REVIEW

A review of pain management interventions in bone marrow biopsy

Sarah Watmough and Maria Flynn

Aims. This review was designed to evaluate the evidence relating to pain management interventions for patients having bone
marrow biopsy.
Background. Bone marrow biopsy is an invasive procedure causing considerable pain and anxiety for adult patients, yet there
are no guidelines to inform effective nursing care. Although this is an under-researched area, a range of pain interventions have
been tested on this patient group, but this evidence has not been synthesised.
Design. Structured evidence review.
Method. The Cochrane Library and databases Medline, Scopus and Cinahl were searched for original research reports. Ref-
erence lists of retrieved papers were hand-searched and researchers in the field were contacted. Retrieved papers were analysed
using the CASP framework. A narrative data synthesis considered the strengths and limitations of included studies and findings
were collated and interpreted.
Results. No systematic reviews of evidence have been undertaken and the search strategy identified twelve research studies
eligible for inclusion in the review. Hand-searching did not identify any additional studies, and emails to researchers confirmed
this is an under-researched field. Analysis shows three main interventions, intravenous midazolam, premedication with analgesia
and/or anxiolysis and the use of EntonoxÔ are used to manage the pain experience for patients undergoing a bone marrow
biopsy.
Conclusions. Evidence is inconclusive and provides little guidance for practice. There is an urgent need for research into
effective interventions for pain management in bone marrow biopsy and in understanding the patient experience.
Relevance to clinical practice. Nurses have a central role to play in the assessment and management of the pain and anxiety
associated with bone marrow biopsy. There is little evidence to guide this aspect of care, but it is important that nurses involved
with bone marrow biopsy are aware of the best evidence to facilitate the most effective management of their patients’ pain.

Key words: bone marrow biopsy, evidence review, nursing care, procedural pain, sedation

Accepted for publication: 31 July 2010

followed by the insertion of a needle into the bone cavity

Introduction
Bone marrow biopsy is an essential investigation in the
diagnosis and monitoring of many haematological condi-
tions. As an invasive technique, it involves infiltration of the
skin and periosteal lining over the posterior iliac crest
(Chakupurakal et al. 2008). It is normally a two-part
procedure; the first stage involving aspiration of liquid
marrow and the second a trephine biopsy removing a core
of bone containing marrow. For patients who are suffering
from a haematological disorder, the procedure will need to

Authors: Sarah Watmough, NIHR Postgraduate Student, School of Correspondence: Sarah Watmough, NiHR Postgraduate Student,
Health Sciences, University of Liverpool; Maria Flynn, PhD, MSc, MRes Programme, School of Health Sciences, University of
BSc, PGCE, RGN, Senior Lecturer, School of Health Sciences, Liverpool, Liverpool L69 3GB, UK. Telephone: 0151 794 5775.
University of Liverpool, Liverpool, UK E-mail: watmough@liverpool.ac.uk

Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 615–623 615
doi: 10.1111/j.1365-2702.2010.03485.x
S Watmough and M Flynn
be repeated many times throughout their patient career. In
children, a bone marrow biopsy is usually performed under
a general anaesthetic; however, in the adult population, the
procedure is most often performed with local anaesthetic as
a standalone method of analgesia. It has long been recog-
nised that for some adult patients, a bone marrow biopsy
can be an extremely painful and distressing experience
(Trewhitt 2001, Vanhelleputte et al. 2003, Johnson et al.
2008). A recent study of 235 patients with haematological
disorders (Lidén et al. 2009) examined the prevalence of
pain during bone marrow biopsy and found that 70% of
patients reported experiencing pain, with one-third of those
patients describing what they suffered as severe pain.
Nurses have a central role to play in the assessment and
management of patients’ pain (McCaffrey 2000, Kohr &
Sawhney 2005, Courtney & Carey 2008), and there is an
extensive body of international research that explores differ-
ent dimensions of effective pain management. Much of this
research has focused on the management of acute postoper-
ative or traumatic pain, chronic pain and terminal pain, but it
appears that there is little that has addressed the management
of acute pain associated with invasive procedures (O’Malley
2005, Johnson et al. 2008). It has also been suggested that
the under-treatment of pain continues to be a widespread
problem for the international healthcare community (Green
et al. 2003, Stalnikowicz et al.2005, Passik et al. 2007). This
results in unwanted physiological and psychological conse-
quences for patients and practical and ethical dilemmas for
those providing healthcare (Ferrell et al. 2001, Resnik et al.
2001, McNeill et al. 2004, O’Malley 2005). In this context, it
is clear to see how the effective assessment and management
of the acute pain and anxiety associated with bone marrow
biopsy (Johnson et al. 2008, Lidén et al. 2009) could pose
real challenges for nurses aiming to deliver the best care to
their patients.
Historically, the responsibility for the management of bone
marrow biopsy procedures has rested with medical practi-
tioners; however, as nurses’ roles and responsibilities expand,
many specialist nurses now carry out this procedure inde-
pendently (Lawson et al. 1999, Bain 2001, Harness et al.
2007). This would suggest that nurses who perform bone
marrow biopsy not only have additional responsibilities for
the management of the procedure itself but also have an
extended responsibility for discharging their nursing duty to
their patients. Although the nature and parameters of
advanced nursing roles have been the subject of professional
research and debate for over 30 years (Wilson-Barnett et al.
2000, Lloyd Jones 2005, Por 2008, Duffield et al. 2009,
Lewandowski & Adamle 2009), there is little evidence to
guide nurses in caring for adult patients who are suffering the
616 Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 615–623
acute pain and anxiety associated with bone marrow biopsy
(Talamo et al. 2010). In this context, it is important that
nurses carrying out, or assisting with, a bone marrow biopsy
procedure are aware of the best evidence to facilitate the most
effective management of their patients’ pain.
Aim of the review
The aim of this review was, therefore, to evaluate the
evidence relating to pain management interventions that have
been tested on adults undergoing bone marrow biopsy.
Method
The review method incorporated a search of the databases in
the Cochrane Library, Medline, Scopus and Cinahl using the
keywords ‘bone marrow’ or ‘bone marrow examination’ or
‘bone marrow biopsy’ or ‘bone marrow trephine’ and
‘methods’ or ‘interventions’ and ‘minimise, or ‘reduc*’ and
‘pain*’. Keywords were combined using Boolean operators
and additional keywords from identified interventions, such
as ‘Entonox’, ‘sedation’, ‘tramadol’ and ‘analgesic’ were
included to ensure all relevant literature was identified.
Inclusion criteria were that papers had to be reporting
research containing a measurement of an intervention for
pain management in bone marrow biopsy in an adult
population. No limit was put on the date for inclusion.
Studies were excluded if they were related to the paediatric
population, were not in the English language or were
editorials, letters or discursive pieces.
Studies were identified on the basis of the relevance of their
titles and abstracts, and those which met the inclusion criteria
were retrieved. The reference lists of all retrieved papers were
then examined for further sources. Key authors identified
through the search were contacted by email to seek additional
information of any unpublished data or current research in
this area.
The retrieved research reports were evaluated using the
framework of the Critical Appraisal and Skills Programme
(CASP) guidelines for critical appraisal (Public Health
Resources Unit 2007). The use of this tool helped provide a
consistent and systematic evaluation of each paper and an
indication of the methodological quality of the study. As the
management of pain in bone marrow biopsy is an under-
researched area, a variety of study designs and interventions
were used in the retrieved studies. It was, therefore, not
possible to extract and pool data from the included studies,
