Nursing Support for Pain in Patients With Cancer: A Scoping Review

Pain is subjective, warranting tailored responses in pharmacotherapy and nursing support. Despite this, the evidence for suitable nursing support for pain is not well established in terminally ill patients such as those with cancer; therefore, it is necessary to provide support in consideration of changes in physical symptoms and quality of life. However, interventional studies for such patients are often difficult. There have been no comprehensive studies to date on non-pharmacological support that can be implemented by nurses. Therefore, with the aim of examining nursing support applicable at the end of life, this scoping review comprehensively mapped nursing support for pain in cancer patients at all stages of the disease. This study complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the Arksey and O’Malley framework. All available published articles from the time of database establishment to January 31, 2022, were systematically searched for in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), CENTRAL, and the Ichushi Web database of the Japanese Society of Medical Abstracts. Overall, 10,385 articles were screened, and 72 were finally included. Both randomized controlled trials (RCTs) (n = 62) and non-RCTs (n = 10) were included. Twenty-two types of nursing support were identified. Eighteen of them showed positive results; five of them were provided only to terminally ill patients, three of which were effective, namely, comfort care, foot bath, and combined therapy. It is important to examine the applicability of types of nursing support in clinical practice in the future.


Introduction And Background
Most cancer patients experience pain [1]; in particular, more than half of patients with advanced, metastatic, or terminal cancer experience pain [2].In addition, cancer pain is a subjective experience and a complex symptom with varying factors (e.g., tumor or treatment-related and non-cancer-related), nature (e.g., nociceptive and neuropathic), and duration (e.g., persistent pain, sudden pain, and chronic pain), and its management requires an individualized approach.Therefore, in parallel with pharmacological therapy, nurses provide education on pain management and care to increase pain threshold through various activities such as foot bathing, positioning, and massage [3].
The National Comprehensive Cancer Network (NCCN) [4] and American Society of Clinical Oncology (ASCO) [5] guidelines for patients with pain at any stage of disease recommend a combination of pharmacological and non-pharmacological pain management strategies according to patient preferences.In terms of nonpharmacological therapy, the NCCN guidelines recommend physical interventions such as conditioning exercise, massage, heating and cooling, acupressure, and cognitive-behavioral interventions such as mindfulness, breathing techniques, and relaxation, as well as psychosocial support and spiritual care [4].The ASCO guidelines recommend moderate acupuncture for joint pain due to the use of aromatase inhibitors and reflexology, massage, acupressure, yoga, and muscle relaxation therapy for general and musculoskeletal pain [5].Only moderate massage is also recommended for patients with cancer receiving palliative care.However, evidence of suitable nursing support for specifically terminally ill patients is still insufficient.
In the case of terminally ill cancer patients with a prognosis of weeks until death, the increased distress of physical symptoms, decline in physical and cognitive functions, and psychological changes warrant special attention to the needs of the patient [6].However, guidelines for nursing support for cancer pain and consensus on nursing support for terminally ill patients are lacking.The purpose of this scoping review was to map nursing support for pain in cancer patients at all phases of the disease before examining the potential of pain care for terminally ill cancer patients.

Review Objective and methodology
In this study, nursing support for pain is defined as any non-pharmacological treatment for pain relief that can be provided by a nurse.This study was conducted in accordance with a previously published protocol [6].
The protocol article states that information would be collected using the Delphi method to examine the feasibility of providing support to terminally ill cancer patients, although, in this study, we continued to map the results of the scoping review.We applied Arksey and O'Malley's five-step scoping review framework [7] and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extended version for scoping reviews (PRISMA-ScR) reporting guidelines [8].
Step 1: Identification of research questions A systematic literature search was conducted on nursing support for cancer pain.The research question for this study was "What types of nursing support are provided to reduce cancer pain?" Step 2: Identification of relevant research PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials in the Cochrane Library, and the Japanese Ichushi Web database of the Japanese Society of Medical Abstracts were searched from the time of database establishment to January 31, 2022.Relevant studies were evaluated from the list of articles, and major journals were manually searched.Search queries were first created in PubMed for an initial search, and then, search formulas were created to match other databases (refer to the protocol study) [6].Two researchers (MM and JK) conducted this initial search in consultation with a librarian.Eligibility criteria were determined by physicians and nurses specializing in symptom management for patients with cancer.The inclusion criteria were studies that reported (a) patient age as 18 years or above, (b) interventions aimed at relieving pain, (c) nursing support, and (d) quantitative assessment of pain using a scale.The exclusion criteria were (a) studies that reported at least 20% noncancer participants, (b) secondary analyses, and (c) those in languages other than Japanese and English.The details are described in the protocol article [6].
Step 3: Study selection process Two investigators (MM and JK) independently evaluated the titles and abstracts of all studies and then screened the complete studies against the eligibility criteria.Discrepancies in study selection were resolved through discussion.The study selection process is summarized in Figure 1.Step 4: Data charting A form was developed to extract study characteristics, including the name of the first author, year of publication, country of publication, design of the study, size of the sample, eligible patients, type of nursing support, outcome measurement tools, and intervention effect.The same two researchers independently extracted the data.Studies that did not meet the eligibility criteria were excluded at this stage.

