 5.00 (0.00) 5.00 (0.00) 4.92 (0.05) 4.77 (0.09) 4.95 (0.05) 0.070

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Comfort Status (2008)* 3.91 (0.16) 3.72 (0.17) 3.79 (0.19) 3.82 (0.18) 3.89 (0.20) 0.320
Physical well-being* 3.00 (0.18) 2.69 (0.21) 2.96 (0.24) 2.85 (0.23) 2.75 (0.29) 0.650

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Psychological well-being* 3.75 (0.22) 3.45 (0.23) 3.75 (0.23) 3.18 (0.34) 3.56 (0.32) 0.101
Social support from 4.96 (0.03) 5.00 (0.00) 5.00 (0.00) 5.00 (0.00) 5.00 (0.00) 0.298
family*
Ability to communicate 4.08 (0.39) 3.88 (0.39) 3.73 (0.44) 4.27 (0.34) 4.35 (0.40) 0.375
needs*
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Personal Well-Being* - - - - - -
(2002)
Social relationships* 4.56 (0.21)a 4.72 (0.14)ab 4.81 (0.12)b 4.69 (0.23)ab 4.88 (0.08)b 0.037
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Client satisfaction: Pain 4.94 (0.03) 4.78 (0.21) 5.00 (0.00) 4.91 (0.06) 4.88 (0.12) 0.223
Management (3016)*
Pain level regularly 5.00 (0.00) 4.78 (0.21) 5.00 (0.00) 5.00 (0.00) 4.94 (0.06) 0.355
monitored*
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Actions taken to relieve 4.89 (0.07) 4.78 (0.21) 5.00 (0.00) 4.81 (0.12) 4.81 (0.18) 0.223
pain/provide comfort*
†
Sleep (0004) - - - - - -
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†
Sleep quality 3.46 (0.25) 3.33 (0.32) 3.77 (0.28) 3.73 (0.26) 3.80 (0.28) 0.654

‡
Vital Signs (0802) 4.65 (0.19) 4.77 (0.10) 4.88 (0.06) 4.77 (0.09) 4.70 (0.19) 0.583
‡
Respiratory rate 4.62 (0.25) ab 4.77 (0.09) ab 5.00 (0.00)b 4.69 (0.13)a 4.62 (0.27) ab 0.023
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‡
Blood Pressure 4.69 (0.17) 4.77 (0.16) 4.77 (0.12) 4.85 (0.15) 4.80 (0.13) 0.949

§
Will to Live (1206) - - - - - -
Expression of 4.22 (0.19) 4.11 (0.20) 4.00 (0.25) 3.83 (0.36) 4.06 (0.30) 0.226
determination to live /
§
hope
ΙΙ
Pain Control (1605) 3.72 (0.20) 3.62 (0.20) 3.56 (0.17) 3.45 (0.23) 3.46 (0.15) 0.095
ΙΙ
Recognizes pain onset 5.00 (0.00) 5.00 (0.00) 5.00 (0.00) 5.00 (0.00) 5.00 (0.00) -
ΙΙ
Describes causal factor 3.78 (0.12) ab 3.67 (0.04)a 3.74 (0.06)a 3.54 (0.10) ab 4.12 (0.15)b 0.017
Use of non-analgesic 1.89 (0.18) 1.67 (0.03) 1.81 (0.10) 1.67 (0.03) 1.49 (0.15) 0.253
ΙΙ
relief measures
Source: Research data.
Note: Generalized Estimating Equation (GEE) Model with values expressed as mean ± standard deviation.
a,b - means followed by the same letter did not differ according to the LSD (Least Significance Difference) test
at 5%
significance.
* Domain: Perceived Health.
† Domain: Functional Health.
‡ Domain: Physiologic Health.
§ Domain: Psychological Health.
ΙΙ Domain: Health Knowledge & Behavior.
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Table 3 - Interobserver agreement in the assessment of nursing outcomes in cancer patients

hospitalized for palliative care. Porto Alegre/RS, 2014
Bland-
Nursing Outcomes Difference P* Altman
(numerical codes) N R1 R2 (95%CI) 95%
confidence

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interval

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Pain Level (2102) 13 4.19 (0.53) 4.19 (0.51) 0.00 (-0.10 to 0.10) 0.979 -0.35 to 0.35

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Comfort Status (2008) 13 3.77 (0.68) 3.85 (0.58) 0.08 (-0.09 to 0.26) 0.318 -0.66 to 0.49

Personal Well-Being (2002) 9 4.62 (0.49) 4.71 (0.34) 0.09 (-0.13 to 0.31) 0.361 -0.67 to 0.48

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Client satisfaction: Pain 9 4.91 (0.28) 4.84 (0.36) 0.07 (-0.02 to 0.15) 0.095 -0.15 to 0.29
Management (3016)

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Pain Control (1605) 11 3.56 (0.83) 3.44 (0.79) 0.12 (0.01 to 0.22) 0.032 -0.20 to 0.43

Sleep (0004) 13 3.47 (0.77) 3.65 (0.63) 0.18 (-0.08 to 0.44) 0.163 -1.05 to 0.69
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Will to Live (1206) 10 3.63 (0.87) 4.17 (0.95) 0.54 (0.11 to 0.97) 0.019 -1.73 to 0.66

Source: Research data

Note: Vital Signs scores did not display interobserver variability.
*paired samples t-test.
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R = rater.
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