A cancer diagnosis is often accompanied with many unanswered questions and concerns, leading to one of the most underestimated effects of cancer: psychosocial distress. In addition to personal and financial concerns, side effects of the disease and treatments can exacerbate the symptoms of distress. Distress is defined as “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.”1 The term was adopted in the health care setting as an alternative to terms such as depression, and its use is proven to increase effective communication with patients.1 It encompasses the full spectrum of psychological and social factors and carries less of a social stigma, making it easier for patient self-identification. In addition, the increase in options for detection and treatment of cancer has led to an increase in the number of long-term side effects that often impact a patient’s quality of life. Nurses have the opportunity to play a key role in assessing psychosocial distress in oncology patients with the use of existing screening tools at pivotal points in the patient’s treatment. This paper analyzes the research on screening for psychosocial distress and concludes with nursing implications for practice and calls for further research.
The Institute of Medicine (IOM) released an expert opinion on providing quality integrated care for the patient with cancer, focusing on psychosocial needs, and recommended that all oncology patients be provided with adequate care that meets the standards for whole body, psychosocial health care.2 When assessing a patient’s psychosocial health, routine screening for symptoms of distress is critical. Because distress can occur at any point within the patient’s care continuum, screening at both the inpatient and outpatient levels is important. Distress screening in the outpatient and clinic setting has become more widely adopted over the past few years, but many facilities still lack inpatient screening. A study focusing on inpatient oncology screening discovered high levels of psychosocial and physical distress in two-thirds of the 80 patients who participated.3 The American College of Surgeons (ACOS) Commission on Cancer (CoC) requires all cancer centers to implement routine screening for psychosocial distress as of January 2015; however, this recommendation does not delineate between inpatient and outpatient services and the definition of routine is unclear.3
In the inpatient setting, identification and treatment of co-morbid psychosocial conditions may be limited due to inadequate screening, either by the physician team or frontline nursing staff. There are several reasons why distress may go unrecognized within the health care setting. Patients with symptoms of distress often have difficulty verbalizing their concerns to their caregivers, especially in today’s fast paced health care setting.4 Furthermore, many clinicians assume that distress is a normal part of the cancer diagnosis, but do not assess for specific needs or probe for problems.4 If psychosocial needs are to be addressed in the inpatient setting, identifying patient needs and initiating appropriate interventions in a timely manner is critical. These interventions include coordination of referrals that aid in providing the patient with quality holistic care based on screening results.2
NCCN DISTRESS THERMOMETER
ACOS recommends the use of a distress-screening tool that assesses a multitude of psychosocial symptoms. A standardized screening tool should be used at routine intervals to improve the consistency of care and the overall outcome for the patient.5 By utilizing a standardized screening tool, health care providers can perform effective and timely screenings, thereby identifying at-risk patients. Even though several instruments exist for identifying psychosocial distress, the National Comprehensive Cancer Network Distress Thermometer (NCCN DT) has become one of the most widely used and verified screening tools specifically for oncology patients.1 The NCCN DT is a self-administered tool with a 0-10 thermometer scale and a 34-point problem list to help identify the areas and severity of distress patients experienced during the previous week with a sensitivity of 0.77 and specificity of 0.68.6
Buchmann demonstrated its effectiveness in his evaluation of psychosocial distress in patients with head and neck cancer.7 He concluded that utilizing this tool was helpful in identifying patients with high levels of psychosocial distress and successfully providing interventions for those patients. In another study, the NCCN DT was used to demonstrate that patients’ distress increased throughout their treatment time, and higher numbers of referrals for supportive services led to increased patient satisfaction scores.8