THE THERAPEUTIC POTENTIAL OF CANCER NURSING IN THE OUTPATIENT SETTING By Jennifer Cameron RGON, BN, PG dip Health Science (Advanced Nursing).
Outline The specific needs of cancer patients in the outpatient services: Information Communication Positivity Psychosocial The nurse s role in meeting these needs
Cancer Control Council of New Zealand (2009) National Cancer Patient Experience Project The Voice of Experience *Results overall positive* BUT GAPS: the provision of information emotional support treating patients with in the context of their living situation. O'Brien, I., Britton, E., Sarfati, D., Naylor, W., Borman, B., Ellison-Loschmann, L.,... Atkinson, C. (2010). The voice of experience: Results from cancer control New Zealand's first national cancer care survey: New Zealand Medical Journal. 123 (1325)
O'Brien, I., Britton, E., Sarfati, D., Naylor, W., Borman, B., Ellison-Loschmann, L.,... Atkinson, C. (2010). The voice of experience: Results from cancer control New Zealand's first national cancer care survey: New Zealand Medical Journal. 123 (1325)
National Guidelines in progress: 1. Guidance for improving supportive care for adults with cancer in New Zealand ( the Guidance ). MoH, March 2010. 2. Implementing supportive care guidance project. MoH, July 2011 (Draft). Ministry of Health (2010) Guidance for Improving Supportive Care for Adults with Cancer in New Zealand. Wellington: Ministry of Health.
Findings from THE GUIDANCE on INFORMATION SUPPORT 1. Understand what is wrong 2. Gain realistic idea of their prognosis 3. Make the most of consultation 4. Understand processes & likely outcomes of possible tests/treatments 5. Provide or assist with own self-care 6. Learn about services & other sources of help available 7. Help others understand their condition & needs 8. Legitimise help-seeking & concerns 9. Learn how to minimise risk of further illness 10. Find additional supportive care information & self-help groups 11. Identify best and most appropriate health care providers. Ministry of Health (2010) Guidance for Improving Supportive Care for Adults with Cancer in New Zealand. Wellington: Ministry of Health.
Ways to give information Verbal support: explain treatment plan reinforced by written and or visual Needs to be: adequate culturally relevant comprehensible holistic Nurse-patient communication Affects how well patients & their families cope with & find meaning in the experience of their illness (Coulter, 2003; Dennison, 1995; Leydon et al., 2000; McIlfatrick, Sullivan, McKenna, & Parahoo, 2007; Shaha, et al., 2006; Slevin et al., 1996)
Principles of information provision majority want to be informed variability in amount/timing needs may change during course of illness may be ignored/avoided regardless of prior knowledge/occupation limitations: patient attitude, individual coping strategies Surbone,(2006),Leydon et a.l (2000)
Challenges in information provision Information alleviates uncertainty, fear, and loss BUT: How to offer truth without destroying hope? Need to be sensitive to amount and impact Most frequent source of patient dissatisfaction Failure to provide sufficient information (Coulter, 2003; Dennison, 1995; Leydon et al., 2000; McIlfatrick, Sullivan, McKenna, & Parahoo, 2007; Shaha, Cox, & Hall, 2006; Slevin et al., 1996, Surbone, 2006)
Reasons for not wanting information Faith doctor knows best additional information could confuse medical knowledge difficult to understand additional searching could be dangerous being the good patient good customer Leydon, G. M., Boulton, M., Moynihan, C., Jones, A., Mossman, J., Boudioni, M., & McPherson, K. (2000). Cancer patients' information needs and information seeking behaviour: in depth interview study. BMJ, 320(7239), 909-913. doi: 10.1136/bmj.320.7239.909
Not wanting information cont: Hope closely linked to fear a facade of hopefulness in most advanced cancer indispensible for survival avoidance of new information presenting a brave face Charity thoughts for needs of others Leydon, G. M., Boulton, M., Moynihan, C., Jones, A., Mossman, J., Boudioni, M., & McPherson, K. (2000). Cancer patients' information needs and information seeking behaviour: in depth interview study. BMJ, 320(7239), 909-913. doi: 10.1136/bmj.320.7239.909
Waiting for information Waiting for information is probably the biggest drain on your nervous system, because you can t do anything. I blame no one. It s just that the situation is that you have to expect to wait, that s all there is to it. Information is very very important. I have to sit here and wait......waiting very much adds to people s suffering, and with waiting comes a loss of control. Kuhl, 2011, p45 Kuhl, D. (2011). Exploring the lived experience of having a terminal illness. J Palliat Care, 27(1), 43-52.
