European Journal of Oncology Nursing 17 (2013) 402e407

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

How nurses assess breakthrough cancer pain, and the impact of

this pain on patients’ daily lives e Results of a European survey
Tone Rustøen a, b, *, Jenske I. Geerling c, Theodora Pappa d, Carina Rundström e,
Isolde Weisse f, Sian C. Williams g, Bostjan Zavratnik h, Yvonne Wengström i
a
Division of Emergencies and Critical Care, Department of Research and Development, Ullevål, Oslo University Hospital, Postbox 4956, Nydalen,
0424 Oslo, Norway
b
Lovisenberg Diaconal University College, Oslo, Norway
c
University Medical Centre Groningen, The Netherlands
d
Ag. Anargyri Oncology Hospital, Greece
e
Department of Oncology, Section of Cancer Rehabilitation, Karolinska University Hospital, Sweden
f
Eberhard Karls University Tübingen, Department of Gynaecological Oncology, Germany
g
Division of Health and Medical Sciences, University of Surrey, Guildford, Surrey, United Kingdom
h
Institute of Oncology, Ljubljana, Slovenia
i
Karolinska Institutet, Department of Neurobiology, Care Science and Society, Division of Nursing, Huddinge, Sweden

a b s t r a c t
Keywords: Purpose: To increase our knowledge of how nurses assess breakthrough cancer pain (BTCP); and whether
Breakthrough cancer pain they find it difficult to distinguish BTCP from background pain; how they estimate the impact of BTCP on
Assessment
patients’ daily lives, and the factors that nurses consider to induce BTCP. Variations in their use of
Impact of pain
Pain management
assessment tools and their ability to distinguish between different types of pain were also examined in
Nurses terms of the number of years of oncology nursing experience and the practice in different countries.
Cancer care Methods: In total, 1241 nurses (90% female) who care for patients with cancer, from 12 European
countries, completed a survey questionnaire.
Key results: Half the sample had >9 years of experience in oncology nursing. Although 39% had no pain
assessment tool to help them distinguish between types of pain, 95% of those who used a tool found it
useful. Furthermore, 37% reported that they had problems distinguishing background pain from BTCP.
Movement was identified as the factor that most commonly exacerbated BTCP across all countries. The
nurses reported that BTCP greatly interfered with patients’ everyday activities, and they rated the
patients’ enjoyment of life as most strongly affected. The use of tools and the ability to distinguish
between different pains varied between European countries and with years of experience in oncology
nursing.
Conclusions: The nurses reported that BTCP greatly interfered with patients’ lives, and many nurses had
problems distinguishing between background pain and BTCP. Nurses require more knowledge about
BTCP management, and guidelines should be developed for clinical use.
Ó 2012 Elsevier Ltd. All rights reserved.

Introduction prevalence of BTCP varies between patient groups, with more

Breakthrough cancer pain (BTCP) affects 19e95% of cancer
patients (Zeppetella and Ribeiro, 2003). A Europe-wide survey
found that as many as 63% of cancer patients who had been
prescribed analgesics experienced BTCP (Breivik et al., 2009). The
* Corresponding author. Division of Emergencies and Critical Care, Department of
Research and Development, Ullevål, Oslo University Hospital, Postbox 4956,
Nydalen, 0424 Oslo, Norway. Tel.: þ47 22 11 95 30.
E-mail address: tone.rustoen@rr-research.no (T. Rustøen).
patients who were receiving palliative treatment reporting BTCP
(Greco et al., 2011). One reason for the variations in the prevalence
of BTCP may be that there are several definitions of BTCP (Caraceni
et al., 2012). One of the most cited definitions was suggested by an
expert group in 2009: “a transient exacerbation of pain that occurs
either spontaneously, or in relation to a specific predictable or
unpredictable trigger, despite relatively stable and adequately
controlled background pain” (Davies et al., 2009).
Cancer patients with BTCP experience a significant negative
impact on their daily lives (Fine and Busch, 1998; Fortner et al.,
2002; Hwang et al., 2003; Portenoy et al., 1999; Zeppetella et al.,

