Background
Distress is a significant emotional consequence of the cancer journey,1 with 35% to 60% of patients experiencing distress following their cancer diagnosis.2–4 Distress is multifactorial,5 and high levels of distress can contribute to more psychosocial problems,6 physical symptoms,7 and poor satisfaction with medical care.8 Furthermore, patient's distress is often unrecognized.9 Research highlights that clinician's accuracy in detecting patients' distress is between 10% to 28%,10,11 with many clinicians reporting that they have received little training in managing psychosocial issues and do not feel confident in dealing with distress.12
Given the negative implications of distress for patients, it has been endorsed as the sixth vital sign.13,14 Many cancer accreditation standards recommend using the approach known as screening for distress (SFD). By identifying, assessing, and acting on patient concerns in the clinical environment, SFD promotes respectful and responsive clinical interactions and shared decision-making, a core component of person-centered care.15 Research indicates that routine SFD improves quality of care, such as patient–provider interactions,16 and symptom management17; however, implementing SFD as a standard of care can be challenging.18
Research has shown the impact of SFD is influenced by program implementation and education about distress management provided.15 Positive effects of SFD were often found when implemented concurrently with other supportive resources.19 Other strategies shown to improve success include staff training and/or using specialized screening staff.19–21 Defined leadership among clinicians, project coordination, and strategic quality improvements (QIs) are enablers.22
Previous research also identified barriers to screening. At the provider level, barriers include lack of time, training, confidence,19,23 and a belief that the management of distress is not core to their role.24 Organizational barriers include lack of resources, inconsistent documentation, physician engagement, and the perception that screening may be intrusive in the clinical setting.23,25,26 Nonetheless, clinicians identified that SFD facilitates symptom management, multidisciplinary team communication, and referral practices.16,27–29 Moreover, healthcare professionals (HCPs) reported that attending to patients' self-reported concerns enhanced person-centered care delivery.29
This article reports on a provincial QI project designed to establish standardized routine screening and management of distress across all provincial cancer care delivery sites. Rigorous evaluation was conducted to establish the impact on patient-reported outcomes.30 This report focuses on how the implementation influenced HCPs' confidence in identifying and managing distress, and awareness of person-centeredness. Additionally, this project explored the impact that different models of care had on the SFD intervention.
Patients and Methods
Participants
HCPs working in any of the 17 cancer centers across the province were invited to evaluate this provincial QI project.
Procedure
Cohort 1: Cohort 1 was accrued before the implementation of SFD at each respective clinical site between September 2012 and September 2013. Participants were provided a letter of introduction to the project and a provincially standardized questionnaire. All questionnaires were anonymous and returned to program staff once completed.
Implementation of SFD: Following the recruitment of cohort 1, staggered implementation of SFD commenced on November 2012 with a 10-month implementation period at each site. Three project coordinators worked with centers to integrate SFD and to host education sessions. All staff members were included in a 1-hour group education session on person-centered care. Nurses and radiation therapists who would be responsible for the initial review of SFD received a second 1-hour individual or small group education session. This was followed by “just in time” education support in the clinical environment for 2 weeks after implementation. Key elements of education included (1) understanding the standardized SFD tool (Edmonton Symptom Assessment System31 and Canadian Problem Checklist32), (2) facilitating a person-centered conversation,33 (3) assessing the impact of distress and self-management efforts, and (4) engaging in shared decision-making regarding interventions. Education sessions were standardized across the province and developed from the implementation guide for SFD15 and a Web-based education program for SFD.33
Each site integrated the SFD intervention into their routine practice. The clinic receptionist initiated the intervention by asking the patient to complete an SFD form. A trained HCP then reviewed the tool and conducted the SFD intervention. Because different care models exist related to the size and resources available at each site, distress management strategies differed. In the smaller regional and community sites, cancer patient navigators (CPNs) were available for complex distress management. In the larger tertiary cancer centers where the CPN role is not part of the care model, psychologists and social workers were available to assist with complex distress management.
