Int Arch Nurs Health Care ISSN: 2469-5823

• Abstract
• Keywords
• Introduction
• Aim
• Methods
• The Questionnaire
• Statistical Analysis
• Results
• Discussion
• Limitations
• Conclusion
• Acknowledgment
• Conflicts of Interest
• Ethical statement
• Figure 1
• Table 1
• Table 2A
• Table 2B
• Table 3
• References

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International Archives of Nursing and Health Care

¹Professor, PhD, RN, CNS (Psychiatric Mental Health), Tokyo Health Care University School of Nursing, Tokyo, Japan
²Professor, PhD, Tokyo Women's Medical University Graduate School of Nursing, Tokyo, Japan
³MN, RN, CNS (Oncology), Tokyo Women's Medical Hospital, Tokyo, Japan
⁴RN, Keio University Faculty of Nursing and Medical Care, Fujisawa, Japan

Abstract

Aim: We aimed to investigate the perspectives and challenges among oncology nurses in terms of 1) the assessment and care of patients' psychological needs and 2) the management of their own stress.

Method: An online questionnaire survey was conducted in Japan among 782 nurses enrolled for health professional surveys in November 2014. The questionnaire consisted of ten questions on the psychological care of cancer patients of all five categories (anxiety, anger, crisis state, how to tell children about cancer in a parent, and grief care) and two questions on nurses' own stress management, which were assessed on a Likert scale. In addition, space was given to free-text responses for difficulties in stress management at work.

Results: The valid response rate was 69.1% (540 of 782). More than half of the nurses surveyed reported that knowledge of the assessment of psychological needs of cancer patients was inadequate. In addition, more than half of the nurses were aware that correspondence was inadequate even when there was multidisciplinary cooperation in psychological care. Regarding the experience of psychological support in the presence or absence of a liaison team, significant differences were observed (p < 0.01) in the following aspects of patient support: 1) psychological crisis after the diagnosis of cancer recurrence or metastasis, including multidisciplinary cooperation; 2) anxiety; and 3) multidisciplinary collaboration in the management of anger.

Conclusion: Cooperation between multidisciplinary teams led to effective support for patients and their families when facing anxiety, anger, or psychological crisis. Thus, appropriate resource allocation and use could enhance psychological care for cancer patients as well as their families. Nurses perceived their knowledge and coping skills as insufficient for their own stress management. Creating a support system for nurses is necessary to encourage them to address stress at an early stage.

Keywords

Psycho-oncology, Oncology nursing, Nurse's stress management, Mental status assessment

Introduction

The crisis theory proposed by Aguilera [1], for which there is adequate support, is said to lead ultimately to adaptation. Crisis intervention is emergency psychological care aimed at assisting individuals in a crisis situation to restore equilibrium to their biopsychosocial functioning and to minimize the potential for psychological trauma. Crisis can be defined as one's perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person's current resources and coping mechanisms. In psycho-oncology, this process can be facilitated by an accurate assessment of a patient's circumstance when requiring psychological support; indeed, this is essential in a psychologically critical situation. It is also necessary to support the quality of life of patients in cooperation with multidisciplinary teams.

Currently, for cancer care, education regarding psychological assessment and treatment is insufficient. Previous studies in Japan and other countries have shown that 30%–40% of cancer patients suffer from psychological problems, including adjustment disorder or depression [2,3]. Cancer patients also require psychological assessment and intervention at specific times, but research has suggested that health professionals engaged in cancer care are likely to overlook conditions such as depression when psychiatric intervention is necessary, which results in insufficient assessment and care for patients [4-6].

In the management of cancer care, it is necessary to improve the care system for holistic palliative care. This will help ensure that psychological care can be provided for the distress experiences by patients and their families from the moment a diagnosis of cancer is made. Establishing a system that provides seamless care and expertise among health professionals is also needed.

Another equally important issue is that nurses often experience an emotional burden when confronting the death of patients. As health professionals in oncology, it is essential that nurses acquire the knowledge and skills to manage their own stress [4,7,8].

Hypothesis of this study is to collaborate multidisciplinary having expertise, making the psychological support for cancer patients and family, promotes the adaptation of cancer patients and their families, it is possible to improve their QOL, it can relieve the nurse stress involved in cancer care.

Aim

In this study, we aimed to investigate the perspectives and challenges among oncology nurses in terms of 1) the assessment and care of patients' psychological needs and 2) the management of their own stress.