and a narrative analysis and synthesis of data was under-
taken. A narrative data synthesis involves the consideration
of the strengths and limitations of reported studies and the
Review
collation and summary of findings from studies that have
been included in a review (Centre for Reviews and Dissem-
ination 2009).
Results
As was expected, the Cochrane Database of Reviews did not
identify any systematic reviews of evidence, which had been
undertaken or were planned in this field. The application of
the search strategy identified a total of twelve research
reports, of variable design, which were eligible for inclusion
in this review. The hand search of reference lists did not
identify any additional material, and the emails to researchers
in the field elicited one response, which acknowledged that
there is very little published data in this area of investigation.
Table 1 shows a summary of the studies, which were
included in the review.
Analysis
The analysis shows the use of three pain management
interventions, all pharmacological, which have been tested
on patients undergoing a bone marrow biopsy. These are
intravenous midazolam, premedication with analgesia and/or
anxiolysis and the use of EntonoxÔ (nitrous oxide).
Intravenous Midazolam
Intravenous midazolam is offered to patients to reduce
distress in bone marrow biopsy as routine practice in many
centres in the United Kingdom (Chakupurakal et al. 2008).
Two studies have been undertaken to evaluate its efficacy as
an intervention for this patient group. The retrospective study
reported by Mainwaring et al. (1996) distributed a question-
naire to 84 patients who, in the routine course of the
procedure, may or may not have had intravenous midazolam.
Of those patients who had received the medication, only 9%
reported any postprocedure pain in contrast to the non-
sedated group in whom 85% reported intense pain. These
results appear to favour sedation with intravenous midazo-
lam, and the researchers recommended its widespread use in
bone marrow biopsy. However, it should be noted that the
study design limits the generalisability of the results. The
uncontrolled and non-randomised sample means it is not
possible to infer a causal relationship between midazolam
and reported pain.
By means of an uncontrolled prospective study, Giann-
outsos et al. (2004) sought to measure the effect of intrave-
nous midazolam on patients’ experiences whilst undergoing
bone marrow biopsy. Patients (n = 112) were asked whether
Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 615–623
Review of pain management interventions
they would prefer to have the procedure with or without
sedation and were then asked to complete a questionnaire
when the procedure was over. It was interesting to find that
only a minority (32%, n = 29) of patients chose to be
sedated, but nonetheless lower pain scores were reported in
this group. Although the majority of patients chose not to be
sedated for the procedure, only 3% of this group subse-
quently reported being unhappy with this decision. No
account is given as to why the patients opted not to receive
sedation, and the results of the study contain inherent bias in
that all patients self-selected for inclusion in the treatment
condition. The study design did not include controls,
blinding to treatment or statistical analysis of results, so
findings again cannot be generalised to the wider patient
population.
Two studies have also been reported that aimed to assess
the effectiveness of intravenous midazolam relative to
EntonoxÔ in bone marrow biopsy. Gudgin et al. (2008)
used a small sample of 22 patients, all of whom had
previously been treated with intravenous midazolam. When
asked to compare their experiences, the majority (69%)
stated they preferred EntonoxÔ to intravenous midazolam,
but nonetheless the researchers recognise that it is not
possible to generalise from these results because of the small
sample size, absence of control or blinding. The randomised
control trial reported by Chakupurakal et al. (2008) also
compared the effectiveness of EntonoxÔ against intravenous
midazolam for pain relief. The study used a power calcula-
tion to estimate sample size and randomly allocated patients
to the treatment arms. They found that midazolam offered
significantly more pain relief to patients undergoing bone
marrow biopsy; however, clinically relevant respiratory
depression was also noted in 19% of this group.
Premedication with analgesia and/or anxiolysis
An early study reported by Milligan et al. (1987) assessed the
effectiveness of oral lorazepam 4 mg as an intervention for
pain relief in bone marrow biopsy by a placebo-controlled
randomised control trials (RCT). Forty-six patients who had
never had a bone marrow biopsy before were included in the
trial. The results demonstrated that lorazepam provided no
analgesic effect; however, it did show a statistically significant
(p = 0Æ01) amnesic effect when recalling pain 24 hours later.
These trial results suggest that whilst the pain itself is still a
problem, the patients’ memory of the pain can be reduced as
a result of the intervention. However, it is arguable that the
goal of the intervention strategy should be to manage the pain
associated with bone marrow biopsy rather than just reduc-
ing the memory of the experience.
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Table 1 Results

