MULTIDISCIPLINARY CARE

An evaluation of patient satisfaction with care provided by a multidisciplinary cancer team GILLIAN HUTCHISON, JULIA ADDINGTON-HALL, MARK BOWER, MARGERET AUSTEN & CHARLES COOMBES

This article describes an evaluation of patient satisfaction with the care provided by a multidisciphay cancer team based in a cancer unit which is a designated specialist cancer-treatment centre. Ax-oppor- tunistic sample of patients attending cancer out-patient clinics were approached, and 93 (84%) com- pleted the questionnaire. Most patients were highly satisfied with the care and information provided by doctors, cancer nurses and other attached professionals. However, dissatisfaction was expressed with the amount of information given about treatment t r ia ls and research, and with waiting times in clinics and pharmacy. In addition, the team was shown to be relatively poor at identifying depressed patients and offering them appropriate services. Changes implemented following this audit of care are described.

Introduction In 1984 a cancer unit was founded at a district general hospital in south London, which has subsequently been designated as the specialist cancer-treatment centre for the South-West Thames regional health authority area. In the present climate of increased cost-effectiveness in the health services, it is unlikely that such specialist services will continue to be supported by health authorities unless the care they provide is evaluated (Higginson & McCarthy, 1989). Indeed, the government White Paper entitled ‘Working for Patients’ (HMSO, 1989) makes it clear that regional specialities will in the future have to justify their funding. It was therefore de- cided to evaluate the service provided by the unit and attached multidisciplinary cancer team by auditing patients’ satisfaction.

The cancer unit comprises a day-unit for patients receiving chemotherapy, and a six- bedded staging ward to which up to 20 patients are admitted each week on an overnight or daily basis for staging investigations, chemotherapy, blood transfusions or trial treatments. Patients and families are given the opportunity to discuss their diagnosis, treatment and future manage- ment with doctors before discharge.

The multidisciplinary team is led by a consul- tant medical oncologist, and includes four junior doctors and five specialist cancer nurses. Other professionals attached to the team include a social worker, liaison psychiatrist, dietitian, pharma- cist, occupational and physiotherapists, mem- bers of the chaplaincy team and a secretary. The

team provides a 24-hour on-call service, and specialist nurses visit patients at home to advise on symptom management, to offer counselling support, and to carry out venepuncture follow- ing chemotherapy. They work closely with the primary health-care team. Weekly team meetings are held to which community nurses, general practitioners, hospice doctors and nurses and Macmillan nurses are invited. These meetings are concerned particularly with the palliative care and discharge planning of terminally ill patients. Patients and families are included in discussions at twice-weekly ward rounds.

The team aims to give all patients information about their disease and its treatment to enable them to share in decisions about future care and management, to help patients come to terms with their disease, and to enable patients to enjoy optimum quality of life and to be able to spend as much time as possible at home.

The evaluation of the unit and attached multi- disciplinary team took place 5 years after its in- ception. The number of referrals has increased rapidly over this period, and in 1989 3698 pa- tients were treated in the day-unit. In addition, 475 patients were discussed in the multidisciplin- ary meeting, which concentrates on the needs of terminally ill patients.

The evaluation took the form of a question- naire survey of patients currently receiving care from the cancer team. The aim was to identify areas of dissatisfaction with the existing service and to make recommendations about how the care provided by the team might be improved.

EuropeanJournal of Cancer Care I:I, 1991 15

Methods Answers were obtained using a five-mint scale

The patient survey took place in October 1989. The sample was drawn from patients attending the twice-weekly cancer out-patient clinics. Patients were approached by the team secretary and were asked if they would complete a questionnaire about their satisfaction with care given by the team. They were assured of confidentiality.

Patients were asked to indicate how satisfied they were with the following aspects of care:

the way in which doctors explained &gs, examined the patient, prescribed drugs, gave information to family members and provided in- formation on treatment trials and research;

the way in which cancer nurses cared for the patient, provided information and gave treat- ment such as chemotherapy, endocrine therapy, cannulation and transfusion;

the nurses encountered in out-patient clinics an& on wards;

other disciplines encountered such as dieti- tians, occupational therapists and psychiatrists;

the waiting times in out-patient clinics, X-ray department, pharmacy, and for transport;

hospital meals; homecare from specialist nurses and members

of the primary health-care team.

Tab’e ’’ with care and explanations received from medical and nursing staff in hospital and in the community

Happy with: way doctors

way doctors

way doctors

explainthings

examine you

prekzibedrugs

93

93

&d explain what drugsarefor 93 35 51

information

nursingcarein

informarion

g ivenn3fdy 59 27 46

thecancerunit 92 8 89

given by cancer ilUrSeS 11 85 ’

givenon cancer ynit IQ

way treatment

carefromnUmes 1

27

in-patient 5 . 26 64

cancernurses 46 0 0 . 0 4 96

districtnurses 17 6 6 12 18 59

home visits from

visits from

vbits from general practitioners 23 9 J 4 4 26 56

with options ranging from ‘nit at all; to ‘all the time’, with the exception of waiting times and satisfaction with information about trials and re- search, for which a three-point scale was used.