Methods

We invited 782 nurses to participate in an online questionnaire survey from among those enrolled to receive surveys for health professionals in November 2014. Recruitment specifically targeted nurses with experience in cancer nursing and who had registered to the medical panel of survey company, INTAGE in 2014. The study was approved by the Tokyo Women's University Medical School Ethics Committee and participation was entirely voluntary. Consent was assumed when a completed questionnaire was submitted.

The Questionnaire

The questionnaire was created with reference to a literature review and previous studies [4,9-11]. It consisted of ten questions regarding the psychological care of cancer patients (anxiety, anger, crisis state, how to tell children about cancer in a parent, and grief care) and two questions on their understanding of stress management in nurses (Table 1). These 12 questions were answered using four-point Likert scales. Finally, space was given to allow free-text responses for difficulties in stress management at work (personal experiences). The content validity of the questionnaire was examined by a psychiatrist specializing in psycho-oncology, a psychiatric liaison nurse, and a nursing researcher specializing in psycho-oncology.

Statistical Analysis

Basic demographic information was collected, including gender, age, and years of experience in cancer nursing, and descriptive data was reported. The percentages of responses at each Likert point for each questionnaire item were calculated. Content analysis was performed on the free-text responses, and we summarized the content by similarity of category.

Regarding the psychological support received by cancer patients, the respondents were divided into two groups depending on the size of the medical facilities in which they worked, using a cut-off point of 500 beds. The Japanese healthcare system uses the number of beds as an important cut-off point. In hospitals with ≥ 500 beds, compared with those that have > 500 beds, there are differences in the first visit fee and the number of facilities for advanced medical care.

Hospitals with ≥ 500 beds, such as university hospitals, are considered to be advanced medical care institutions. Therefore, it was considered necessary to construct a sufficient system also psychological care. Therefore, in the present study, we investigated the cooperation of resources or recognition of nurses by the 500-bed cut-off point.

A t-test was conducted on the nurses' years of experience. Mann–Whitney U tests were conducted on the five categories in these two groups for the degree of psychological support given to cancer patients. The five categories of support were as follows: 1) patients with anxiety; 2) patients with anger; 3) patients and families in psychological crisis after being diagnosed with cancer recurrence or metastasis; 4) families who need help communicating with the son or daughter of the cancer patient, including inter-professional care; and 5) grief care for bereaved family members.

Results

Participant characteristics

The valid response rate was 69.1% (540 of 782). Among these, the predominant gender was female (90.5%) and the mean age was 37.1 years (SD = 8.3; range 22-63 years). The average experience in oncology nursing was 7.3 years. The majority of the participants were general nursing staff (86.7%), followed by chief nurses (8%), head nurses (2.6%), and clinical nurse specialists (CNSs) (2.2%).

Regarding the number of beds in facilities, we excluded nurses who recorded "No beds" or "Unknown." Of the 347 valid responses, 230 facilities (42.6%) had < 500 beds and 117 facilities (33.7%) had ≥ 500 beds. The average duration of employment was 8.6 years in facilities with ≥ 500 beds and 8.1 years in facilities with < 500 beds, and there was no significant difference in the number of years' experience in oncology nursing between the two groups by facility. Both groups were represented by mid-career nurses.

Responses to the degree of psychological support

Regarding whether nurses felt they had sufficient knowledge of the psychological assessment for cancer patients, most nurses responded "slightly disagree" to all items (anxiety, anger, crisis state, how to tell children about cancer in a parent, and grief care). The proportions responding "slightly disagree" among the 540 valid respondents were as follows: anxiety (52%), anger (60%), crisis state (54.1%), how to tell children about cancer in a parent (57.6%), and grief care (56.9 %). In contrast, the proportion who responded "slightly agree" was as follows: anxiety (35.9%), anger (28.1%), crisis state (33.9%), how to tell children about cancer in a parent (15.4%), it was grief care (20.2%).

With respect to the responses for the degree of psychological support provided to patients and families, including multidisciplinary cooperation, most of the 540 nurses also responded "slightly disagree", as follows: anxiety (50.4%), anger (60%), crisis state (54.4%), how to tell children about cancer in a parent (54.3%), and grief care (55.2 %). In contrast, the proportion who answered "slightly agree" was considerably smaller: anxiety (37.4%), anger (33.3%), crisis state (19.4%), how to tell children about cancer in a parent (15.4%), and grief care (28.5%).