1462-3889/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejon.2012.12.002
 T. Rustøen et al. / European Journal of Oncology Nursing 17 (2013) 402e407
2000). Psychological distress, activity, mood, walking, working,
social relationships, sleep, enjoyment of life, and quality of life
(QOL) are negatively affected by BTCP (Portenoy et al., 1999;
Portenoy et al., 2010). For example, movement is reported to trigger
BTCP in 20.4% of cancer patients (Portenoy et al., 1999). It is
important to understand the factors that induce BTCP to provide
nurses with the best information about patient pain and the best
training in pain management (Davies et al., 2009). Breivik et al.
(2009) found that 69% of cancer patients suffering pain reported
pain-related difficulties with everyday activities, but their health-
care professionals did not give their QOL priority in their overall
care.
BTCP is hard to evaluate or to diagnose, and no tools for the
assessment of BTCP have been fully validated (Haugen et al., 2010).
To assess BTCP, it is necessary to identify its source and subtype
(Bennett et al., 2005). Furthermore, understanding the impact of
BTCP on a patient’s QOL is important in determining the goals of
treatment.
In successful pain management, a team with various profes-
sional backgrounds is likely to manage the patient’s pain most
effectively (Wilson, 2008). Nurses are an important part of that
team, especially when patients are hospitalized, because nurses
spend more time than other professionals with the patients
throughout both day and night, administering medications and
evaluating their pain management. Therefore, it is important that
nurses feel confident in assessing BTCP and in administering the
treatments prescribed. However, it has been shown that health
professionals continue to lack knowledge about pain management
in cancer patients (Howell et al., 2000; Jacobsen et al., 2009;
McMillan et al., 2000).
The roles and functions of nurses in cancer care vary across
Europe (Glaus, 2011). In many European Union countries, specialist
nursing roles are not recognized, whereas in others, additional
education and continuing professional development have led to the
establishment of advanced roles (Schneider and Faithfull, 2011).
The Bologna Process was implemented across Europe to ensure that
study programs are compatible and comparable, to facilitate
transparency and academic recognition at the European level
(Faithfull, 2006).
To gain further insight into nurses who work with cancer
patients and about their knowledge of and views on BTCP, we
examined in this study how nurses assess BTCP and whether they
find it difficult to distinguish BTCP from background pain. We also
examined whether the use of an assessment tool and the ability to
distinguish one pain from another were related to the number of
years of oncology nursing experience, and whether they varied
across countries. We also investigated the impact that nurses
perceived BTCP to have on their patients’ daily lives and their QOL,
and the factors that nurses consider induce BTCP.
Methods
Before the study, the European Oncology Nursing Society
(EONS) recruited a working group and a multidisciplinary advisory
board. The working group consisted of six oncology nurses from
Germany, Greece, the Netherlands, Slovenia, Sweden, and the
United Kingdom (UK).
Participants and procedure
Nurses from 12 European countries who care for patients with
cancer took part in an EONS survey on BTCP. The 12 countries
selected to participate in the survey were the Czech Republic,
Denmark, Finland, France, Germany, Greece, Hungary, the
Netherlands, Norway, Slovenia, Sweden, and the UK. The way the
403
nurses were recruited to the survey varied slightly between coun-
tries. The nurses were recruited through the EONS website (www.
cancernurse.eu) in all countries. Other related websites were also
used to inform nurses about the survey, including the websites of
the national oncology nursing societies or the National Pain Society
(Sweden, UK). Invitations were also sent via email to nurses
involved in cancer care (Norway), to head nurses in major hospitals
(Slovenia), or to the relevant networks (the Netherlands). In some
countries, nurses were informed about the survey at meetings and
conferences (Sweden, Slovenia). No reminder was sent because the
nurses were approached in different ways.
Instrument for data collection
The questionnaire was developed by the EONS Breakthrough
Cancer Pain Working Group, with a multidisciplinary advisory
board assuming the overall scientific responsibility. The question-
naire was developed from clinical experience and an overview of
the literature, and the group held face-to-face and telephone
meetings in addition to email contact to reach a consensus on the
content of the questionnaire. Standardized steps in developing
a survey were followed (Passmore et al., 2002). After a consensus
was reached, the questionnaire was tested on nurses in cancer care
in the different countries before use. The main aim of the pilot test
was to determine whether the questionnaire was easy to under-
stand and complete.
The final survey questionnaire, which consisted of 36 questions,
was written in English and then translated from English into the
local languages of the participating countries. Each translation was
reviewed and approved by an oncology nurse in each of the
participating countries. After the return of the survey responses, an
experienced translation agency in the UK (RP Translate Ltd)
considered each response to ensure its optimal translation to and
from English.
Data collection procedure
Registered nurses who work with oncology patients were asked
to complete an online questionnaire. EONS provided the online
survey on its website and promoted the survey by involving the
relevant national societies. Virtual Surveys Ltd, based in the UK,
conducted the survey in close collaboration with members of the
advisory board when the survey was sent to nurses involved in
cancer care.
The questionnaire
The questionnaire elicited some background characteristics of
the nurses, such as age, sex, and years of experience in oncology
nursing (<1 year, 1e3 years, 4e6 years, 7e9 years, >9 years,
or unknown). The nurses were also asked whether they saw
patients with cancer (yes, no), approximately how many cancer
patients they saw each month (no patients, 1e4 patients, 5e9
patients, 10e14 patients, 15e19 patients, 20e24 patients, 25e29
patients, or 30 patients), and in which division of oncology they
worked. They were given fixed alternatives (see Table 1).
The instrument also included questions about pain manage-
ment, pain assessment, the nurse’s experience with BTCP, the
characteristics of BTCP, the impact of BTCP, the treatment of BTCP,
patient compliance, and the nurse’s confidence in pain manage-
ment. The present paper only reports the data about the nurses’
assessments of BTCP, including their use of any tool to distinguish
one type of pain from another, their ability to distinguish back-
ground pain from BTCP, and the impact of BTCP on their patients.
Any variations in the use of tools to assess pain or in the nurses’
404 T. Rustøen et al. / European Journal of Oncology Nursing 17 (2013) 402e407