Step 5: Consolidation, summarization, and reporting of results
Nursing support reported in the articles extracted from the literature review was categorized by element of care using qualitative thematic analysis.First, the nursing support data described in the subject study were extracted into Microsoft Excel (Microsoft Corp., Redmond, WA) as raw data and analyzed for possible patterns, and notes were made as initial codes leading to the classification of the nursing support elements.Second, initial codes were created based on the intent and content of care provided.Third, patterns were searched, and potential nursing support components were grouped.Fourth, the initial codes were reviewed to find common nursing support components.Finally, each component was identified and clearly named.Several nursing support terms defined in the included studies were used as references.The analysis validated the classification by one author (MM) through discussion with another researcher (JK) and the entire study group.

Results
Our initial literature search listed 11,348 studies.After the removal of 963 duplicate studies, the titles and abstracts of 10,385 studies were screened, following which 10,177 studies were excluded.A total of 208 fulltext studies were assessed for study eligibility and relevance, of which 72 were judged to satisfy the eligibility criteria (Figure 1).The interventions in the 72 studies were qualitatively categorized into 22 types of nursing support.Each intervention was divided according to the stage of the participant's illness (all phases, treatment phase, terminal phase, and no notation); the number of tabulated studies is shown in Table 1.The details of the identified studies are presented in Table 2       Of these studies, 62 were randomized controlled trials (RCTs), five were non-RCTs, and five were prospective observational studies.The United States accounted for the largest number of these studies (26 studies), followed by Taiwan (seven studies), China (six studies), Turkey (five studies), and other countries (28 studies).A total of six studies had been published in the 1990s, 25 in the 2000s, 36 in the 2010s, and 13 in the 2020s.In terms of pain assessment tools, the Brief Pain Inventory (BPI) was the most commonly used (24 studies), followed by a numerical rating scale (NRS) (23 studies), and the visual analog scale (VAS) (22 studies).These scales convert pain into a numerical value.Associated factors such as beliefs, barriers, and concerns about analgesics and pain management, which may have an influence on perception of pain, were not identified in this study.
The largest number of studies were related to education and were categorized into four types based on the characteristics of the educational programs.Studies focused on providing knowledge and information, selfcare management, using coaching skills, and emphasizing education and psychological care.In total, 10 and 11 studies focused on providing knowledge and information [9][10][11][12][13][14][15][16][17][18] and self-care management [19][20][21][22][23][24][25][26][27][28][29], respectively, and four and six studies used coaching skills [30][31][32][33] and educational and psychological care interventions [34][35][36][37][38][39], respectively.A total of 31 studies on education of all types were extracted, 29 of which were RCTs, one a non-RCT, and one a prospective observational study.All studies included a treatment phase.Although only one study each for specific cancers such as that of the lung, breast, and head and neck was extracted, most of the studies involved patients with various cancer types.
For nursing support to promote physical activity, two cases each of exercise [40,41] and progressive muscle relaxation therapy [42,43] were identified.One study on exercise and muscle relaxation therapy was reported for all disease stages and one for the treatment stage, both of which were RCTs.
Two studies on massage therapy [60,63] and one study each on aromatherapy massage therapy [60], reflexology [71], and foot bathing [74] were conducted only in the terminal phase, whereas the others were conducted in the treatment phase or all phases of the disease.
One study each of self-administered acupressure [75], auricular point acupressure [76], and Reiki [45] were identified as considering nursing support related to Eastern medicine.The studies of self-acupressure and auricular acupressure used RCT designs, whereas the study of Reiki used a non-RCT design.In addition, two comfort care (environmental adjustment/mental healthcare/oral care) [77,78] and two adjustments to home care programs [79,80] were identified, all of which were RCTs.
Of the 72 studies, 48 showed a statistically significant reduction in pain.These included 15 studies of education (five focused on the provision of knowledge and information, five on self-management, and five on education and psychological care), six of music therapy, four each of massage and reflexology, three of combination therapy, and two each of exercise, progressive muscle relaxation therapy, comfort care, and adjustments to home care programs.There was one study each of acupressure, poetry appreciation, cognitive-behavioral intervention, relaxation, foot bathing, and Reiki.