Recognition of psychological support with respect to the number of beds

Regarding recognition on psychological support (with respect to the number of beds), we performed Mann-Whitney U tests to identify differences between facilities with ≥ 500 beds and those with < 500 beds in terms of all five categories (anxiety, anger, crisis state, how to tell children about cancer in a parent, and grief care). Significant differences were observed at a 1% level in the categories for support of patients with anxiety, patients with anger, and patients and families in psychological crisis after the diagnosis of cancer recurrence or metastasis. There was also a significant difference (p < 0.05) observed in support for families, such as for communicating with a son or daughter of the cancer patient, including multidisciplinary cooperation. However, there was no significant difference regarding grief care for bereaved family members who require psychological support. These data are summarized in Table 2A and Table 2B.

Facilities with ≥ 500 beds (n = 117) usually had access to the following: palliative care teams composed of palliative care physicians, full-time nurses, and pharmacists (99.1%); psychiatrists (82.1%); psychiatric liaison teams composed of psychiatrists and psychiatric CNS liaison staff (48.7%); oncology CNS (79.5%); and psychiatric CNS liaison staff (25.6%). With respect to the availability of psychological support in the presence or absence of a liaison team significant differences were observed by the size of the facility (p < 0.01) in three areas. These areas were as follows: 1) support for patients in psychological crisis after the diagnosis of cancer recurrence or metastasis, including multidisciplinary cooperation; 2) support for patients with anxiety; and 3) support for patients with anger, including multidisciplinary collaboration.

The results, better resourced facilities were able to provide better psychological support.

Sufficiency of stress management among oncology nurses

In this analysis, 61.7% of participants responded "disagree," and 74.5% responded "disagree" or "strongly disagree" to whether oncology nurses had sufficient knowledge about their own stress management. Furthermore, 53.1% of subjects responded "disagree" and 64.2% responded either "disagree" or "strongly disagree" for whether oncology nurses could manage their stress sufficiently in a stressful situation (Figure 1).

Finally, we received 102 free-text descriptions providing details about stressful experiences. From these, 106 items were identified and classified into six categories (Table 3). The most common stress descriptions were related to emotional control and coping strategies for dealing with stress, which accounted for approximately half of the responses (50 cases). This was followed by job responsibilities (20 cases), such as dealing with patients who need careful support or dealing with the death of patients. These features are, however, characteristic of oncology nursing.

Discussion

Our findings indicate that education for nurses should be enhanced to provide better assessment and care for patients with anxiety or anger and for those facing psychological crisis. This should include support for families, particularly of children whose parents are diagnosed with cancer or who are bereaved. In addition, there is a need for cooperation between multidisciplinary teams, including liaison teams, psychiatrists, and CNSs. Indeed, there inclusion was shown to be associated with effective support for patients and their families, including those with anxiety or anger, and those in psychological crisis. Thus, appropriate allocation and use of resources can enhance the psychological care of patients and their families after a diagnosis of cancer.

Nurses also reported that they lacked basic self-care skills. Therefore, we must seek to improve self-care knowledge and skills, including stress management, among nurses. Developing appropriate training to encourage nurses to address their stress at an early stage is necessary to manage their own health.As shown in Table 3, emotional control and self-management, job responsibilities, and interpersonal relationships were identified as areas where nurses might gain the most benefit from raining.

Limitations

A major limitation of this study is that the reliability and validity of the questionnaire were not tested. In addition, because the questionnaire was completed by research nurses who had registered with a medical panel company on the Internet, there is a possibility that selection bias was introduced. We obtained information from the perspective of only nurses and cannot comment on the opinions of actual cancer patients and families regarding psychological care.

Conclusion

In this study, more than half of nurses recognized that they had insufficient knowledge to assess the psychological needs of cancer patients, and more than half also felt that there was insufficient multidisciplinary cooperation in this domain. Moreover, we showed that, in facilities with a liaison team (i.e., ≥ 500 beds) there was a significant difference in favor of their use when managing anxiety, anger, and crisis states. In future research, we will need to refine the care needs of cancer patients and their families. However, in the meantime, there is a need to refine nurse education to include stress management among nurses themselves. To improve the care of cancer patients and to ensure they receive medical treatment in peace, a future challenge is to develop and evaluate nurse education programs that provide adequate skills for the assessment and care of psychological distress in cancer patients and Stress management for Oncology Nurse.

Acknowledgment

This research was supported by a Grant-in-Aid for Scientific Research (C, 26463357). The authors are grateful to the participants and the research facility.

Conflicts of Interest

There are no conflicts of interest.

Ethical statement

The study was approved by the Tokyo Women's University Medical School Ethics Committee and participation was entirely voluntary. Consent was assumed when a completed questionnaire was submitted.

References

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