The challenge for nurses is finding a way of providing information that is appropriate for patients who may benefit from knowing something about their illness and treatment but may not wish to know everything about it at all times. Leydon, 2009, p910 Leydon, G. M., Boulton, M., Moynihan, C., Jones, A., Mossman, J., Boudioni, M., & McPherson, K. (2000). Cancer patients' information needs and information seeking behaviour: in depth interview study. BMJ, 320(7239), 909-913. doi: 10.1136/bmj.320.7239.909
Communication skills mainstay of good clinical practice technical skills & communication skills equally important the basis of the therapeutic relationship aid an intervention serve as the intervention manage anxiety/emotional distress/relieve symptoms (Dennison, 1995; Parker et al., 2001, Langewitz et al.,2010)
Touchy stuff make + feel a connection empathetic touch means of communication may reduce suffering may alter pain a necessity of life Kuhl, D. (2011). Exploring the lived experience of having a terminal illness. J Palliat Care, 27(1), 43-52.
Positivity
Positivity normative way of talking about cancer attribute positively appraised by nurses multiple meanings can be a means to meaningful & therapeutic interactions can be part of the good patient persona can be a front to protect loved ones BUT may be oppressive for patient positive outlook = positive outcome? McCreaddie, M., Payne, S., & Froggatt, K. (2010). Ensnared by positivity: A constructivist perspective on [`]being positive' in cancer care. European Journal of Oncology Nursing, 14(4), 283-290. doi: 10.1016/j.ejon.2010.03.002
Friends and family expect you to be depressed and talk about it, but if you re all doom and gloom people won t want to come near you, and you need people, this is why you tend to switch off a bit and just have a bloody good laugh when people come to see you because then they ll want to come back to see you Leydon, 2000, p911 Leydon, G. M., Boulton, M., Moynihan, C., Jones, A., Mossman, J., Boudioni, M., & McPherson, K. (2000). Cancer patients' information needs and information seeking behaviour: in depth interview study. BMJ, 320(7239), 909-913. doi: 10.1136/bmj.320.7239.909
When patients actually say what they mean rather that what they think we want to hear, we will have truly made progress......it is not for patients to make our job easier, but for us to make their cancer journey an understanding, supportive and therapeutic experience. McCreaddie, 2010, p289 McCreaddie, M., Payne, S., & Froggatt, K. (2010). Ensnared by positivity: A constructivist perspective on [`]being positive' in cancer care. European Journal of Oncology Nursing, 14(4), 283-290. doi: 10.1016/j.ejon.2010.03.002
Psychosocial Support MoH (2011). Implementing Supportive Care Guidance (Draft). Key objective The mental health and well being of people with cancer and their carers is considered at all stages of the cancer pathway Psychosocial services are under-resourced, and this is contributing to service gaps Contrary to recommendations in the Guidance, there are few fully integrated psychosocial support services Ministry of Health (2011). Implementing supportive care guidance project. July (Draft). Adults with Cancer in New Zealand. Wellington: Ministry of Health.
Psychosocial distress Definition: a multifactorial unpleasant emotional experience of psychological social, and or spiritual nature Abrahamson, 2010, p67 Effects: Undermines coping abilities Influences treatment decisions compliance quality of life disease progression Abrahamson, K. (2010). Dealing with cancer-related distress. Am J Nursing, 110(4), 67-69.
The nurse s role in psychosocial distress Improve recognition & management Accurate assessment is complex May mimic symptoms of disease progression or treatment, e.g. Fatigue Disruption in sleep or activity patterns Difficulty concentrating Changes in appetite
The nurses role cont: physicians either too busy or unskilled fail to recognise nonverbal signals don t follow up when distress related statements are made highest risk women, young, poor, limited education, Hx emotional or social problems greater if rural + access to specialists ltd Abrahamson, K. (2010). Dealing with cancer-related distress. Am J Nursing, 110(4), 67-69.