Discussion
This study is the first to comprehensively map nursing research on non-pharmacological therapies for cancer pain.We reviewed nursing support for patients from the treatment phase to the end of life and identified 72 types of nursing support.Only six studies were conducted exclusively on terminally ill patients.
Patient education was identified as a form of nursing support for cancer pain.Pain management education focused on providing knowledge and information, including the introduction of videos, slides, booklets, and online applications to the patients.Education focused on self-care comprised several support packages, including the PRO-SELF Plus pain control program (a pain education intervention program that frames Orem's self-care theory), which provides information and pillboxes to correct misconceptions about opioids and enable effective medication and communication with healthcare providers.It has been reported that a patient's ability to effectively self-manage cancer pain can be negatively affected by inadequate knowledge and negative attitudes.Therefore, it is expected that these interventions will be useful to ensure that patients have the correct knowledge and demonstrate appropriate self-care skills [81].Oldenmenge et al. [82] reported that education of patients with cancer pain not only improved their knowledge about cancer pain but also alleviated pain in 31% of the studies.In their review, Koller et al. [83] divided the content of the educational intervention into four components: cognitive, behavioral, goal setting, and direct contact between research staff and clinicians.They reported that interventions could not be clearly categorized by the educational component; although the present study also focused on the characteristics of educational interventions and categorized them, the components were not clearly separated.Nevertheless, as the purpose of the current study was to comprehensively map nursing support, the objective was achieved.Many of the studies identified in this study were educational for various cancer types and all disease phases, suggesting that the support is adaptable to many cancer patients.In contrast, many studies reported longterm interventions that included follow-up and should be scrutinized when considering their application to terminally ill patients.
Exercise was identified as an aid in promoting physical activity.Meta-analyses on exercise therapy for cancer pain management have shown that it is effective in reducing pain, although the effect size is small [84].It has been suggested that exercise be tailored to the patient, as generalized exercise may be ineffective or lead to worsening of pain depending on the patient's situation [84,85].Similarly, muscle relaxation therapy has been shown to be effective, but the level of evidence is low [86], and evidence building is important before considering it as nursing support.The muscle relaxation and guided imagery therapies extracted in this study have been examined using recorded data, and such interventions would be easier for nurses to introduce in clinical practice.In this study, nursing support that can provide comfort and relieve local tension included relaxation using VR, combination therapy (progressive muscle relaxation/guided imagery therapy/cognitive therapy), massage, reflexology, foot bathing, music therapy, and poetry appreciation.Notably, many types of support were identified that address the diverse needs of patients and play a complementary role in pain management.Although a systematic review conducted on the effects of massage on cancer patient symptoms suggests that it has a beneficial effect on pain [87], only two of the six studies reported pain relief.This may partly be attributed to the fact that this study excluded treatments performed by qualified therapists and included those that could be performed by nurses and other medical personnel.It should also be noted that while differences in techniques used between practitioners are generally noted [88], it is more difficult to standardize techniques when they are performed by nurses than therapists.More effective comfort care interventions to raise patient pain threshold [3] should be studied, and relevant evidence should be built in the future.
Reiki, auricular acupressure, and self-acupressure instructions were also identified as other types of nursing support based on Eastern medicine, which are also referred to in the ASCO guidelines [5] as nonpharmacological therapies.In this study, these nursing support items were extracted in a format that nurses could easily incorporate into their clinical practice, such as auricular point acupressure, in which seeds are applied to the ear, and self-administered acupressure.Further study is needed to determine whether these can be implemented in clinical practice and the effectiveness of their implementation by nurses.
In addition, it was suggested that preparing the patient's living and recuperation environment, including adjustments to comfort care and home care programs, is a fundamental element of nursing, and these are also important types of support in cancer pain management [77][78][79][80].
This scoping review has some limitations.First, because the search was limited to studies published in Japanese and English, this review may have excluded relevant studies published in other languages.Second, this scoping review was not designed to assess methodological quality, as its purpose was to map nursing support.Thus, this conclusion is primarily based on the extraction of nursing support investigated in studies rather than on the effectiveness of nursing support for cancer pain.

Conclusions
In this study, we comprehensively mapped the non-pharmacological support provided by nurses for cancer pain and identified 22 types of nursing support from 72 studies.Of these, six studies were exclusively of terminally ill cancer patients, and only five types of nursing support were identified.The most common nursing support for cancer pain was related to education.Other types of support included those pertaining to the patient's perception of pain, promoting patient comfort (believed to raise pain threshold), and adjusting the patient's care environment.Further research on and consideration of the possible support for terminally ill patients are needed in the future.

Appendices
Table 3 presents the PRISMA-ScR checklist.Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.

P6-7
Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.P8

Information sources* 7
Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.

