"Moving Swiftly On." Psychological Support Provided by District Nurses to Patients with Palliative Care Needs

Jane Griffiths, PhD; Gail Ewing, PhD; Margaret Rogers, PhD

Disclosures

Cancer Nurs. 2010;33(5):390-397. 

In This Article

Abstract and Introduction

Abstract

Background: Patients are living longer with incurable cancer, and for most of the time, they are at home. Psychological morbidity is high and increases with advanced disease and poor prognosis, and evidence suggests that patients' psychological needs at this time are not met. District nurses provide support visits to patients for long periods before they die. Little is known about district nurses' skills in detecting patients' concerns and meeting psychological needs.
Objective: The aim of the study was to explore how UK district nurses describe and conduct early support visits with palliative patients and patients' perceptions of visits. We report 1 aspect of the findings: psychological assessment and support provided during early support visits at home.
Methods: Six focus group were conducted with 53 district nurses. Interactions between 10 patients, their carers, and district nurses were observed and audio recorded during home visits. Patients and carers were also interviewed before and after the observation visits. Data were analyzed using a thematic approach.
Results: District nurses described assessing and meeting patients' psychological needs informally through "chatting." Observation of practice, however, revealed avoidance behaviors when faced with patients' psychological concerns, exemplified by the statement "moving swiftly on," which was 1 district nurse's response to a patient's overt distress.
Implications for Practice: District nurses have a potentially important role in assessing and meeting cancer patients' psychological needs, but appear to lack confidence and skills. District nurses need to be taught a simple intervention based on active listening and problem solving to assess and manage mild psychological morbidity.

Introduction

Patients with incurable cancer are living for increasingly long periods. For most of their cancer journey, they are at home. It is known that patients are likely to have psychological concerns at various stages in the disease trajectory.[1,2] Overall, psychological morbidity for cancer patients is around 20% to 30%.[1,3] At diagnosis, around half of patients experience levels of anxiety and depression that disrupt their daily lives, and a quarter are still affected during the next 6 months.[2] Rates increase in patients with advanced and metastatic disease and a poor prognosis.[3] Psychological support is needed when disease progresses, active treatment stops, and until death.[2]

Although in the United Kingdom district nursing is a service that is associated with physical care for patients in their own homes, the district nursing literature also describes psychological support for patients living with cancer. There are frequent references to the importance of building relationships with patients over extended periods and of getting to know them and fostering trust to support them psychologically.[4–11] British district nurses prefer to receive referrals early in the cancer trajectory to provide this support[12–14] and have been described as "the backbone" of palliative care in the community.[15]

There is evidence to suggest, however, that patients' psychological needs are not being met[2] and that nurses in both hospices and secondary care are not good at eliciting patients' psychological concerns.[16,17] District nurses in the United Kingdom also spend a lot of time with cancer patients "supporting" them at home, but it is unclear how skilled they are at detecting psychological concerns and providing basic psychological support. In some studies, district nurses report that they have good communication skills[18] and provide skilled psychological and emotional support to cancer patients.[6,14] Other evidence suggests, however, that district nurses lack confidence in communication skills[19,20] and in meeting cancer patients' psychological needs.[21,22]

There appears to be a mismatch therefore between district nurses' desire to be involved in psychological support for cancer patients and evidence of their effectiveness in this role. Furthermore, with the exception of a very small study,[14] what we know about district nurses and psychological support comes from accounts of reported rather than observed practice.[7–10,12] Kennedy's[14] study comprised only 3 patient observations and 12 district nurse interviews and did not report patients' and carers' perspectives of the support they received. Therefore, to investigate further the role of district nurses in providing early support to cancer patients at home and in response to the lack of observational studies, we conducted a qualitative study combining interview and observation methods, the purpose of which was to obtain a broad account of all aspects of support, including psychological, provided at this time.

The aim of the study was to explore how UK district nurses (a) describe and (b) conduct early support visits (ESVs) with palliative care patients at home. The overall study was therefore concerned with the broad nature of support, including activities such as hands-on physical care, ordering equipment, and coordination of services to meet patients' needs. In this article, however, we focus on 1 aspect of our findings, relating to psychological support for patients with palliative care needs. In doing so, we report on (1) district nurses' descriptions of their assessment and management of patients' psychological concerns, (2) their observed practice in this respect, and (3) patients' perceptions of the district nurses' visits.

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