Results One hundred and eleven questionnaires were given to patients, 93 (84%) of which were re- turned. Seventeen percent of respondents were under 50 years of age, 5 1% were between the ages of 50 and 64,21% were aged between 65 and 74, and 11% were over 75 years of age.

Over 90% of patients were happy most or all of the time with the way in which doctors on the team explained things to them and examined them (Table 1). A similar proportion (86%) were happy with the way in which the doctors pre- scribed drugs and explained what the drugs were for. Fewer patients were happy most or all of the time with the information that the team gave to their families (73%), and several patients com- mented that they would have particularly ap- preciated the doctors’ help in giving information to teenage children.

Satisfaction with information about treatment trials or research was low, with 38% of 68 patients answering th is question feeling that they were given too little information.

High levels of satisfaction with the care, expla- nations and treatment given by cancer sisters were expressed, with patients commenting that, although the cancer day-unit was often busy, the cancer nurses always made time for explanations and to give information and care. The majority of respondents were also satisfied with the care re- ceived from nurses in the out-patient clinic and on the wards. However, a minority felt that the nurses in out-patient clinics needed to be more sensitive to their needs.

Half the patients (45) had seen the team dieti- tian, 84% of whom reported that they had found this helpful most or all of the time. Eleven of the twelve patients who had seen the social worker had found it helpful. Eleven patients had seen either the occupational therapist or the physiotherapist, eight of whom had found this helpful most or all of the time.

Three patients had seen the liaison psychia- trist, eight had received some counselling help, and two both had seen the psychiatrist and had counselling. Three-quarters of respondents found the help they had received from the psychiatrist or counsellors helpful all or most of the time. Patients were asked whether they had felt depressed. Fifty-seven percent of 58 patients who replied to this question had done so. Only one-quarter (8) of these patients were receiving help and, of the remainder, only 16% (4) would have liked psychiatric help.

16 EuropeanJounzal of Cancer Care 1:1, 1991

High rates of dissatisfaction with waiting times were found (Table 2). Four-fifths of respondents reported that they had had to wait more than 1 hour to see the doctor on the previous occasion they had attended the out-patient clinic. Not SUT- prisingly, 67% felt they had waited too long to see the doctor, with one patient commenting, for in- stance, that ‘I could have died and no one would have noticed’. In the pharmacy 37% of respon- dents had waited an hour or more for their drugs or chemotherapy, and 59% felt that they had waited too long. Three-fifths of the small number of patients reliant on the ambulance service for transport home had waited more than a hour and were dissatisfied with this. Despite the high levels of complaints, however, patient comments re- vealed that many appreciated being able to see the doctor, have blood tests and receive chemo- therapy all in one afternoon and, despite the lengthy waiting times, felt this to be preferable to the alternative of an in-patient admission.

Hospital food was another source of dissatis- faction, with 16% reporting being very rarely or never satisfied with food, 31% being some- times satisfied, and only 55% of patients being satisfied all or most of the time. Patients com- plained about food being cold and the unavail- ability of wholemeal bread, fresh fruit and vegetables.

Turning to services provided outside the hos- pital, 46 patients (52%) reported that a nurse from the cancer team had visited them at home. All respondents were satisfied all or most of the time with these visits (Table 1). Twenty-nine pa- tients who had not had a home visit responded to a question asking if they would have liked this service: 38% said that they would have done. One-fifth of respondents had received a visit from a district nurse, 77% of whom were satisfied all or most of the time. Only 6% of 51 respondents would have liked a visit from a district nurse. One-quarter of patients had received a home visit from their general practitioner, 82% of whom were satisfied all or most of the time.

Discussion

These results show that most patients responding to the questionnaire were very satisfied with the care provided by the multidisciplinary cancer team and the attached cancer-treatment unit.

However, some areas of dissatisfaction were identified. Poorly informed patients are likely to be anxious (Fallowfield et al., 1987). Attention therefore needs to be paid to ensure that all patients are given adequate information about treatment trials and research, and that the ex- planations given by medical staff are clear. Better ways of giving information to family members are also needed, as are ways of helping teenage children get the information they need.

Despite the evidence that psychological therapies can improve the quality of life of cancer patients (Greer, 1989)) only a minority of the patients reporting feelings of depression were re- ceiving any counselling or psychiatric help. The cancer team needs to improve its assessments of the psychological needs of patients and, in par- ticular, to improve its recognition of depression. This needs to be accompanied by appropriate services for depressed patients as it seems that only a minority would be prepared to accept psychiatric help.

