Peter MacCallum Cancer Centre
A diagnosis of cancer has a profound impact on individuals and family members and is usually accompanied by a range of psychological reactions ranging from shock and disbelief to occasionally more serious psychiatric presentations. Most cancer patients describe anxiety and fear associated with an uncomfortable, yet inevitable sense of their own mortality, irrespective of prognosis. For example Kissane et al1 found in their research on breast cancer patients that 45% (135/303) had a psychiatric disorder and 42% had depression or anxiety, or both, and referrals were not made for review of these needs. Cancer has far reaching effects on individuals and families including sickness, long-term disability or functional loss, financial impacts, alterations in family relationships and existential and psychological challenges faced by individuals and families. The burden of cancer on the individual and the community is therefore high and the need for supportive care as well as biological management of disease is well documented.
Fitch2 defines supportive care in the context of cancer care as including the provision of physical, psychological, social, information and spiritual needs during the diagnostic, treatment and follow-up phases. Supportive care embraces the full range of issues that emerge for an individual and family as the impact of cancer and treatments are felt and they try to manage the situation2. Numerous research studies have demonstrated the benefits of supportive care interventions3.
Supportive care in the oncology setting is essential to improving patient outcomes. Research suggest benefits include improvements in quality of life4. There is also a growing consumer demand regarding expectations for assistance and support throughout the cancer experience2. The term supportive care is frequently used to describe various support programs, however few organisations have shown how to implement supportive care in routine clinical practice3.
This paper describes an innovative approach to the provision of supportive care services and programs in a tertiary cancer centre and its implications for nurses. The aim of the supportive care project was to deliver best-practice, integrated supportive care in a systematic, timely and routine way across the care continuum of cancer patients, by ensuring that all patients and their families:
An organisational change process was required to meet the aim of the supportive care project, which involved a number of interrelated changes occurring concurrently. The changes involved:
(a) A change in the organisational approach that led to an increased awareness and understanding of the value of supportive care programs to the overall well-being of patients.
(b) A review of the management and provision of supportive care programs to ensure they were evidence-based and targeted effectively to efficiently meet the needs of the patients.
(c) A review of the core functions of the multidisciplinary team to promote hospital-wide understanding of disciplines and the need for effective use of appropriately skilled staff.
(d) The development and implementation of a routine systematic screening and referral process for the identification and addressing of supportive care needs of patients and carers.
Organisational changes are still in progress, as effective change requires ongoing review. The change cycle being used is assess-plan-do-review-reassess cycle, which is a mnemonic for testing changes in real work settings.
A Change in the Organisational Approach
Organisational recognition of the integral value of supportive care in cancer care services provision is essential. Recognition was provided by the formation of a committee structure to oversee supportive care service provision. Executive sponsorship and multidisciplinary representation, including nurses, in the Supportive Care Steering Committee were required to facilitate staff “buy-in” of the organisational change process. An organisational statement was developed and standards of care were adopted. These were accepted by the hospital executive committee and ensured organisation-wide recognition of supportive care services as a core function of the hospital’s cancer services.
A supportive care model (fig 1) was adopted to provide a framework for the targeting of programs to meet patient needs. The model proposes that supportive care programs should take into account differing levels of need across the population, distinguishing the needs of all patients from the needs of a few patients across the entire spectrum of supportive care issues. For example, from the model it can be assumed that all partners of women with breast cancer would require some level of written information but significantly fewer would need or wish to attend a support program. In reviewing the provision of supportive care services and programs the model provided a framework to more efficiently target services at patient/family needs.
To facilitate efficient provision of evidence-based supportive care interventions and programs in a structured and integrated way throughout the hospital, the Supportive Care Steering Committee identified a series of sub-committees that would oversee all supportive care services and programs. The chairs of each program sub-committee were asked to invite relevant multidisciplinary representatives throughout the hospital to become members. Nurses were chairing or members of the sub-committees. Evidence-based programs were then prioritised according to the needs of the patient population using the conceptual model of supportive care (fig 1) to guide service provision. The organisational recognition for supportive care services and the need for a structure to provide evidence-based targeted services and programs are essential steps in providing improved integrated supportive care services. Nurses need to have a role in the organisational structure by participating in these committees at their formation and on an ongoing basis.
Efficient use of the skills of the multidisciplinary team requires understanding by clinicians of when to refer and to which services, as well as the availability of suitably qualified staff to meet the needs of the patients and carers. A study of the breast care nurse specialists in Victoria in 2001 found that there were low rates of referral to other health professionals with specific skills, such as counsellors, psychologists and psychiatrists5. If the clinician is not aware of the role of other disciplines and therefore does not make referrals, access is more difficult for the patient and family. Hopwood6 suggests awareness of the role of the other disciplines can facilitate collaboration and appropriate referrals.