As per the QI methodology, the approach for implementing the SFD intervention included Plan, Do, Study, Act (PDSA) cycles to optimize the process.34 Chart audits were used to drive PDSA cycles and gauge effectiveness of ongoing QI efforts. Upon request from sites, 2- to 3-hour booster education sessions were conducted.
Cohort 2: Ten months after implementation, HCPs were asked to complete the same anonymous questionnaire used with cohort 1. This occurred between August 2013 and June 2014. No controls were taken to manage which HPCs participated in either cohort.
This project was conducted in compliance with the Helsinki Declaration and the Alberta Research Ethics Community Consensus Initiative (ARECCI)35 ethical guidelines for QI and evaluation. After screening with the ethical principles established by ARECCI, full Research Ethics Board review was waived. No harm was anticipated or actually reported in relation to this project.
Measures
Confidence in Assessing and Managing Distress: This tool was developed to measure HCP's confidence in assessing and managing patient distress after the completion of a Web-based education program for SFD.33 One additional item was added to assess the level of confidence in referring patients to outside agencies. The revised 12-item scale confirmed the original one-factor structure. The internal consistency (Cronbach's alpha) was 0.92. Respondents were asked to indicate to what extent each statement applies to them on a 5-point Likert scale ranging from “not confident at all” to “extremely confident.” A total score was created by summing the 12 scores.
The Person-Centered Care Assessment Tool: The Person-Centered Care Assessment Tool (P-CAT) was originally developed to measure perception of person-centeredness for geriatric care settings.36 One item not relevant to cancer was excluded. Factor analyses for the revised 12-item scale confirmed the original 3-factor structure. The internal consistency (Cronbach's alpha) was 0.85. Participants were asked to indicate to what extent they agreed with each statement on a 5-point Likert scale ranging from “disagree completely” to “agree completely.” A total score was created by summing the 12 scores.
Post-Implementation Evaluations
HCPs in cohort 2 were asked 4 additional questions, including an assessment of the usefulness of SFD, the extent to which screening might cause a delay in clinic visits, and whether they experienced positive or negative impacts of SFD.
Chart Reviews for Ongoing QI
Medical charts were randomly reviewed by project coordinators at midpoint and the end of the implementation period at all sites. The percentages of patients screened, tool reviewed, conversations documented, and actions taken were recorded to direct further improvements.
Statistical Analyses
Normality was assessed for the distribution of the outcome measures. Chi-square tests were used to compare the 2 cohorts in the binary/categorical variables for occupations, tumor groups (single or multiple), and locations. In order to assess the main effect of the intervention, independent t-tests were conducted to compare staff's confidence level and awareness in person-centeredness between the cohorts. In order to assess the potential impacts of different models of care, t-tests were conducted to compare confidence and awareness levels in staff at tertiary and regional/community sites within each cohort. When significant differences between sites within each cohort were found, a regression analysis was performed to examine whether the differences between sites before the intervention was significantly different from the differences after the intervention (cohort × site interaction). Additional sensitivity analyses were included to address potential selection bias, effect modification, or confounding effects related to pre- and post-intervention differences in the proportion of respondents treating single versus multiple tumors. Chi-square tests were used for analyses of post-implementation evaluations. All statistical analyses were performed with SPSS version 21.
Results
Participants
Table 1 represents participant characteristics. Cohort 1 included 254 HCPs, whereas cohort 2 included 158. The 2 cohorts were well-balanced in their occupations and clinic locations; however, significantly fewer staff in cohort 2 cared for single tumors relative to staff in cohort 1 (χ2[N=412], 45.39; P<.001).
Validation of Program Implementation
The SFD intervention was adopted and routinely conducted. The provincial-average screening rate reached 94.6%. The average rate of follow-up assessments or referral related to the SFD intervention reached 68.8%.