Table 1 “eating”; “something else (please specify)”; “nothing induces/

Characteristics of the respondents. exacerbates breakthrough pain”; and “don’t know”.
N %
Sex Statistics
Female 1003 89.5
Male 118 10.5 All analyses were performed with SPSS version 16 (SPSS Inc.,
Age
Chicago, IL, USA). Only the data from nurses who answered more
16e24 years 45 3.6
25e34 years 292 23.5 than 50% of the questions in the questionnaire were included in the
35e44 years 378 30.5 analysis. Descriptive statistics were used to present the demo-
45e54 years 390 31.4 graphic and clinical characteristics of the sample. Cross-tabulation
55e64 years 135 10.9
with c2 analyses was used to test for differences in the use of tools
> 64 years 1 0.1
Workplace
for pain assessment, the nurses’ ability to distinguish between
Department of oncology surgery 72 5.8 different pains, the years of oncology nursing, and variations
Department of radiation oncology 93 7.5 between the countries. A p value of <0.05 was considered statis-
Department of medical oncology 328 26.5 tically significant.
Department of oncology intensive care 40 3.2
Outpatient oncology clinic 206 16.6
Children’s clinic 13 1.0 Results
Palliative care 126 10.2
Other 359 29.0 Participants
Don’t know 2 0.2
No. years’ experience of oncology nursing
<1 year 39 3.5
A total of 1618 nurses initially completed the questionnaire.
1e3 years 171 15.2 Sixty-two nurses were excluded from the survey because they did
4e6 years 196 17.4 not see patients with cancer. In total, 1241 successfully completed
7e9 years 138 12.2 more than 50% of the survey questionnaire (80% of the sample). The
>9 years 568 50.4
number of nurses who completed the survey varied geographically,
Don’t know 15 1.3
as shown in Fig. 1.

