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

(Coulter, 2003; Dennison, 1995; Leydon et al., 2000; McIlfatrick, Sullivan, McKenna, & Parahoo, 2007; Shaha, et al., 2006; Slevin et al., 1996)

Nurse-patient

communication

Affects how well patients & their families cope with & find meaning in the experience of their illness

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.

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

“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

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

Shaha, M., Cox, C., & Hall, A. (2006). The Omnipresence of Cancer: its implications for colorectal cancer. Cancer Nursing Practice, 5(4), 35-39.

Enables patient

to voice fear

and anxiety

openly

Minimises

stress and

anxiety

Establishes

trust

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.