Improving the psychological care of cancer patients and their relatives: The role of specialist nurses
Introduction
This article first highlights how deficiencies in communication between health care professionals and cancer patients adversely affect psychological adjustment. Reasons for these deficiencies and the use of communication skills training to overcome them are then discussed. Finally, we consider how specialist cancer nurses trained in such skills can play a key role in improving psychological care providing they are given adequate training, supervision and support.
Section snippets
Problems eliciting patients' concerns
Only 40% of patients key concerns about their predicament are usually elicited by health care professionals [1]. In a hospice setting the ability of nurses to elicit terminally ill patients' concerns is no greater [2]. Patients who are anxious or depressed are least likely to disclose their concerns.
This low rate of eliciting concerns is of considerable relevance to psychological care. For strong links have been found between the number and severity of patients' concerns and later emotional
Reasons for distancing
Health care professionals give three key reasons for their use of distancing strategies.
Training in communication skills
One way forward would be to train all health care professionals involved in cancer care to improve their ability to elicit patients' concerns and try to resolve them, identify patients' needs for information and respond accordingly, be able to identify those patients who have developed affective disorders, and know when and how to refer them on for specialist help.
Research has found that there are only a small number of skills that need to be used if patients' concerns are to be fully elicited
Role of specialist nurses
A major question is, should all health care professionals be trained in these skills in the hope that this will improve psychological care or should specific groups be trained? In the UK, the role of specialist nurses has been advocated since the early 1980s [28]. In a controlled trial, patients were randomised to counselling by a specialist breast cancer nurse or to a control group. The specialist cancer nurse was trained to assess patients' problems, try to resolve them and refer them on for
What training do specialist cancer nurses need?
Pilot workshops with specialist cancer nurses found that they alibied difficulties they experienced in assessing patients' concerns and information needs on the grounds that doctors broke bad news poorly. So, it was thought preferable to train doctors and nurses together so they could learn about each others' problems and consider how they might support each other better [26].
These multidisciplinary workshops revealed that specialist nurses needed help with specific communication tasks. Their
Impact of workshops
These workshops were effective. They increased the specialist nurses' rate of eliciting concerns from 20% to 40% beforehand to 60% to 80% afterwards [8].
Yet, these skills-based workshops did not improve the ability of specialist nurses to become more empathic and use more educated guesses. Paradoxically, as they became better at eliciting patients' concerns they began to use distancing strategies again because they did not know how to respond.
The workshop methods were then changed to allow
Transfer of skills
To determine the extent of transfer, specialist cancer nurses were randomised to residential workshops alone or workshops plus clinical supervision. Clinical supervision included three half days where a facilitator watched the nurse in her consultations with a real patient. The nurse was then given feedback on her performance. The nurse was also encouraged to reflect on any difficulties she had experienced in the previous week with patients and to talk in general about her work [29].
Transfer of
Reasons for limited transfer
A recent medical student project involved interviewing 18 health professionals 6 to 8 weeks after a workshop about the extent to which they had transferred skills (Chaudrey T, personal communication). It found that they believed they had insufficient practice in using specific skills in different contexts and with different patients. They felt they would have benefited from direct feedback of consultations within the workplace after the workshop.
Our personal experience of supervising specialist
Implications
In helping specialist nurses improve their communication skills they need to be encouraged to acknowledge that this is just a beginning. They need to be supported by ongoing supervision, follow up courses and feedback on their performance with real patients in the workplace to give more range and depth to their learning and more opportunity to reflect on their practice and the problems they encounter.
Ongoing supervision needs to help them examine difficulties they encounter when they try to
Our own experience
Within our own cancer hospital and network we have been able to train a cohort of specialist cancer nurses through our workshop programme.
This has led them to acquire key communication skills, relinquish inhibitory behaviours and become much more able to assess patients' concerns, information needs and the need for psychiatric referral in the workplace.
The quality of their psychiatric referrals is excellent and few inappropriate referrals are made. Patients and relatives requiring psychiatric
Conclusions
Specialist cancer nurses can be a key resource in improving the psychological care of cancer patients. There is still more to be done to ensure that their developing psychological role is properly integrated within their multidisciplinary teams.
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