ability to distinguish between BTCP and other pain are also re- Demographic and work-related characteristics of the nurses
ported across the different European countries or according to the
nurses’ years in oncology nursing. Of the nurses in the final sample, 90% were female. Germany had
the highest proportion of male nurses (21%), followed by Greece
Pain assessment and the use of tools (16%). The ages of the nurses varied from 16 to 24 years (4%) to >64
years (0.1%). The majority of nurses were aged between 35 and 54
Six questions were asked about pain assessment: “Do you have years (62%) (Table 1).
an assessment tool to help you diagnose one type of pain from In all, 27% of the nurses worked in departments of medical
another?” (yes, no, not sure); “Do you think it would be helpful to oncology (inpatient clinics), and 17% worked in outpatient oncology
have a pain assessment tool?” (yes, no); “How useful do you find clinics (Table 1). Of the nurses surveyed, 29% specified “other” to
the pain assessment tool?” (very useful, somewhat useful, not very describe their workplace, which included a large number of
useful, not useful at all); and “How often do you tend to use the differently named, usually oncology-related departments. Half the
assessment tool to assess a specific patient?” (only on the patient’s respondents (50%) had >9 years of experience in oncology nursing,
first visit, on all visits, at regular intervals, when the pain pattern
changes, cannot say/it varies). Finally, the nurses were asked to
specify the tool they used. If they did not know the name of the tool,
Norwegian 212
they were asked to describe the tool and how they used it.
The nurses were also asked whether they found it difficult to
French 151
distinguish between background pain and BTCP when presented
with the symptoms. They could answer “yes” or “no” to this Greek 139
question.
Slovene 130
Impact of BTCP on daily life
Hungarian 111

Three questions were asked about the impact of BTCP on the

Danish 102
patients’ daily lives. First, the nurses were asked “Does break-
through pain typically have an impact on your patients’ quality of German 93
life?” The response alternatives were: “no impact”, “little impact”,
“some impact”, and “significant impact”. The second item asked the Czech 90
nurses to rate the extent to which BTCP typically interfered with
the following everyday activities of the patients on a scale from Swedish 77

0 ¼ “does not interfere” to 10 ¼ “completely interferes”: general

Dutch 56
activity, including eating; mood; movement, e.g., walking; normal
work (including both work outside the home and housework); e) English 45
relationships with other people; f) sleep; and g) enjoyment of life.
Lastly, the nurses were asked to specify all the factors that might Finnish 35
induce/exacerbate BTCP: “other treatments, e.g., radiotherapy”;
“another existing condition, e.g., a fracture”; “moving around”; Fig. 1. Number of survey participants per country.
 T. Rustøen et al. / European Journal of Oncology Nursing 17 (2013) 402e407 405

whereas only 4% of the total sample had <1 year of experience in Table 3
oncology nursing. Variations across countries if nurses’ have an assessment tool to distinguish between
types of pain.

How nurses assessed BTCP Do you have a pain assessment tool?

Yes (%) No (%) Not sure (%)