Comparisons Between Cohorts: Pre- and Post-Intervention
Cohort 2 staff reported significantly greater confidence in managing and assessing patient distress (mean, 37.88; SD, 9.36) relative to cohort 1 staff (mean, 35.89; SD, 8.80), [t(357), −2.05; P=.041; mean difference, −1.99; 95% CI, −3.90 to −0.08]. Similarly, cohort 2 staff reported significantly greater awareness in person-centeredness (mean, 46.70; SD, 6.09) relative to cohort 1 staff (mean, 44.48; SD, 6.65), [t(381), −3.31; P=.001; mean difference, −2.22; 95% CI, −3.54 to −0.90]. Figure 1 represents the mean confidence scores, and Figure 2 represents the mean awareness scores for each cohort.
Comparisons Between Sites: Models of Care and Sensitivity Analyses
In cohort 1, staff at tertiary and regional/community sites were similar in their levels of confidence in assessing distress [t(210), 0.27; P=.738]. However, staff at regional/community sites reported greater awareness in person-centeredness relative to staff at tertiary sites [t(227), −2.39; P=.018]. Similarly, in cohort 2, no differences were found between staff at tertiary and regional/community sites in the levels of confidence [t(144), 0.26; P=.798]. However, staff at regional/community clinics reported significantly greater awareness in person-centeredness relative to staff at tertiary sites following the implementation of SFD [t(151), −3.67; P<.001]. Regression analyses showed no significant interaction effect between cohort and site for the awareness (B: 1.37; 95% CI, −1.24–3.97; P=.303), indicating the difference in awareness between sites was similar before and after the intervention. Figure 3 shows mean confidence scores, and Figure 4 represents mean awareness scores for each site and cohort. Table 2 summarizes means and SDs for the outcomes for each site and cohort.
As reported earlier, fewer respondents treated single tumors in cohort 2 relative to cohort 1. Similarly, fewer HCPs at regional/community sites cared for single tumors (20%) relative to HCPs at tertiary sites (40%). Therefore, a sensitivity analysis was conducted by selecting only those who treat single tumors and those who treat multiple tumors. The
Background Characteristics of Staff Members
Mean scores of confidence in assessing and managing patients' distress for cohorts 1 and 2.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of confidence in assessing and managing patients' distress for cohorts 1 and 2.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of confidence in assessing and managing patients' distress for cohorts 1 and 2.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of awareness of person-centered care for cohorts 1 and 2.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of awareness of person-centered care for cohorts 1 and 2.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of awareness of person-centered care for cohorts 1 and 2.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Post-Implementation Evaluations
Most staff evaluated the SFD intervention either very helpful (22.2%) or somewhat helpful (49.4%) as opposed to not at all helpful (17.7%). Staff variously rated the length of delay in patient appointment times caused by screening; no delay (30.4%), 1 to 2 minutes (7.6%), 5 to 10 minutes (18.4%), and more than 10 minutes delay (26.0%). Most commonly endorsed positive impacts were “SFD was useful to get more comprehensive picture of how the patient is doing” (44.3%), and “SFD allowed more focused assessment” (38.0%). Most often-endorsed negative effects were “Too time-consuming” (31.0%), and “Extra details not relevant to care” (22.2%).
Staff at tertiary and regional/community sites were similar in their evaluation of the usefulness of SFD (χ2[N=140], 5.41; P=.067) and the extent to which screening caused a delay in patients' appointment times (χ2[N=129], 0.15; P=.928). Staff at tertiary and regional/community sites endorsed positive impacts of SFD in a similar manner; however, significantly more staff at tertiary sites (29.5%) endorsed “SFD addressed extra details not relevant to care” relative to those at regional/community sites (13.9%) (χ2[N=157], 5.60; P=.018). There was a statistical trend that more staff at tertiary sites (38.5%) endorsed “Too time-consuming” (χ2[N=157], 3.80; P=.051) relative to staff at regional/community sites (24.1%). Figures 5 and 6 illustrate the positive and negative impacts of SFD, respectively.
Discussion
This evaluation examined HCPs perceptions of the impact of a provincial QI project aimed at integrating the SFD intervention into routine cancer care.
