Barriers/Facilitators

Transcription

1 Barriers/Facilitators Barriers Self-identified lack of knowledge & underdeveloped skills Perceived paucity of psychosocial care Facilitators Opportunities for Education/Skill Enhancement Evidence-based Practice Nursing is ubiquitous Care NCCN guidelines at NCCN Clinical Practice Guidelines in Oncology Complete Library of guidelines Guidelines for supportive care Distress management Also available on compact disk free of charge 1 2 Care DISTRESS is a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social &/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, & its treatment. Care DISTRESS extends along a continuum, ranging from common normal feelings of vulnerability, sadness & fears to problems that can become disabling such as depression, anxiety, panic, social isolation, & existential & spiritual crisis. NCCN, 2004, DIS-2 3 NCCN, 2004, DIS-2 4 Care DISTRESS More acceptable & less stigmatizing than psychiatric, psychosocial, or emotional Sounds normal & is less embarrassing Can be defined & measured by self report Screening Tools Distress Thermometer (NCCN 2004) FACT-G (Cella & Tulsky 1993) HADS (Hamilton, 1967) CES-D (Radloff, 1977) BSI (Derogatis, Lipman, & Covey, 1973) Holistic Nursing Assessment NCCN, 2004, DIS-1 5 6

2 Slide not available Problem List 1. Practical Problems a. Child Care b. Housing c. Insurance d. Work/School e. Transportation 7 NCCN, 2004, DIS-A 8 Problem List 2. Family Problems a. Partner b. Children c. Parents Problem List 3. Emotional Problems a. Depression b. Fears c. Nervousness d. Sadness e. Worry NCCN, 2004, DIS-A 9 NCCN, 2004, DIS-A 10 Problem List 4. Spiritual/Religious Concerns a. Loss of Faith b. Relating to God c. Loss of meaning or purpose of life 5. Physical Problems a. Appearance k. Fevers b. Bathing/dressing l. Getting around c. Breathing m. Indigestion d. Urination n. Mouth sores e. Constipation o. Nausea f. Diarrhea p. Nose dry/congested g. Eating q. Pain h. Fatigue r. Sexual i. Feeling swollen s. Skin dry itchy j. Sleep t. Tingling hands/feet NCCN, 2004, DIS-A 11 NCCN, 2004, DIS-A 12

3 Slide not available Care :Triage: Guidelines Mild Distress < 5 (i.e., 1-4) 1. Personally managed by the Primary Oncology Team (POT) 2. Referral to Self Help Resources 13 NCCN, 2004, DIS-4 14 Mild Distress <5 NCCN Intervention Guideline Themes Communication Helping/Therapeutic Relationship Support Psychoeducation Anticipatory Guidance NCCN, 2004, DIS POT Management: Increase ICAN Distress Management Training for Oncology Nurses 4 free continuing education programs on Distress Management On the APOS website ( Specifically developed for nurses by nurses Permission to use symbol granted by APOS POT Management: Increase 1. POT Management: Increase READ Psychosocially oriented NURSING textbooks READ NURSING journals with psychosocial content Carroll-Johnson, Gorman Bush, 1998; Burke, 1998; Oncology Nursing Press 17 Carroll-Johnson(ed),ONS;Griffin-Sobel(ed),ONS 18

4 1. POT Management: Increase READ multidisciplinary Psychosocially oriented oncology journals 1. POT Management: Increase READ multidisciplinary Psychosocially oriented books Holland, Watson(eds),Wiley Publishers 19 Hewitt, Herdman, Holland, 2004,National Academic Press; Kuebler, Esper, 2002, ONS POT Management: Increase SEARCH out other sources of psychosocial education/information ONS website Clinical Practice tab Nursing Education tab Publications tab Oncology Education Services (OES) affiliate site Internet Within your own & extended community a. General non-profit support organizations ACS Wellness Community YMCA Within your own & extended community b. Diagnosis Specific non-profit support groups and organizations Susan G. Koman Breast Cancer Foundation Lung Cancer Alliance Us, Too (Prostate CA) Within your own & extended community c. For profit entities Appearance/Image Centers Spas Wig Stores, Hair salons Prostheses fitters (e.g., Nordstrom s) Catalogs (e.g., ACS TLC) 23 24

5 Long distance resources Nonprofit Internet websites ONS ( NCCN ( NCI ( ACS ( NCCS ( CancerCare ( For Profit Internet websites Appearance Centers Internet Benefits Pts. can assemble a lot of evidence for what they think is happening to them May come up with dx their Dr. had not thought of or missed Use as a basis for communication with health care team 2nd International Conference on Cancer on the Internet, Oncology Times, XXVI(21),16-21 Internet Benefits Better understanding of own care & tx Manage much of own care Find additional emotional support Spend less time in Dr. office or on phone with clinic staff Internet Benefits 6 to 8 million people in the US visit the Internet every day for health information 2.2 million office visits per day 2nd International Conference on Cancer on the Internet, Oncology Times, XXVI (21), nd International Conference Cancer on the Internet, Oncology Times, XXVI(21),16-21 Internet Online Support Group Benefits Promote self education & self responsibility Encourage pt. initiative & assertiveness Provide members with an opportunity to help others Long distance resources (continued) Telephone Hotlines for information NCI CANCER ACS ACS-2345 CLRC (Cancer Legal Resource Center) CancerCare HOPE 2nd International Conference on Cancer on the Internet, Oncology Times, XXVI(21),