P7
Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

P8-9
Data items 11 List and define all variables for which data were sought and any assumptions and simplifications made.P8-9 Critical appraisal of individual sources of evidence § If done, provide a rationale for conducting a critical appraisal of included sources of evidence and describe the methods used and how this information was used in any data synthesis (if appropriate).
-Synthesis of results 13 Describe the methods of handling and summarizing the data that were charted.P8-9

Results
Selection of sources of evidence 14 Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.

Synthesis of results 18
Summarize and/or present the charting results as they relate to the review questions and objectives.

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.*Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites.†A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies.This is not to be confused with information sources (see first footnote).‡The framework by Arksey and O'Malley (6) and Levac and colleagues (7) and the JBI guidance (4 and 5) refer to the process of data extraction in a scoping review as data charting.§The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision.This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).

FIGURE 1 :
FIGURE 1: PRISMA flow diagram PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PICO: population, intervention, comparison, and outcomes education program (education on the basic principles of pain management, instruction on diary writing, and communication on pain) + telephonic follow-up at 2management program (information and education on pain management, explanation of how to describe it using a pain diary, communication with medical personnel) + telephonic follow-up on days 3 and 7 Plus pain control program: face-to-face individual intervention (psychoeducational intervention and management of medications) phone calls (2, 4, and 5 weeks) + visits at 3 and 6 Plus pain control program: (psychoeducational intervention, management of medications: how to manage medications and communicate with healthcare providers during the week using a medicine box), phone calls (2Plus pain control program: face-to-face individual intervention (psychoeducational intervention, management + 6 visits and 4 telephonic follow-ups over a 10-week period of medications) Plus pain control program: face-to-face individual intervention (booklet, pain diary, and pill box) + telephonic follow-up at 1, 3, program (sessions to reduce misconceptions about pain and improve self-care skills) + telephonic follow-up within 3 days of discharge information, skill building, and nurse coaching), booklets and pill boxes to organize oral medications + post-discharge telephonic followeducation (information, impact of pain on life, barriers to pain management, and introduction to pharmacological and non-pharmacological therapies): 20 minutes for each session education (information, acquisition of skills, and guidance) knowledge and attitudes toward addressing patientspecific barriers to effective pain management, communication with healthcare providers, and reluctance to take analgesics × 2 sessions (30 minutes in person and 15 minutes by phone after 1 week) videotaped coaching to encourage self-monitoring + 5-10 minutes of in-person or phone coaching tailored to the patient'on attitudes toward coping with barriers using videos and booklets and coaching group: 4 × 30-minute sessions using motivational interviewing techniques over the phone (beliefs about pain, pain management, information and education using iPad and PowerPoint + create a personalized symptom self-management plan based on Five A Model of Self-Management Support (identify patient concerns, barriers, etc.; set behavior change goals for them; and propose plans for improvement) BPI × Ward (2000) USA RCT Gynecologic All 43 Provide informational booklet + discussion of barriers to pain + telephonic follow-up BPI 2023 Morikawa et al.Cureus 15(11): e49692.DOI 10.7759/cureus.496925 of 22 on imagery-guided therapy (20 minutes × 5 times/week × 2 weeks) areas of pain and ask them to imagine replacing the pain with at 30-45° position: listening to instrumental music while viewing pictures of nature on the computer (15.53 minutes) × 3 practice cognitive-behavioral therapy tapes (20 minutes × 5 times/week × 2 weeks) symptom management, cognitive-behavioral therapy: behavioral strategies (relaxation exercise, guided imagery, including recordings of nature sounds), listen as needed by the patient for 2 therapy (information, explanation, and overview of cognitivebehavioral therapy) (12 contents) + relaxation exercises: at least once a day × of cancer on life: once a week for 20 minutes or more for : one 90-minute session (in a group facilitated by a nurse, telling and retelling a story focused on your illness and building community) muscle relaxation therapy and 20 minutes of imagery visualization therapy for a total of 75 minutes and 20 minutes of muscle relaxation therapy and 20 minutes of imagery visualization therapy and use of a booklet on 23 ways to relieve pain for approximately 120 minutes or less exercise sessions, followed by progressive muscular relaxation and finally, pleasure-guided imagery (to improve mood and physical well-being) muscle relaxation, 20 minutes of imagery-guided therapy ESAS-r, NRS 2023 Morikawa et al.Cureus 15(11): e49692.DOI 10.7759/cureus.496926 of 22

P6
for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.P7-8 Data charting process ‡ 10

Funding Funding 22 Describe 3 :
interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.P17 sources of funding for the included sources of evidence, as well as sources of funding for the scoping review and describe the role of the funders of the scoping review.PRISMA-ScR checklist JBI: Joanna Briggs Institute, PRISMA-ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews