Austin & Repatriation Medical Centre
There is increasing recognition by health professionals of the supportive and complex needs of individuals with cancer. Nursing’s contribution in addressing these needs in particular has been acknowledged as critical. A number of studies of the Breast Care Nurse (BCN) in particular have provided level one and level two evidence that the BCN can contribute to improved patient outcomes1,2.
The recent Psychosocial Clinical Practice Guidelines recommend the presence of the specialist BCN as they reduce psychological morbidity and improve wellbeing3. The purpose of this paper is to describe the model of the Cancer Support Nurse (CSN) role implemented at the Austin and Repatriation Medical Centre (A&RMC). This model was established to address support needs of newly diagnosed patients with any cancer type.
The CSN position was established at the A&RMC in March 1998. The aim of the position is to provide expert resources, support and development opportunities to staff involved in the care of patients with cancer, and in consultation with the multi-disciplinary team, to provide additional and specific support to newly diagnosed patients with cancer, their families and carers. The role aims to deliver an integrated approach to the care of patients with cancer, across all specialties throughout the A&RMC.
The notion of a CSN was first discussed approximately four years ago at the A&RMC. Nurses in the surgical areas identified the special needs of newly diagnosed patients with cancer, and those of their family and friends. The nurses also identified their inability to address these needs, either because they did not have sufficient cancer nursing knowledge or because they felt they did not have time within their everyday practice.
Experienced cancer nurses from the oncology wards of the Medical Centre were called upon, as a resource to nursing staff, patients and families. The subsequent appointment of the CSN has meant nursing staff are supported where there was an identified lack of oncology nursing knowledge, and patients and families have access to an experienced oncology trained nurse who brings counselling, teaching and assessment skills to their care.
The key dimensions of the CSN role include:
Discussions with nursing staff often reveal a degree of anxiety and apprehension and sometimes lack of clarity regarding the care of their patient. The CSN is able to addresses this as soon as practicable to facilitate optimum communication among members of the team, and to patients and families. The CSN role has an invisible feel at times, as the CSN is aware of information communicated to all members of the team involved in the patient’s care, including the patient. The CSN intervenes when information may not have been shared between all parties involved.
Coordination and referral
It is often necessary for other supportive disciplines to intervene and the CSN facilitates timely referrals to these professionals. Referrals can be made to areas such as social work, clinical psychology, nutrition, physiotherapy, occupational therapy, chaplaincy and community health organisations.
Identifying the information and support needs
The specialist CSN role provides the information and social support that has long been identified as important in the adjustment to the cancer diagnosis and the patient’s search for meaning4,5. The CSN role is not specific to one cancer type, like the role of Breast Care Nurses, but encompasses all cancer types. Cancer is age dependent with 59% of cases occurring in persons over 65 years, and more men than women develop cancer6. More CSN roles established to identify and address the specific supportive needs of individuals and their family and friends, with any cancer type at any age, would be beneficial.
Providing emotional support
The role is multidimensional and the CSN provides expert resources, support and development opportunities to medical and nursing staff involved in the care of patients with cancer and also provides support to newly diagnosed patients with cancer, their families and carers.
Elderly post-surgical patients with cancer need informational support during the transition from hospital to home7. The CSN role provides this information and support. The position creates and sustains a valuable link for patients and families at the time of the cancer diagnosis, and facilitates the timely provision of information and supportive resources.
One important aspect of the specialist CSN role is that it has the potential to provide significant tacit support to nursing and medical colleagues in the surgical areas. This support facilitates an individual, patient-focused approach to the surgical needs of the patient, and the psychological, emotional needs of the patient and family. Medical and nursing staff have the opportunity to discuss many aspects of the care needs of individuals newly diagnosed with cancer and the patients’, and their own, personal reactions to the cancer diagnosis.
It seems prudent to have a position that has the potential to reach all newly diagnosed individuals with any cancer type at any age. The literature has already identified that women with breast cancer are frequently provided with more information and support than individuals with other cancer types8. It is also recognised that younger female patients are more likely to be better informed and supported than the elderly8. The CSN provides a resource to areas where there are few established processes in place to address the supportive care needs of individuals.
Breaking bad news
Giving the news of a cancer diagnosis, is an unenviable task for which doctors often feel poorly prepared9. Individuals experience stress in many areas as a result of a new cancer diagnosis and ensuing treatment10.
Ideally the CSN should be present when a patient and family member are informed of a cancer diagnosis, regardless of whether the cancer diagnosis was expected or not. Hearing precisely what is discussed is important when clarifying patient comments and questions at a later time. It allows for the assessment of personal reactions to the cancer diagnosis and enables timely support to be provided to the patient and family. Support to the medical colleague who is giving the bad news, particularly if it is an inexperienced junior medical officer, is also provided. The presence of the CSN allows the identification of the immediate areas of need – patient or family – and planning for future needs can commence.
The volume and depth of information that is provided to patients by medical staff regarding diagnosis and sometimes prognosis, is acknowledged. Appropriately timed visits by the CSN to patients and their family are based on the content of this information and their reactions.
The provision of up to date and accurate information is an important aspect of the CSN role. Patient education is approached from many perspectives as the literature suggests, and is acknowledged as an effective coping strategy for some individuals with cancer10,11. Many issues arise where the provision of information is valuable in assisting the individual or family member. The information promotes an understanding of events throughout the cancer experience, and is supportive in mobilising coping strategies. Becoming familiar with information and emotions reinforces confidence and enables the development of appropriate coping strategies throughout the cancer experience12.
Education provided takes into account disease, age and cultural specific needs of individuals and families. For some, general structured programs like the Living with Cancer Education Program are helpful. This program, as with the I Can Cope program, is proven to be effective and beneficial to people with cancer and their friends and family13,14.
Education includes the provision of written materials, such as patient information booklets and other printed matter made available through resources such as the Cancer Information Service. Information can also be visual or audio.
Responding to information needs during transition to home is important in helping patients and families to appropriately manage illness7. Common teaching topics include those specific to the cancer site, pain management, diet, exercise and activity in the post operative period, self care, and follow up care details. Information on community resources is also provided.
Structured teaching sessions are undertaken to inform nurses in the surgical areas of the care needs of patients with a new cancer diagnosis, and also on relevant cancer types.
The CSN provides a vital link within the cancer care team in many ways. The role enables provision expert resources, support and development opportunities to staff involved in the care of patients with cancer. Specific needs of newly diagnosed patients with cancer, their families and carers are identified and addressed.
The CSN contributes to the knowledge of the nursing team through formal education and provides support for less experienced team members, regarding coping with reactions to a new cancer diagnosis.
The CSN provides support to medical colleagues in the confronting role they face often without a clearly identifiable supportive framework.
1. JMC McArdle, WD George, CS McArdle, DC Smith, AR Moodie, AVM Hughson, GD Murray. “Psychological support for patients undergoing breast cancer surgery: a randomised study.” British Medical Journal, 312 (1996), 813-816.
7. L Hughes, N Hodgson, P Muller, L Robinson, R McCorkle. “Information needs of elderly post surgical cancer patients during the transition from hospital to home.” Journal of Nursing Scholarship. 32, 1 (2000), 25-30.
8. S McNamara. “Information and support: a descriptive study of the needs of patients with cancer before their first experience of radiotherapy.” European Journal of Oncology Nursing. 3, 1 (1999), 31-7.
12. G Grahn, M Danielson. “Patient education. Coping with the cancer experience. Evaluating an education and support program for cancer patients and their significant others.” European Journal of Cancer Care, 5, 3 (1996) 182-7.