Authors Sample Study design Main findings Authors conclusions

Milligan 50 patients Double blind randomised control trial Use of oral lorazepam prior to the procedure Oral lorazepam is a useful premedication
et al. (1987) lorazepam 4 mg PO vs. placebo demonstrated no difference in pain recalled before bone marrow biopsy because of its
S Watmough and M Flynn

immediately after the procedure. However, amnesic effect.

it did reveal a significant amnesic effect with
a significant reduction in recall of pain
24 hours later.
Mainwaring 102 patients Uncontrolled non-randomised study The majority of respondents (87%) had Intravenous midazolam is safe and effective
et al. (1996) To evaluate the safety and efficacy of IV received intravenous sedation and only 9% and more widespread use for patients
midazolam of those reported postprocedural pain. In undergoing bone marrow biopsy is
the non-sedated group 85% had intense advocated.
pain during the biopsy.
Dunlop et al. 24 patients Uncontrolled prospective study Two-thirds of respondents reported none or Premedication with oral narcotic and
(1999) All patients given oral narcotic mild pain and premedication induced some benzodiazepine is effective in preventing or
(lorazepam) and oral benzodiazepine amnesia in half of the patients. reducing pain during bone marrow
(hydromorphone) prior to procedure examination.
Wolanskyj 25 patients Randomised control trial: double blind No statistical significance was found in the Oral sedation with lorazepam and
et al. (2000) with Oral narcotic (lorazepam and oral reporting of pain between both treatment hydromorphone did not decrease pain or
lymphoma benzodiazepine (hydromorphone) arms. Recall of pain 24 hours later was of anxiety, and significant pain was recorded in
vs. placebo borderline significance in the arm that had both treatment arms. Future studies should
received the narcotic and benzodiazepine. consider using IV midazolam for conscious
sedation.
Vanhelleputte 100 patients Randomised control trial: double blind Pretreatment with oral tramadol was found Preemptive analgesia with tramadol appears
et al. (2003) Oral analgesic (tramadol) vs. placebo to lower pain intensity significantly and was to be safe and effective.
well tolerated.
Giannoutsos 112 patients Uncontrolled prospective study The majority of the patients chose not to have If resources are available patients should be
et al. (2004) All patients asked to choose whether to additional sedation (68%), and the majority given the choice of sedation but for the
receive IV sedation or not were happy with that decision. Those who majority of patients sedation can be
did have sedation reported lower pain avoided.
scores.
Steedman 136 patients Uncontrolled prospective study The results showed a trend towards increased The use of Entonox is a useful adjuvant to
et al. (2006) All patients asked to chose whether to pain in the group who chose not to use local anaesthesia for patients undergoing
use Entonox or not entonox but not statistically significant. The bone marrow biopsy.
majority (84%) of patients who chose to use
Entonox would use it again and no adverse
events were experienced.

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 Review

Table 1 (Continued)

Authors Sample Study design Main findings Authors conclusions

Park et al. 138 patients Randomised control trial: double blind The results showed no significant difference Despite the safety and positive effects on
(2008) Intravenous lorazepam as premedication in the pain experienced by each group. patient satisfaction IV lorarazepam provides
vs. placebo However, intravenous lorazepam was more no reduction in pain. Further studies should
effective than placebo in enhancing patient focus on providing appropriate analgesia
cooperation and willingness to have a future
procedure.
Gudgin et al. 22 patients Uncontrolled comparison study Ninety-four per cent of those who had Entonox is an effective safe alternative to IV
(2008) (previously IV midazolam vs. Entonox previously had IV sedation found Entonox midazolam for bone marrow biopsy and is
had IV better or equal to midazolam. considered acceptable by both patients and
midazolam) staff.
Johnson et al. 48 patients Randomised control trial: double blind Use of Entonox resulted in significantly less Entonox is a safe, effective, easy to use
(2008) Entonox vs. placebo pain for men than for women. No significant analgesic that merits further investigation in
adverse effects in either group. this setting.

Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 615–623

Chakupura- 46 patients Randomised control trial Midazolam provided significantly more pain Midazolam is superior to Entonox in
kal et al. Entonox vs. IV midazolam relief in comparison with Entonox. providing pain relief, however, care must be
(2008) Clinically relevant respiratory depression taken to monitor respiratory function.
occurred in 19% of patients in the
midazolam arm; however, sedation was
reversed with flumazenil.
Talamo et al. 84 patients Uncontrolled non-randomised study Those patients who received oral Owing to the lack of a significant difference
(2010) Patients received oral analgesia administration of analgesia and anxiolysis in pain scores in the two groups, the authors
(acetaminophen & oxycodone) and (n = 34) reported a significant reduction in feel that local anaesthesia alone is an
oral anxiolysis (lorazepam) as the perception of pain but its effect did not acceptable approach for most patients.
premedication vs. local anaesthetic seem to provide a major and clinically
alone significant reduction in pain level.
Review of pain management interventions