The majority (54%) of the nurses used a pain assessment tool Germany 92.3 4.4 3.3
to help them diagnose one type of pain from another (Table 2). The Netherlands 83.9 12.5 3.6
The use of pain assessment tools varied geographically Norway 71.7 17.0 11.3
Finland 64.7 32.4 2.9
(p < 0.001), with almost all nurses having access to a pain
France 62.3 32.5 5.3
assessment tool in Germany (92%) and the Netherlands (84%), Sweden 57.1 37.7 5.2
whereas only 17% of Greek nurses and 21% of Hungarian nurses Czech Republic 55.1 29.2 15.7
had access to an assessment tool (Table 3). The vast majority (95%) UK 52.3 40.9 6.8
of those who had a pain assessment tool reported that they found Denmark 48.0 50.0 2.0
Slovakia 44.2 48.8 7.0
it either very useful or somewhat useful (Table 2). When we
Hungary 20.7 75.7 3.6
looked at the use of tools and the years of experience with Greece 17.3 74.8 7.9
oncology patients, 61% of the nurses with >9 years’ experience
used a tool, whereas 33% of nurses with <1 year of experience
used a tool (p < 0.001). Living with BTCP
The most commonly used assessment tool was a visual analogue
scale (VAS; n ¼ 213), followed by a numerical rating scale (NRS; Moving around was the most common factor identified as
n ¼ 116), the Edmonton Symptom Assessment System (ESAS; inducing or exacerbating BTCP (80%) across all countries; an
n ¼ 100), a body map (n ¼ 53), and the Echelle Visual Analogue “existing condition” (56%) and “another treatment” (49%) were also
Scale (n ¼ 42). Sixty-one nurses reported that they used a scale reported as common causes, whereas only 2% of nurses stated that
without specifying the type of scale. When asked how often they nothing induced or exacerbated BTCP (Table 5).
used the tool to assess a specific patient, 56% of the nurses reported As outlined in Table 5, the nurses reported that BTCP interfered
that they used it on a regular basis or on all visits (Table 2). Nearly with patients’ everyday activities to a great extent, with mean
all the nurses (92%) felt it would be relevant to have a pain scores that ranged from 8.14 to 9.03, where 10 was “interferes
assessment tool. completely”. The nurses cited enjoyment of life as the most affected
aspect, and relationships with others as the least affected aspect. In
Nurses’ ability to distinguish between background pain and BTCP response to the question of whether BTCP affected their patients’
QOL, 78% said that it had a “significant impact”, 20% said that it had
When the nurses were asked if they found it hard to distinguish “some impact”, 2.1% said that it had “little impact”, and 0.2% said
between background pain and BTCP, 37% said yes and 63% said no. that it had “no impact”.
The self-reported ability to distinguish between these types of pain
varied across countries (p < 0.001) (Table 4). In Germany, 76% re- Discussion
ported that they did not find it difficult to distinguish between the
pains, whereas in the Czech Republic, 56% reported that they felt it In this study, nearly half (46%) of the nurses did not use any
was a problem. assessment tool to distinguish between different kinds of pain (or
The nurses’ ability to distinguish between these pains also were not sure if they had used any tool), and only one-fifth (18%)
varied with years of experience in oncology nursing (p < 0.021). Of used a tool during all patient visits. A recent review of the obstacles
the nurses with >9 years’ experience, 34% reported that they found to cancer pain management among physicians (Jacobsen et al.,
it difficult, whereas in the group of nurses with <1 year of expe- 2009) found that the majority of doctors did not use an instru-
rience, 42% reported that it was difficult. ment to measure pain intensity. Breivik et al. (2009) found that only
15% of patients reported that their clinicians measured pain using
a pain scale, but with prompting, the figure rose to 33%. What is
Table 2 promising in the present study is that 92% of the nurses thought it
Use of pain assessment tools.

