Distress Assessments Improve Psychosocial Support Referrals for HNC Patients

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A quality improvement project demonstrates that routine distress assessment using the NCCN DT/PL in patients with head and neck cancers improves referrals for psychosocial services.
A quality improvement project demonstrates that routine distress assessment using the NCCN DT/PL in patients with head and neck cancers improves referrals for psychosocial services.

In 2005, the National Academy of Medicine (NAM), formerly the Institute of Medicine, began the arduous task of evaluating the effect psychosocial factors have on the care of patients with cancer. The 2008 report, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, included recommendations for improving assessment of psychosocial distress, providing psychosocial support, and reimbursement for psychosocial services so that patients could receive holistic care.

The authors of the report noted that establishing a patient-provider partnership is critical to assessing and providing psychosocial services that can improve patient outcomes.1

The definition of distress, specific to a patient with cancer, is: a multifactorial unpleasant emotional experience of a psychological, social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.2

Distress and the inability to cope can affect a patient's quality of life, adherence to complex treatment regimens, and overall survival or return to health.1 Specifically, patients with head and neck cancer (HNC) have high levels of pretreatment distress as well as comorbid depression and anxiety.3

In addition, surgical and radiation treatments for head and neck cancers often leave patients with debilitating physical defects that affect their ability to speak, swallow, and breathe, making this patient population more vulnerable to experiencing psychosocial distress.4 Along with comorbid conditions and challenges presented by treatment, these patients are also more likely to have tobacco and alcohol abuse problems.5 As a result, patients with HNC often lack adequate coping skills and support systems.

Nursing assessment of patient distress on an inpatient surgical oncology unit at an academic medical center in the southeastern United States was found to be inadequate.

The purposes of this quality improvement (QI) project were: to collect additional evidence to support implementing a distress assessment program for patients with cancer and to suggest steps oncology nurses can take to advocate for consistent and programmatic assessment of distress in their patients. Equipped with this information, the oncology nurse will be better prepared to provide patients with the psychosocial support they need.

Plan-Do-Study-Act Method Utilized

This quality improvement project was initiated with the support of the HNC surgical team, the unit nurse manager, and the HNC program coordinator at the project site. The project director was a staff nurse on the unit and a student completing a doctoral nurse practitioner program.

The project followed a Deming's (plan-do-study-act [PDSA]) framework for QI programs and was administered on a 24-bed, surgical oncology inpatient unit. The instrument used for the intervention was the National Comprehensive Cancer Network (NCCN) distress thermometer and problem list (DT/PL), a short self-assessment instrument developed for and validated in cancer populations.

The instrument was given to surgical patients on admission to the HNC inpatient unit. The nurse reviewed patients' completed DT/PL and, if appropriate, referred patients for psychosocial support via the electronic medical record (EMR). Once a referral occurred, a psychiatric liaison nurse (PLN) provided psychosocial support services and consulted with the medical team. To assess project efficacy, the project director averaged and compared preintervention and postintervention referral rates for PLN services.

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