619
S Watmough and M Flynn
Park et al. (2008) evaluated the effectiveness of lorazepam as
a premedication for a bone marrow biopsy, but in this case
the medication was administered intravenously. This rando-
mised, double blind, placebo-controlled trial involved 138
patients and found this to be a safe intervention, which
enhanced patient cooperation. However, it did not show any
statistically significant effect on the pain experienced by
patients in the treatment group.
Other studies have also aimed to use the amnesic properties
of anxiolysis agents with the addition of an analgesic agent to
determine whether a combination of drugs serves to reduce
the pain experience. Dunlop et al. (1999) published the
results of an uncontrolled prospective study of 24 patients,
aiming to evaluate the effect of oral lorazepam and hydro-
morphone when given prior to the bone marrow biopsy
procedure. Two-thirds of the participants reported ‘no pain’
or ‘mild pain’, and amnesia was induced in half the patients,
so the researchers concluded that this is a useful intervention
for preventing and reducing pain. However, it should be
noted that although these results appear promising, the report
of the method of investigation makes it difficult to interpret
or assess their relevance to the wider population of haema-
tology patients.
Wolanskyj et al. (2000) reported an RCT where the
patients served as their own controls. This was possible as
North American patients receive bilateral bone marrow
aspirates for staging, which is not practiced in the United
Kingdom. A power calculation was used to estimate the
sample size, and patients were randomly allocated to receive
placebo or oral lorazepam and hydromorphone before each
bone marrow biopsy. Pain was assessed using a Visual
Analogue Scale (VAS). Analysis of data showed no significant
differences in the pain experienced in the experimental and
control conditions. Although significant pain levels were
recorded in both trial arms, there was a trend towards a
lower level of recorded pain in the treatment group. Wolan-
skyj et al. (2000) concluded that the use of oral narcotics and
benzodiazepines is inadequate for pain relief for many
patients and suggested that perhaps intravenous midazolam
is a more suitable alternative.
The efficacy of another oral analgesic agent, Tramadol,
given prior to a bone marrow biopsy was studied by
Vanhelleputte et al. (2003). This double blind RCT assessed
the effectiveness of the analgesia compared to placebo when
given orally an hour before the biopsy procedure. The results
from 100 patients showed statistically significant differences
in VAS pain scores for the Tramadol patients (p = 0Æ03), and
it would appear that its use has the potential to be an effective
intervention for pain reduction during bone marrow biopsy.
However, no other studies have been reported which tested
620 Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 615–623
the effectiveness of tramadol, and it is unclear whether these
findings have been implemented in clinical practice.
The most recently reported study in this field of investiga-
tion reported by Talamo et al. (2010), examined the use of
oral analgesia, acetaminophen and oxycodone, with oral
lorazepam. The study recruited 84 patients and compared
oral medication plus local anaesthetic, to local anaesthetic
alone. The study design did not randomly allocate patients to
the treatment arms, and, as with previous studies, the results
do not show significant differences in reported pain attrib-
utable to the use of these oral medications.
EntonoxÔ
EntonoxÔ is a 50:50 mix of nitrous oxide and oxygen and is
commonly used in other clinical settings for pain manage-
ment. It has therefore been suggested that it may also have
utility in pain relief during bone marrow biopsy. EntonoxÔ
has a good safety profile and is easy to administer, and
Chakupurakal et al. (2008) suggest that this makes it an
acceptable alternative to intravenous midazolam for pain
management in bone marrow biopsy.
In a prospective study reported by Steedman et al. (2006),
136 patients were offered a choice between local anaesthetic
alone or local anaesthetic with the addition of Entonox.
Results showed a trend towards decreased pain in the
EntonoxÔ group but this was not statistically significant.
Although the use of EntonoxÔ was dependent on patient
preference, 84% of the patients who had used it wished to use
it again. Similarly, Johnson et al. (2008) published the results
of a double-blind RCT designed to assess Entonox versus
placebo in a group of 48 patients undergoing bone marrow
biopsy. The results of this study also showed no significant
difference in pain scores between the two groups, but again
patient satisfaction seemed high with 93% stating they would
choose to use EntonoxÔ again.
Discussion
It is acknowledged that a narrative review is limited by the
often subjective nature of interpretation; nonetheless, this
review has identified some important issues for nurses
concerned with managing or assisting with bone marrow
biopsy. Perhaps the most telling finding is the scarcity of
published evidence in the field, which means nurses do not
have access to clear evidence to guide their practice in caring
for this patient group.
The review findings suggest that intravenous midazolam
may have some utility as an intervention for reducing the pain
associated with bone marrow biopsy, but this evidence is not
Review
conclusive. In practical terms, the drug is safe (Burkle et al.
2004), but the sedative and respiratory depressant effects
carry some risk, and it is estimated that around 200 people