Ways nurses assist patients in coping physical presence, being there atmosphere of trust & honesty empathetic attitude listen carefully provide comfort be authentic promote future planning/goals continuity of care in team Enables patient to voice fear and anxiety openly Minimises stress and anxiety Establishes trust Shaha, M., Cox, C., & Hall, A. (2006). The Omnipresence of Cancer: its implications for colorectal cancer. Cancer Nursing Practice, 5(4), 35-39.
What inhibits emotional support? outpatient setting eliminates opportunities to interact & build rapport changes in the medical team or nurses organisational factors lack of authority lack of space lack of privacy pressure on time lack of teamwork Patient satisfaction with care improves when nurses have time and resources Abrahamson, K. (2010). Dealing with cancer-related distress. Am J Nursing, 110(4), 67-69.
resilience
References Abrahamson, K. (2010). Dealing with cancer-related distress. Am J Nursing, 110(4), 67-69. Broughton, M., Bailey, J., & Linney, J. (2004). How can experience of patients and carers influence the clinical care of large bowel cancer? European J Cancer Care, 13(4), 318-327. Coulter, A. (2003). Patient information and shared decision-making in cancer care. Br J Cancer, 89(S1), S15- S16. Dennison, S. (1995). An exploration of the communication that takes place between nurses and patients whilst cancer chemotherapy is administered. Journal of Clinical Nursing, 4(4), 227-233. doi: 10.1111/j.1365-2702.1995.tb00211.x Kidd, L., Kearney, N., O'Carroll, R., & Hubbard, G. (2008). Experiences of self-care in patients with colorectal cancer: a longitudinal study. [Article]. Journal of Advanced Nursing, 64(5), 469-477. doi: 10.1111/j.1365-2648.2008.04796.x Kuhl, D. (2011). Exploring the lived experience of having a terminal illness. J Palliat Care, 27(1), 43-52. Langewitz, W., Heydrich, L., Nübling, M., Szirt, L., Weber, H., & Grossman, P. (2010). Swiss Cancer League communication skills training programme for oncology nurses: an evaluation. Journal of Advanced Nursing, 66(10), 2266-2277. doi: 10.1111/j.1365-2648.2010.05386.x Leydon, G. M., Boulton, M., Moynihan, C., Jones, A., Mossman, J., Boudioni, M., & McPherson, K. (2000). Cancer patients' information needs and information seeking behaviour: in depth interview study. BMJ, 320(7239), 909-913. doi: 10.1136/bmj.320.7239.909 Ministry of Health (2010) Guidance for Improving Supportive Care for Adults with Cancer in New Zealand. Wellington: Ministry of Health.
McCreaddie, M., Payne, S., & Froggatt, K. (2010). Ensnared by positivity: A constructivist perspective on [`]being positive' in cancer care. European Journal of Oncology Nursing, 14(4), 283-290. doi: 10.1016/j.ejon.2010.03.002 McIlfatrick, S., Sullivan, K., McKenna, H., & Parahoo, K. (2007). Patients experiences of having chemotherapy in a day hospital setting. Journal of Advanced Nursing, 59(3), 264-273. doi: 10.1111/j.1365-2648.2007.04324.x Ministry of Health (2011)implementing supportive care guidance project July (Draft)Adults with Cancer in New Zealand. Wellington: Ministry of Health. Ministry of Health (MOH) (2010), the Guidance for Improving Supportive Care for Adults with Cancer in New Zealand O'Brien, I., Britton, E., Sarfati, D., Naylor, W., Borman, B., Ellison-Loschmann, L.,... Atkinson, C. (2010). The voice of experience: Results from cancer control New Zealand's first national cancer care survey: New Zealand Medical Journal. 123 (1325) (pp 10-19), 2010. Date of Publication: 05 Nov 2010. Shaha, M., Cox, C., & Hall, A. (2006). The Omnipresence of Cancer: its implications for colorectal cancer. Cancer Nursing Practice, 5(4), 35-39. Slevin, #160, L., M., Nichols, E., S., Downer,... M. (1996). Emotional support for cancer patients : what do patients really want? (Vol. 74). Basingstoke, ROYAUME-UNI: Nature Publishing Group. Surbone, A. (2006). Telling the truth to patients with cancer: what is the truth? Lancet Oncol, 7(11), 944-950.