The success of the organisational change to supportive care services was reliant on a high level of interdisciplinary cooperation. To improve the access of supportive care services and programs to patients and carers a high level of interdisciplinary cooperation and recognition of specific skill sets available within the team were required. Breaking down the barriers and eliminating the “turf wars” that are sometimes found in organisations are the most important tasks toward adopting a multidisciplinary approach7. A multidisciplinary team seeks to share responsibility for patients by working collaboratively. “Early in the life of the team, this usually leads to turf battles, as each team member realises that his or her skills overlap, often substantially, with the skills of other team members”8. A role mapping exercise and the supportive care model (fig 1) were used to clarify core functions of each discipline and identified the need to match specific skill sets to patient needs. Increased understanding of where skills may overlap and clarification of when to refer to others within the team has improved the flow of patients through the system. Collaboration between the multidisciplinary team members was enhanced effective and efficient use of multidisciplinary skills within the team resulting in quality patient outcomes.
An important step in the provision of supportive care services is the identification of the patient and family’s needs. A needs assessment helps identify patient perceptions of needs for optimal health and quality of life outcomes9. The identification of gaps through a needs assessment “provides an indication of the relative magnitude of need for help in different domains, allowing for better targeting of support services”10.
A system for routine identification of needs and a process for planning intervention was introduced. The review of literature suggested a self-completed tool has advantages over a clinician-completed tool in that they are inexpensive to produce, require minimal time and energy input from staff and yield quantifiable responses11. The Supportive Needs Screening Tool, a patient self-completed questionnaire, was developed with input from the multidisciplinary team including nurses and medical staff.
The screening tool is a questionnaire completed by the patient, which is then followed up by a nurse who conducts a focused interview and plans appropriate interventions. Five domains of care are considered in the screening tool: physical; information; social; psychological; and spiritual needs. Between Aug 2003 and July 2004, 236 patients new to the hospital in the breast, lung and gastrointestinal streams completed the Supportive Needs Screening Tool. From these screenings a total of 631 referrals, an average of 2.7 referrals per patient, were made. For example, the physical need, fatigue was identified on the screening tool by 44% (105/236 patients). Following their interview with the nurse 15% required and agreed to referrals to occupational therapists for fatigue interventions, 5% were referred to physiotherapy and 3% agreed to ongoing monitoring or education by nurses.
Psychological needs were also identified with the aid of the screening tool. Forty per cent patients indicated they were unhappy or depressed over the last two weeks and 43% indicated that there was something causing them distress. Following the interview with the nurse, 13% agreed to see a social worker for support and monitoring of their anxiety or depression, 6% agreed to monitoring of their anxiety by the nurse, 5% agreed to referral to the occupational therapist for relaxation techniques to reduce stress, 3% agreed to a psychology referral, 1% agreed to referral to a psychiatrist for management of depression and 1% patients agreed to see a social worker to help with their coping and adjustment to illness. This sample of results indicates that the screening tool is identifying needs that require further assessment and intervention by the multidisciplinary team. The role of the nurse provides the link for the patient, between the identified need and the required supportive care intervention. Without the focused interview with the nurse, the screening tool would provide information to a clinician, but the required intervention might not be instigated. Patients are more likely to accept an intervention if they have an understanding of what is involved and it is this critical information that the nurse can provide about the various supportive services available.
Research indicates that the diagnosis of cancer has an impact on all aspects of a person’s life, the physical, psychological, social and spiritual domains. To provide best practice oncology care is to include evidence-based supportive care services as part of the core service provision.
This paper describes an organisational change to facilitate the integration of supportive care services and programs into everyday clinical practice in a tertiary oncology setting. Nurses were key players in the changes at both the organisational level, as well as in leading systematic change to help routinely identify patient need and facilitate a process that enhances access by the patient to supportive care services and programs. Using a systematic approach to care provision, nurses can intervene more effectively and efficiently by targeting services to differing levels of need in a timely manner across the care continuum.
1. Kissane DW, Clarke DM, Ikin J, Bloch S, Smith GC, Vitetta L, et al. Psychological morbidity and quality of life in Australian women with early-stage breast cancer: a cross-sectional survey. Medical Journal of Australia 1998;169(4):192-96.
5. Centre for palliative care, Victorian centre for nursing practice research, Breast care nurses in Victoria: A workforce study of practice and factors influencing practice. Centre for palliative care and Victorian Centre for Nursing Practice Research, 2001.
8. Zeiss AM, Steffen AM. Interdisciplinary Health Care Teams in Geriatrics: An International Model Comprehensive Clinical Psychology. In: Bellack AS, Hersen M, eds. Comprehensive Clinical Psychology: Elsevier Science, 1998:551 – 70.