Questionnaire items N % Table 4

Variations across countries in the difficulty encountered in distinguishing break-
Do you have a pain assessment tool to help you distinguish one type of pain
through cancer pain from background pain.
from another?
Yes 669 54.1 Country Do you find it difficult to distinguish between
No 482 39.0 background pain and breakthrough cancer pain
Not sure 85 6.9 when presented with the symptoms?
Do you think it would be helpful to have a pain assessment tool?
Yes 501 91.9 Yes (%) No (%)
No 44 8.1 Germany 23.7 76.3
Is it useful to have a pain assessment tool? Finland 26.5 73.5
Very useful 250 39.7 Greece 27.9 72.1
Somewhat useful 350 55.6 The Netherlands 29.1 70.9
Not very useful 27 4.3 Norway 36.7 63.3
Not useful at all 2 0.3 Sweden 36.8 63.2
How often do you use an assessment tool to assess a specific patient? Slovakia 38.3 61.7
On the patient’s first visit 6 0.9 France 38.9 61.1
On all visits 116 18.3 Hungary 40.5 59.5
At regular intervals 240 37.9 UK 44.4 55.6
When the pattern of pain changes 147 23.2 Denmark 46.1 53.9
Cannot say/varies 124 19.6 Czech Republic 55.6 44.4
406 T. Rustøen et al. / European Journal of Oncology Nursing 17 (2013) 402e407
Table 5
Impact of breakthrough cancer pain on daily life.
Questionnaire item N %
What may exacerbate/prompt BTCP?
 Moving around 989
 An existing condition, e.g., a fracture 684
 Another treatment, e.g., radiotherapy 597
 Eating 430
 Something else 172
 Don’t know 74
 Nothing exacerbates/prompts 28
breakthrough pain
Mean
To what extent does BTCP typically interfere
with the following everyday activities
(NRS from 0 to 10 “completely interferes”)?
 Enjoyment of life 9.03
 Normal work (including both work outside 9.02
the home and housework)
 Mood 8.91
 Sleep 8.90
 Movement, e.g., walking ability 8.72
 General activity, including eating 8.16
 Relationships with other people 8.14
would be helpful alto have a tool, and that most all (95%) found it
useful. However, it is noteworthy that the use of tools varied from
17% to 92% across the European countries included in the study
(Table 3). The fact that the use of any tool was almost twice as high
in nurses with >9 years of oncology nursing as in nurses with less
than a year of experience could mean that the use of a tool in
clinical practice must be learned. Another possibility is that nurses
who feel safer in their role use a tool when working with patients.
Of the nurses who used a tool, almost half (49%) used an NRS or
VAS for pain assessment, and most reported that they used a VAS.
Research has shown that both NRSs and VASs are valid, reliable, and
appropriate for use in clinical practice (Williamson and Hoggart,
2005). However, the use of a VAS in elderly patients has been
associated with higher rates of completion failure than the use of an
NRS, and the elderly have been shown to prefer an NRS to a VAS
because it is easier to use (Ferreira-Valente et al., 2011; Gauthier
and Gagliese, 2001; Jensen and Karoly, 2001). In this context, it
has also been recommended that an NRS be used in preference to
a verbal rating scale (in which names are given to the points on the
scale) for the measurement of cancer pain exacerbation (Brunelli
et al., 2010). Although our study revealed that a VAS was used
more often than an NRS, clinical personnel often use a mixture of
these two pain intensity scales.
One challenge when using a VAS or NRS is that they only
measure the presence of pain or pain intensity. Therefore, nurses
cannot use these scales to distinguish between BTCP and back-
ground pain. This is consistent with the finding in the present study
that 37% of the nurses felt it was difficult to distinguish between
background pain and BTCP when they were required to do so. This
may indicate that a large group of nurses throughout Europe need
to learn about the different mechanisms underlying cancer pain to
give the optimal treatment. Jacobsen et al. (2009) reported that one
of the most prominent obstacles for physicians involved in cancer
treatment was insufficient knowledge of cancer pain management.
This is also considered to be true of nurses (Vallerand et al., 2011).
The ESAS, the third most used scale among the nurses in these
European countries, is widely used and well known for the
assessment of symptoms in palliative care (Nekolaichuk et al.,
2008). Different versions of the ESAS exist, but the version most
commonly used in Norway assesses the presence of 10 symptoms:
pain at rest, pain during movement, tiredness, nausea, shortness of
breath, oral dryness, appetite, anxiety, depression, and well-being
(Bergh et al., 2011). This scale has been criticized, because, among
other reasons, errors in interpretation and misunderstandings have
been demonstrated among respondents completing the question-
naire (Bergh et al., 2011). One strength of the ESAS is that it
80.3 measures not only pain but also other symptoms, thus providing
55.5 a more comprehensive picture of the patient. Because pain
48.5
assessment is an essential focus of nursing practice (Vallerand et al.,
34.9
14.0 2011), more education about pain assessment and management is
6.0 required (Howell et al., 2000).
2.3 The results of one review showed that general tools, such as
VAS, NRS, and the ESAS, cannot adequately accommodate the
SD
