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October 2014, Supplement to Volume 18, Number 5
CJON Writing Mentorship Article
Managing Late Effects of Breast Cancer Treatment
Jamie Arnett, RN, OCN®, Barb Henry, MSN, APRN-BC, and Ann Fankell, LISW, MSW
This article illustrates the authors’ participation in the ONS Foundation–supported Breast Cancer Survivorship (BCS) Quality Measures Set pilot study at Southern Ohio Medical Center (SOMC) Cancer Center. The data collection, outcomes, and action plans based on results are described. Included are the SOMC distress tool, psychosocial assessment tool, a survivorship care plan, and a clinical vignette describing how the tools and implementation of the action plan improved care and facilitated connection to supportive community resources. The BCS Measures pilot study provided a learning opportunity in identifying important quality assessments early in the plan of care. These valuable measures are necessary to provide better care in breast cancer survivorship.
The Southern Ohio Medical Center (SOMC) Cancer Center participated in the ONS Foundation–supported Breast Cancer Survivorship (BCS) Quality Measures Set pilot study. The SOMC Cancer Center is a small, rural community outpatient facility that offers both radiation and medical oncology services in the same location. In southeastern Ohio, breast cancer is the leading cancer diagnosed in women and accounted for 43% of cancer diagnoses in women at SOMC from 2010–2012 (SOMC Cancer Services, 2013).
SOMC submitted data for 26 patients to the BCS Measures pilot study. The data required on each patient were detailed and very specific. At the SOMC Cancer Center, all of the patient records are electronic. Although the electronic medical record was beneficial, significant time was invested gathering specific data components for the study. The information required was not segmented in certain sections for easy report retrieval, and some data elements were not captured. During the collection process, areas for improving collectability of information were identified, and opportunities for streamlining data were discovered. These opportunities were realized for all clinical areas, including providers, nurses, social services, and the breast health navigator.
The staff at SOMC Cancer Center created action plans after the study was completed to address opportunities for improvement. One area of particular interest was the survivorship care plan. Improvements were made to the plan in an effort to add missing information and provide more information to patients. Psychosocial concerns are addressed by the social worker using a self-administered distress inventory (see Figure 1) on the patient’s first visit to the center. The social worker receives the distress inventory information and meets with patients with emphasis placed on the score and criticality. After the visit, a note is documented in the chart informing other staff members of potential problems the patient is having or may face in the future as well as the plan to address the concerns. The social worker continues to address the patient’s needs throughout his or her care and communicates with the team regarding any issues or concerns that need attention. This process has helped tremendously in providing better psychosocial care to the patients.
The social worker for the SOMC Cancer Center depends on the results of the distress inventory to provide direction for meeting the needs of each new patient with cancer in a holistic approach. Maslow’s Hierarchy Theory of Need (Taormina & Gao, 2013) states that self-actualization or acceptance cannot be reached unless physiologic needs, as well as safety, love, and esteem, are satisfied. If a patient’s immediate concerns are not addressed, he or she may have difficulty focusing on coping with healing and acceptance of a cancer diagnosis. The following case study is a vignette that illustrates how the distress inventory tool helped identify the needs of one patient with cancer.
A 55-year-old woman came to the cancer center with a diagnosis of invasive ductal carcinoma of the right breast. Her cancer was HER-2 positive and appropriate for high-dose rate radiation treatment. She came to her first appointment with the self-administered distress inventory that had been mailed to her in the new patient packet. The social worker was not available to meet that day but called the patient the next day. The patient had a score of 7 on a 10-point scale on the distress inventory, specifically listing nervousness, anxiety, and fear of treatment as concerns. The patient voiced no concerns during the phone interview or at the follow-up visit. She informed staff that she was independent and had a spouse to assist as needed. The patient downplayed any emotional distress that the cancer was having on her life, and her family physician was helping her with medication. The patient’s distress seemed to stabilize during treatment, but her distress level increased after treatment ended and she developed lymphedema in her arm. She had been referred to physical therapy and was having panic attacks from fear that the therapy would exacerbate an old shoulder injury. At this point, she felt comfortable with the social worker and called for assistance. The patient was in tears because she felt as if she was “falling apart.” She explained that when anything new happens, it sends her “south into despair and panic.” She was guided to speak to a psychiatric professional about medication adjustment and encouraged to attend “I Can Cope,” an education class for people facing cancer and their family members, or a breast cancer support group. The patient still attends the monthly I Can Cope group, which discusses a new cancer topic each month on a one-year rotation. She was so appreciative that a social worker was there to help her through this time, and although she took a while to discuss her concern, the distress inventory was the key that unlocked the door to communication about her needs and concerns. After a year of I Can Cope classes, the patient felt ready to transfer to a breast cancer support group.