Waiting times were a particular bone of con- tention. Previous reports of satisfaction with hospital services have reported similar findings (Buckles, 1990), and the government White Paper ‘Working for Patients’ has highlighted the unacceptability of appointment times that bear little resemblance to the time the patient actually sees the doctor. Although some of these patients may have been prepared to accept long waiting times in pharmacy and out-patient clinics in order to avoid an in-patient admission, these re- sults show that the present waiting times are un- acceptable to most patients.

The evaluation has therefore been valuable in identifying areas of dissatisfaction with the ser- vice currently provided by the cancer tSam. HOW-

-

Bemeen More land2 than2

e for ambulance

Table 2. Satisfaction with waiting time

EuropeanJournal of Cancer Care l : l , 1991 17

ever, the growing literature on medical audit stresses that such exercises must lead to the im- plementation of changes (McKee et al., 1989). What changes have resulted from this audit?

Firstly, meeting the informational needs of pa- tients and their families has been made a priority. An individualized Patient Information package has been written and published by the cancer nurses, in which treatment, medication and ser- vice requirements can be planned and docu- mented for each patient.

Secondly, doctors on the team have been alerted of the need to give greater priority to identi- fying the psychosocial needs of patients and their families. More care has been taken in identifying the member of the team who is most appropriate to listen, counsel, advise and support a particular patient. This has resulted in a broadening of the roles of team members, which has been per- ceived as a bonus enabling a greater sharing of responsibilities and skills.

Thirdly, while little can be done to reduce waiting times in out-patient clinics without re- ducing the amount of time that each patient can spend with the doctor, plants, pictures, carpeting and videos or televisions will be added to the out- patient waiting areas in order to make them more pleasant places in which to wait. The out-patient nursing staff have been alerted to the patients’ needs identified by this study, and notice boards in both out-patient clinics and the day-unit now give information on local cancer support-groups , events and services. Specialist nurses, members of the chaplaincy team and liaison psychiatrists are now available to provide a support service for patients, relatives or staff.

Fourthly, the educational needs of nurses employed in the hospital and in the community have been addressed. A weekly session on as- pects of cancer care has been established, which covers interpersonal communication skills as well as more traditional sessions on pain control, chemotherapy and radiotherapy. A twice-yearly short course on the care of the cancer patients, which includes both cancer and palliative care, has been initiated by one cancer nurse and now involves all members of the team sharing their knowledge and expertise.

Cost implications of these improvements have been minimal to date, but a fund-raising commit- tee has now been established to raise money for extra equipment, comfortable chairs, china cups and saucers, a video for teaching purposes, and pictures to enhance waiting areas.

In summary, the principal benefit of this exer- cise in audit has been to increase awareness amongst all staff of the patients’ psychosocial and emotional needs throughout treatment and the course of disease. There has been a greater flex-

ibility in the sharing of roles within the team and for all cancer patients treated by the team. It is planned to repeat this evaluation in order to assess whether the changes implemented to date have been maintained and to see whether im- provements in the more intractable areas of wait- ing times and hospital facilities have been achieved.

In the new climate within the National Health Service (HMSO, 1989), regional centres will have to demonstrate their effectiveness and efficiency in order to retain their funding. The results of this audit suggest that patient satisfaction is one argument that this regional specialist cancer centre can use to justify its existence.

Acknowledgements We would like to thank Vera Darling of the Lisa Sainsbury Foundation for her help and advice on an initial draft of this paper, and all members of the cancer team for their help and support throughout this study.

References Buckles E. (1990) Evaluation of patient satisfaction in an accident and emergenty department. Nursing Standard, 4,33-35.

Fallowfield L.F., Baum M. & Maquire G.P. (1987) Addressing the psychological needs of the conserva- tively treated breast cancer patient: discussion paper. Journal of the Royal Society of Medicine, 80,

Greer S. (1989) Can psychological therapy improve the quality of life of patients with cancer? BritishJounzal

Higginson I. & McCarthy M. (1989) Evaluation of pal- liative care: steps to quality assurance? Palliative Medicine, 3 , 267-2 74.

HMSO (1989) Workingfor Patienu. The Health Service: Caring for the 1990s. HMSO, London.

McKee C.M., Lauglo M. & Lessof L. (1989) Medical audit: a review. Journal of the Royal Society of Medicine, 82,474-478.

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Gillian Hutchison is Senior Sister in the Cancer Treatment Unit of St George’s Hospi- tal, London; Julia Addington-Hall is a Research Fellow in the Deparhnent of Com- munity Medicine, University College, Lon- don; Mark Bower is currendy a Clinical Research Fellow in the ICRF Depamnent of Medical Oncology, St Bartholomew’s Hospi- tal, London; Margaret Austen is Secretary to the Department of Medical Oncology, St George’s Hospital, London; and Charles Coombes is currenth Profesor of Medical Oncology at Charing Cross Hospital, London.

18 EuropeanJournal of Cancer Care l : l , 1991