complexities of BTCP (Haugen et al., 2010). Haugen et al. (2010)
concluded that the features of an ideal BTCP assessment tool
should include the following domains: the number of different
2.1 BTCPs, relation to background pain, intensity, temporal factors
2.0 (frequency, onset, duration, course, relationship to fixed analgesic
dose), localization (body map), pain quality, treatment-related
2.0 factors (exacerbating and relieving factors, including precipitating
2.2
2.1
events and predictability, treatment, response to treatment, treat-
2.2 ment satisfaction), and interference with the activities of daily
2.3 living and QOL. It is also recommended that patients suffering BTCP
use a pain diary, filled out by the patients themselves, to collect
multidimensional information (Bennett et al., 2005). The diary can
be used both in the initial patient evaluation and as an ongoing
guide to the modification of treatment. Nobody reported the use of
a diary in the present survey.
Up to 80% of the nurses said that BTCP negatively and severely
affected different areas of their patients’ lives, with the greatest
impact on their enjoyment of life. Furthermore, 78% of the nurses
said BTCP had a significant impact on the patients’ QOL. Breivik
et al. (2009) found in a European survey that 51% of cancer
patients reported having stopped concentrating or thinking, 69%
had difficulty with normal activities and work, and 43% of patients
reported that cancer made them an increased burden to others.
Moreover, 30% said that they were in too much pain to care
adequately for themselves, and 32% said that they felt so bad that
they wanted to die. The fact that pain affects patients’ lives so
negatively further indicates that a comprehensive tool should be
used to measure BTCP, to ensure that patients’ needs for pain
management and support are met.
Variations were observed across the European countries in the
present survey, which are attributable to diverse causes. It is
important to note that in Greece, for instance, only 29% of the
nurses had >9 years’ experience with oncology patients. In the
other countries, 40e65% of nurses had that degree of experience. It
is also important to note that 11% of the nurses from the Czech
Republic said that they did not know whether they had used an
assessment tool. As a result of the Bologna Declaration, the
education systems in most European countries are undergoing
a process of reform, and these changes offer an opportunity for
cancer nursing to establish and institute a common curriculum for
cancer nurses across Europe (Faithfull, 2006). This might help to
increase the knowledge of pain and pain management among
nurses throughout Europe.
Limitations
The present survey had many limitations. Nurses from many
countries were included, but the sample sizes varied from country
to country and were quite small in some countries. This reduced the
possibility of drawing valid conclusions about individual countries
or valid comparisons of these countries. Another limitation was
that many of the nurses were recruited through the EONS website,
by invitation from the national oncology nursing societies, or by
invitation via email to nurses in cancer care. The invitations
 T. Rustøen et al. / European Journal of Oncology Nursing 17 (2013) 402e407
extended via the website or by the nursing societies could have
recruited nurses who were more than averagely dedicated to their
work. If this were the case, this survey probably overestimates the
knowledge of the nurse populations.
Another limitation could be that as many as 400 nurses in the
original sample did not complete the survey. The reasons for this
could include that it contained too many questions, or that the
nurses did not know enough about BTCP to respond to all the items.
Finally, it seems that most of the nurses were recruited from
different clinics, which could reduce how well they represented the
oncology nursing community. However, the survey included a large
sample of nurses from throughout Europe, which suggests that it
gives an important picture of nurses’ experiences and knowledge of
the specific areas of BTCP presented in this paper. However, further
research is needed regarding nurses’ knowledge of and clinical
competence to handle BTCP in this vulnerable group of patients.
Conclusion
In summary, pain assessment continues to be an essential focus
of nursing practice. Because cancer patients, and especially patients
with BTCP, suffer a great deal of pain, more education about pain
assessment and management is required. A comprehensive tool
should be developed and used to measure BTCP. The dissemination
and implementation of clinical practice guidelines can improve
pain management (Rustøen and Miaskowski, 2008), and it is clin-
ically important to develop and implement guidelines for BTCP.
EONS is currently working on the development of these guidelines.
Conflict of interest statement
Nycomed: A Takeda Company supported the survey with an
educational grant. The authors declare no conflicts of interest.
Acknowledgments
Nycomed: A Takeda Company supported the survey with an
educational grant. EONS as well as the authors of the paper would
like to express their deep gratitude to the nurses who participated
in the survey.
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