The SOMC Cancer Center identified that nurses were not documenting issues with sleep, fatigue, or neuropathy. This was not an assessment question typically asked, and, even if discussions occurred, they were not documented in discrete fields for data mining in the future. These items were added to the electronic nursing assessment in each patient’s medical record and are addressed during each visit to the center. When problems are identified, the physician is notified and documentation ensues related to the action plan to address the issue. In this manner, subsequent nurses can follow these areas on the assessment and ascertain improvement or decline.
Results from the BCS Measures pilot study helped identify that the plan for post-treatment education was not assessed in a complete manner. After the study, an improved survivorship program was launched for all patients with breast cancer. The breast health navigator developed a breast cancer treatment summary for the patients with breast cancer that addresses all areas of the survivorship care plan after treatment (see Figure 2). The breast health navigator meets with every patient after treatment ends and educates them on important areas lacking in the past on post-treatment education. Handouts are provided on diet, exercise, and lymphedema. Patients are educated on late effects they may experience and are provided information on recurrence. The breast health navigator also provides information on community resources.
Community resources include the “Life Matters” program for all cancer survivors. This program provides information after treatment on diet, exercise, goal setting, survivorship, and psychosocial issues patients may encounter after treatment. The program is a free six-week course offered for one hour weekly at SOMC to any cancer survivor in the area. A variety of team members, including a dietitian, fitness expert, nurse, social worker, and a cancer survivor, educate the participants during the meetings. A breast cancer support group also meets monthly at the cancer center. This program provides information on all phases of cancer care. Patients are given the opportunity to speak about their issues and concerns during this support group, and professional speakers are also present at quarterly meetings. Another program offered is I Can Cope, which provides a holistic approach to newly diagnosed patients and those receiving treatment. The classes are led by a social worker, nurse, dietitian, financial expert, and hospice staff depending on the topic being covered. I Can Cope classes are offered to anyone who wants to attend.
Findings from the BCS Measures pilot study created many learning opportunities for the center. Public reporting of quality measures has shown to promote changes in healthcare providers (Agency for Healthcare Research and Quality, 2012). The results helped the center to develop action plans that strengthen the care provided to people with breast cancer. With the support of the whole team, more aspects of the patient’s care are addressed and symptom assessment and educational tools have been strengthened in the process. The community resource programs have made a difference in the rural community. They provide an outlet for cancer survivors to meet and get answers to difficult questions they may not feel comfortable speaking to their physicians about. At the SOMC Cancer Center, staff continue to look for areas that need improvement and are always researching for the best practice to provide evidence-based health care for the community.
Implications for Practice
Ø Add sleep, fatigue, and neuropathy to the nursing assessment done at each follow-up visit, and address any issues in those areas that are discovered.
Ø Recruit a breast health navigator to help develop and implement survivorship care plans.
Ø Provide distress inventory documents to new patients, and address any psychosocial issues that the patient reports with the help of a social worker.
Agency for Healthcare Research and Quality. (2012). Public reporting as a quality improvement strategy. Retrieved from http://www.ahrq.gov/research/findings/evidence-based-reports/gapqistp.html
Southern Ohio Medical Center Cancer Services. (2013). 2013 annual report. Retrieved from http://www.somc.org/cancer/assets/Cancer_Report_2013.pdf
Taormina, R.J., & Gao, J.H. (2013). Maslow and the motivation hierarchy: Measuring satisfaction of the needs. American Journal of Psychology, 126, 155–177.
Jamie Arnett, RN, OCN®, is a clinical trials research nurse at Southern Ohio Medical Center (SOMC) Cancer Center in Portsmouth; Barb Henry, MSN, APRN-BC, is a psychiatric advanced practice nurse at Melvin S. Gale MD and Associates in Cincinnati; and Ann Fankell, LISW, MSW, is a social worker at SOMC Cancer Center, all in Ohio. The authors take full responsibility for the content of the article. The authors were participants in the Clinical Journal of Oncology Nursing (CJON) Writing Mentorship Program. Henry received honorarium from the Oncology Nursing Society for her role as a mentor in the CJON Writing Mentorship Program.The authors received editorial support from Kristen Fessele, PhD, RN, AOCN®, in preparation of this article funded by a grant to the ONS Foundation from the Breast Cancer Fund of the National Philanthropic Trust. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the independent peer reviewers or editorial staff. Arnett can be reached at email@example.com, with copy to editor at CJONEditor@ons.org. (Submitted April 2014. Revision submitted June 2014. Accepted for publication June 22, 2014.)
Key words: breast cancer; survivorship; assessment; quality measures