Mean scores of confidence in assessing and managing patients' distress for tertiary sites and regional/community cancer center (RCC/CCC) sites within each cohort.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of confidence in assessing and managing patients' distress for tertiary sites and regional/community cancer center (RCC/CCC) sites within each cohort.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of confidence in assessing and managing patients' distress for tertiary sites and regional/community cancer center (RCC/CCC) sites within each cohort.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of awareness of person-centered care for tertiary sites and regional/community cancer center (RCC/CCC) sites within each cohort.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of awareness of person-centered care for tertiary sites and regional/community cancer center (RCC/CCC) sites within each cohort.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Mean scores of awareness of person-centered care for tertiary sites and regional/community cancer center (RCC/CCC) sites within each cohort.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Means and SDs for Outcome Measures at Tertiary and Regional/Community Sites in Each Cohort
The observed benefits can be explained by efficacious use of clinical resources in this project. Some distressing conditions are best managed by physicians, such as pain, whereas other issues are best managed by other members of the interdisciplinary team. Given previously identified barriers for accurately detecting patients' distress,10–12,19,23 this project assigned other HCPs to conduct the initial distress assessment. The observed improvement in HCPs' confidence levels and awareness in person-centeredness shows that the SFD intervention can build interdisciplinary teams' competency while physicians can remain more focused on issues that must be managed by a physician.
In line with previous work,16,27–29 most of the HCPs in this study valued the addition of the SFD intervention in their practice. The most often endorsed positive impact was that staff saw a more comprehensive picture of their patients (44%), aligning with HCPs' evaluation from a different provincial cancer agency's initiative.29 The current project reached more than a 90% screening rate, with a satisfactory level of follow-up (69%). This result was
Means and SDs for Outcome Measures Among HCPs Caring for Single and Multiple Tumor Groups at Tertiary and Regional/Community Sites in Each Cohort
Positive impacts of screening for distress.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Positive impacts of screening for distress.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Positive impacts of screening for distress.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
A greater awareness in person-centeredness was found among staff at regional/community sites relative to staff at tertiary sites before and after SFD implementation. This is rather expected given that the patient–provider interaction tends to be more personal at smaller care facilities. However, no significant interaction effect between cohort and site suggests that similar benefits were found after implementation at all sites. This study identified caring for single or multiple tumors as an effect modifier, with effects observed in the HCPs treating multiple tumors, but not HCPs treating single tumors. We presented the group-specific effects because the average effect would be misleading as the effects differ between HCPs treating single and multiple tumors. This may reflect different models of care in actual clinical settings. At tertiary sites, tumor-specific care can be provided, whereas at smaller sites, most HCPs take a generalist model of
Negative impacts of screening for distress.
*P<.050.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Negative impacts of screening for distress.
*P<.050.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Negative impacts of screening for distress.
*P<.050.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 14, 10; 10.6004/jnccn.2016.0135
Fewer staff at sites with a CPN endorsed the negative impacts of SFD, suggesting that navigators significantly ease staff burden related to managing distress. At tertiary sites where navigators were not available, more staff felt that SFD introduced issues that were outside of their perceived scope of responsibility. Future work involving staff education regarding the pervasive influence of distress on patients and cancer care, and the benefits of SFD is required. Given the benefits found in this evaluation, integrating the SFD intervention into clinical environments where navigators are available may be an ideal model.37,38 It also enhances the feasibility of distress management within community settings where supportive care resources are limited.22
This study had some limitations. We did not use a control group or follow the same group of individuals before and after the implementation; hence, this evaluation does not allow comment on cause-and-effect relationships. However, the current design was more suited for this pragmatic study in which the SFD intervention was implemented within the existing clinical environment. The self-selected nature of the study might result in the unbalance of HCPs treating single and multiple tumors between the cohorts and facility types, representing a risk of selection bias. Analytically, we could not deny this risk because of the small number of HCPs who treated single tumors in cohort 2. Previous studies highlight a more positive attitude toward routine screening among nurses and allied HCPs relative to physicians.29,39 Most of our participants were nurses (61.2% in cohort 1; 57.6% in cohort 2). Therefore, our results may not be generalizable to other HCPs. Building on this work, future research to evaluate the sustainability of the SFD intervention as a standard of care would be valuable.
Acknowledgments
The authors would like to thank all of the healthcare professionals who participated in this evaluation.
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