6 Long distance resources (continued) Telephone support Individual consultations Group conference call support groups Magazines Coping with Cancer ( $19 per year 6 issues Drug company sponsored psychosocial/educational material (usually free) Audio tapes & CDs Videos Pamphlets Developed by: NCCS (copyright) ONS AOSW NASW Paid for by: Amgen Lilly 33 OR TOOLS-4-U 34 Commercially prepared patient oriented psychosocial books, videos, CDs, & brochures Krames ( or Lange ( 1. Search for interventions already tried and proven effective (i.e., Evidence Based Practice - EBP) NCCN Guidelines Nursing text books Nursing Research Journals 35 36

7 What is Evidence? Research Based Evidence Meta-analysis of multiple controlled clinical trials Experimental studies Systematic review of all types of evidence Multiple non-experimental studies Published EBP guidelines Non-Researched Based Case studies Program evaluation Quality Improvement data Case Reports Opinion of Experts (e.g., standards of practice) 2. Develop New EBP Interventions as needed Problem Identification: Converting information needs into an answerable question Finding the Evidence: Finding the best evidence with which to answer the question Critique: Determining the merit, feasibility and utility of evidence Rutlegde, DN & Grant, M. (2002) Introduction. Seminars in Oncology Nursing, 18, New EBP Interventions (cont.) Summarize the Evidence: Combining findings from all evidence to make a practice recommendation Application to Practice: Incorporating the recommendation into a clinical setting or organization Evaluation: Determining the effectiveness of the practice change over time 1. Problem ID: Outpatient Deaths and Family Bereavement Staff Issues Anxiety & fear of upsetting pts./family by bringing up death, dying, & bereavement issues Lack of knowledge & confidence in own expertise; sense of helplessness Lack of closure with pts. & families Problem ID: Outpatient Deaths and Family Bereavement Pt/Family Issues Emotionally overwhelmed Lack of knowledge re: multiple issues now facing Sense of abandonment by staff Lack of closure with staff 2. Finding the Evidence 3. Critique 4. Summarize 5. Apply to Practice

8 New EBP Intervention: Comfort Care Packet Introductory letter Pamphlets on Death & Dying: Letting Go with Dignity and Grace and Understanding Grief: Facing Loss and Moving On ( or Information on legal issues (CLRC) Intervention: Comfort Care Packet Articles on helping dying parents deal with children 1 & how children perceive death 2 List of all hospice organizations in local area 3 Information on burial options and local services Request for family to contact staff in future 43 1 Fawzy, N ;2 Stuber, M. (July,1989) In Focus; 3 Hospice Association of America 44 Care: Evaluation of Nursing Sensitive Outcomes Nursing Outcomes Classification (NOC) Johnson, Maas, & Morehead (2000) The Omaha System Martin & Scheet (1992) Intern l Classification for Nursing Practice International Council of Nurses (2002) Others Care: Evaluation of Nursing Sensitive Outcomes Comfort Care Packet (pilot project n=15) Nursing Staff Decreased anxiety & fear Increase knowledge, confidence in expertise, decreased sense of helplessness Approached rather avoided pts./families Felt sense of closure Care: Evaluation of Nursing Sensitive Outcomes Patients/Family Members Expressed gratitude when packet received All reported using some aspect of packet and finding it very helpful All called back to report death of patient and status of family survivors - closure All expressed gratitude for the psychosocial support no issues of abandonment Care: Documentation Triage Check List (TCL) Number of problem marked by patient (e.g., 2b,5f) is written next to relevant action taken by primary care team All available resources are listed on TCL with phone or contact information A written copy of all referral resources are available in clinic and given to patient 47 48

9 TRIAGE CHECKLIST Staff Please write the Problem List number(s) (e.g. 1b, 3d) next to the t action taken. A single problem may have more than one action taken. List all. Explanatory information should be entered in progress notes. 5c Further Discussion with Doctor 5h,sVerbal teaching/counseling by staff nurse 3b,dVerbal teaching/counseling by APN Educational flyer/pamphlet (briefly describe) Referral to Nutritionist (phone) Referral to Physical Therapy (phone) TRIAGE CHECKLIST Staff Please write the Problem List number(s) (e.g. 1b, 3d) next to the t action taken. A single problem may have more than one action taken. List all. Explanatory information should be entered in progress notes. 1c Referral to Cancer Legal Resource Center (213) Referral to Appearance Center (phone) Referral to ACS (phone) Referral to Bioethics (phone) Referral to Wellness Community (or local equivalent) TRIAGE CHECKLIST Staff Please write the Problem List number(s) (e.g. 1b, 3d) next to the t action taken. A single problem may have more than one action taken. List all. Explanatory information should be entered in progress notes. Distress >5 requires referral to 1 or more of following: Immediate consultation with Psychiatry (phone) 3a Referral to Psychiatry Dept. (phone) Referral to Adult Psychology Dept. (phone) 2b Referral to Child Psychiatry (phone) Referral to Social Work (phone) 4b Referral to Pastoral Care (phone) Referral to outside mental health consultant (see list) Framework of Psychosocial Care: Summary 1. Assessment Distress Thermometer-Problem List (NCCN) 2. EBP Intervention Algorithms (NCCN) Distress <5 POT Management Patient Self Help Resources Distress 5 Appropriate Referral (Psych, SW, Pastoral Care) 3. Documentation TCL (Fawzy) 4. Evaluate nursing sensitive outcomes (NOC, ICNP, etc) Slide not available 53 54

10 Slide not available Slide not available 55 56