Psychosocial Issues and Care in Pediatric Oncology: Medical and Nursing Professionals' Perceptions

Gemma Kiernan, PhD, Postgrad Dip Counselling and Psychotherapy; Emma Meyler, PhD; Suzanne Guerin, PhD

Disclosures

Cancer Nurs. 2010;33(5):E12-20. 

In This Article

Abstract and Introduction

Abstract

Background: Children with cancer and their families have psychosocial support needs. Medical and nursing professionals in pediatrics and pediatric oncology are in a position to identify and help manage these. However, little is known about their perceptions of psychosocial issues and interventions.
Objective: The purpose of this study was to investigate physicians' and nurses' perceptions of psychosocial issues in pediatric oncology including their awareness of the psychosocial impact of childhood cancer on families and their knowledge and views of psychosocial interventions.
Methods: A phenomenological approach was taken whereby semistructured interviews were conducted with a purposive sample of 10 physicians and nurses.
Results: Findings showed that despite a lack of formal training in psychosocial issues, professionals identified a number of psychosocial issues associated with childhood cancer, including effects for family members. In addition, findings illustrated the psychosocial roles that they frequently adopt in relation to the identification, treatment, and referral of psychosocial issues. Finally, physicians and nurses recognized the value of formal intervention, reporting benefits for children, families, and themselves.
Conclusion: These findings give a preliminary insight into physicians' and nurses' perceptions and awareness of the psychosocial issues experienced by children with cancer and their families and their knowledge of psychosocial interventions. They highlight ways to enhance the delivery of care in pediatric oncology.
Implications for Practice: Specifically, they suggest the need for more formal training on psychosocial issues for medical and nursing professionals, for additional experienced psychosocial professionals to be recruited, and for more access to services for both families and medical and nursing professionals.

Introduction

There is a growing body of literature documenting the psychosocial effects of childhood cancer on the children and their family.[1] With advances in treatment and improved prognosis, there is an increasing number of children and families living through the experience of serious illness.[1,2] However, increased survival rates come at the cost of aggressive combinations of chemotherapy, radiotherapy, and surgery, each of which may be associated with adverse effects and associated psychosocial difficulties for families. Furthermore, these treatments can lead to physical "late effects," which may also have psychosocial consequences long after treatment has ended.[1,2] Given this context, children with cancer and their families have universal support needs; nonetheless, there is evidence to suggest that some show resilience and cope well with minimal intervention, whereas others find it harder. Indeed, a significant minority of families experience difficulties that require intensive intervention,[3,4] and many studies have documented positive effects of participation in interventions for children and families (for a review of interventions, see Kazak[1]).

Physicians and nurses working in pediatrics, and in pediatric oncology specifically, are in a unique position to identify and manage psychosocial issues in childhood. Potential roles may include preparation for and provision of support during medical procedures, ensuring developmentally appropriate information sharing, awareness of cultural issues, awareness of palliative/bereavement issues, survivorship, involvement of parents in care, collaboration, and management of professional boundaries in relationships.[5–7] In addition, these professionals often have to make decisions regarding the management of psychosocial issues, including decisions regarding referral of children and their families for psychosocial interventions.[8] Physicians, in particular, typically act as gatekeepers of mental health services.[8,9] Despite this, little is known about their perceptions and understanding of psychosocial issues and interventions.[10]

Where research has been done on this issue, it has tended to focus more on physicians' rather than nurses' views and generally relates to pediatrics rather than to pediatric oncology specifically.[11–14] Findings suggest that medical professionals miss opportunities to identify and respond to psychosocial issues. For example, in a reported study,[7] physicians failed to identify 50% of children with behavior problems (as identified using the parent report form of the Eyberg Child Behaviour Inventory). Physicians also failed to record psychosocial issues in a number of cases where parents had raised concerns and were more likely to attend to parent concerns when parents themselves showed distress. Another study[8] examining referral for psychosocial services placed the overall referral rate at 16%. This was higher for new diagnoses (27%). Where referral was not made, the most common action taken by physicians was no treatment or "watch and wait" (38.4%), whereas a further 33% of cases were managed within the context of primary care. This is concerning given that better outcomes have been reported for many psychosocial issues with early identification and treatment.[11]

Studies have identified a number of factors that influence medical and nursing professionals' recognition and management of psychosocial issues. For example, professionals who have had advanced training are more likely to identify issues and to use multiple management strategies.[13,15,16] The nature of the presenting psychosocial difficulty has also been highlighted, with studies reporting that more severe difficulties are more likely to be identified and referred to specialist services.[8,13,14,17] Interestingly, there are inconsistencies in relation to the specific type of psychosocial issue that is referred. Some studies have reported that behavioral issues are less likely to be referred and emotional issues are more likely to be referred,[8] whereas others suggest that behavioral issues are more likely to be referred.[15] Another factor mediating professionals' recognition and management of psychosocial issues is parent disclosure of a psychosocial issue.[9] Their own familiarity with the child also increases the likelihood of issues being recognized.[13] Finally, a number of studies have highlighted the influence of resources in medical professionals' management of psychosocial issues. For example, a study identified lack of time to treat as a barrier to management of psychosocial issues,[18] whereas access to mental health professionals and services has also been identified as a problem.[8]

Overall, evidence from the limited amount of research that has been conducted seems to suggest that physicians and nurses working in pediatric settings may sometimes fail to recognize psychosocial issues in children, leading to missed opportunities for appropriate intervention and care. However, the generalizability of these findings to pediatric oncology is questionable. Given the specific effects associated with childhood cancer and its treatment, the presentation of psychosocial difficulties is likely to differ from that in general pediatric settings. This, coupled with the frequent need for prolonged hospitalization in childhood cancer, means that that there may be differences in medical and nursing professionals' perceptions of psychosocial issues and interventions in pediatric oncology. In addition, there is a lack of Irish research investigating either physicians' or nurses' perspectives. This, along with the limited number of nursing studies in this area internationally, further supports the need for this study.

The purpose of this study was therefore to investigate physicians' and nurses' perceptions and awareness of psychosocial issues in pediatric oncology. Specific objectives were to examine their

  • awareness of the psychosocial impact of childhood cancer on families,

  • knowledge of psychosocial interventions for children and their families, and

  • views of the contribution of psychosocial interventions in mitigating the impact of childhood cancer.

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