die each year as a result of midazolam administration (Hall &
Richardson 2003). Routine use of midazolam in bone
marrow biopsy may increase the time needed to undertake
the procedure and also require more staff resources to
monitor patients during and after their biopsy. Intravenous
sedation normally incapacitates the patient, so prolonging the
use of bed space and possibly limiting the facility to carry out
bone marrow biopsy as an ‘outpatient’ procedure.
As a pharmacological agent, midazolam is not intended as
a first-line treatment for pain, but it does seem that the
sedative and amnesic properties of the drug renders the bone
marrow biopsy procedure more tolerable and the memory
less unpleasant. However, given the recognised problem of
the under-treatment of pain in the wider healthcare commu-
nity (Green et al. 2003, McNeill et al. 2004, Stalnikowicz
et al. 2005, Passik et al. 2007), it could be argued that the
ideal intervention for this patient group is one that reduces
the patients’ experience of pain as well as eliminating it from
the memory.
The results of the studies of analgesia and/or anxiolysis are
inconsistent and seem to show a less-than-adequate impact
on pain relief. The one study that shows some convincing
evidence of effectiveness is the use of Tramadol prior to the
procedure (Vanhelleputte et al. 2003). However, this raises
the question as to why this intervention has not been tested
further. The difficulty of recruiting patients to randomised
controlled trials is well known (Cooley et al. 2003, Jones
et al. 2007 and Gul & Ali 2010), and this may be
compounded with a patient population that are undergoing
a procedure that they know will cause them pain. Although
this review sought evidence of the efficacy of interventions to
reduce pain in bone marrow biopsy, it also revealed a lack of
research exploring the patients’ experience of this procedure.
Perhaps if the patient perspective was better understood, then
more appropriate effort could be directed towards evaluating
and implementing appropriate pain management interven-
tions (and recruitment to subsequent trials may also be
improved). Understanding the patient experience of bone
marrow biopsy may be an area of nursing research that could
have an important impact on patients in the future.
The use of EntonoxÔ seems to be a recently tested method
of providing pain relief in bone marrow biopsy; however,
again the evidence as to its efficacy is not conclusive. The
comparisons of EntonoxÔ with midazolam (Chakupurakal
et al. 2008, Gudgin et al. 2008) suggest that despite its
greater risk, midazolam appears to have more impact on the
pain experience. It would appear that EntonoxÔ has advan-
Ó 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 615–623
Review of pain management interventions
tages over intravenous sedation in terms of patient prefer-
ence, time and resources, but it could be argued that if it is
not effective then it is not worthwhile.
Conclusions
Nurses have a central role to play in the assessment and
management of patients’ pain (McCaffrey 2000, Kohr &
Sawhney 2005 and Courtney & Carey 2008) and in
ensuring that the acute pain and anxiety associated with
bone marrow biopsy is treated appropriately. This search
has yielded a small and inconclusive body of evidence that
offers little clear guidance for practice. There is a lack of
adequately designed trials to provide clear evidence of the
most effective method of pain management for this patient
group. It is also recognised that we do not have any evidence
of the patient experience of this procedure and for some
people undergoing bone marrow biopsy additional interven-
tions may not be required and local anaesthetic alone will be
sufficient. However, it is important that nurses do not
expect patients to accept pain during such procedures, but
work with patients as partners in care. For some patients
who require repeated bone marrow biopsies, the fear and
anticipation of pain during this procedure can cause great
distress (Johnson et al. 2008). While contending with the
stress of their underlying disease or diagnosis, an acutely
painful procedure is an additional stressor that could be
avoided, so nurses have a responsibility to ensure that
interventions are in place to reduce pain wherever possible.
There seems to be an urgent need for research to inform
standardised practice guidelines, and so ensure that pain
relief is provided for those who require it and nurses are
able to provide the highest standard of holistic patient-
centred care.
Relevance to clinical practice
The assessment and management of pain associated with
bone marrow biopsy is an important nursing responsibility,
whether the nurse is assisting with the procedure or actually
undertaking it. This review has revealed that different
approaches to pain management exist, and research has been
carried out to examine the efficacy of such interventions.
However, the evidence is inconclusive and there is nothing to
indicate which approach may be most beneficial to patients
undergoing this procedure. In addition, little is understood
about the patient’s perspective of the bone marrow biopsy
experience.
For the clinical nurse, there is a lack of a clear evidence
base to guide this important aspect of care and suggests that
621
S Watmough and M Flynn
this is perhaps a worthwhile area for future clinical nursing
research.
Acknowledgements
This review was carried out as part of the Master of Research
in Health Sciences, where SW is a full-time postgraduate
student, funded by the NIHR Clinical Academic Training
Programme.
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