Recognizing Distress in Cancer Patients in Day Hospital, by Trained Nurses vs. Non Trained Nurses: A Pilot Study

1. Introduction

Cancer can significantly impact all aspects of the lives of patients and their families, including psychological, affection, sexual, and family relations. The most frequent emotional reaction in cancer patients is psychological distress. Distress has been defined as “an unpleasant emotional experience that can interfere with how a patient deals with cancer itself, with its physical symptoms and with the therapy”; distress can be characterized by normal feelings of vulnerability, sadness, and fear or by symptoms that are more indicative of a psycho-pathological problem [1,2]. Between 30 and 40% of cancer patients, throughout the different phases of the disease, experience various levels of distress, while approximately 15-20% show symptoms that are insufficient to diagnose a full-blown psychological disorder but which do have consequences for the patient’s health and social relationships [3,4]. This psychological framework presents itself as an independent factor in worsening the quality of life [5], increasing the risk of psychological distress, reducing treatment adherence, altering the doctor-patient relationship, prolonging recovery and hospitalization times, reducing the biological effectiveness of therapy, decreasing survival rates and increasing the risk of disease recurrence [6,7]. To quickly identify psychological distress, we have recommended the use of rapid tools. The guidelines developed by the National Comprehensive Cancer Network (NCCN) for Distress Management [2]are particularly well. The Distress thermometer, the tool used in the pilot study, has been validated and applied to all cancer patients in all stages of the disease and different cultural contexts [8]. Although the value of routine screening for distress has been widely documented [9], numerous studies have highlighted the difficulty that healthcare professionals have in detecting psychological problems and distress, often due to a lack of specific training on these aspects [10,11]. Among healthcare workers, the nurse plays a fundamental role in supporting the emotional well-being of patients. In fact, in addition to clinical skills, which include administering medications, monitoring vital signs, wound management, etc, nurses must possess communication and empathy skills. A crucial aspect of nursing skills is the ability to build a trustful relationship with patients, listening to and addressing their emotional needs, as they are always in close contact with them throughout the various stages of the diagnostic and therapeutic process. Furthermore, for many patients, it may be easier to relate to a nurse rather than to other healthcare workers. In this regard, the literature emphasizes the role of the nurse in the monitoring of distress [12] and in the interview aimed at identifying psychic discomfort [13]. When distress is detected, sending the patient for a psychosocial consult is often insufficient [14]. It is important for a healthcare unit treating cancer to be trained on distress to allow for timely recognition and management and to be able to refer the patients for a psycho-oncological consult when necessary. Considering that nurses play a crucial role in improving the health of the patients, not only regarding the disease, their physical conditions, and treatment but also concerning their emotional, mental, and social well-being [15], it is necessary to train the right healthcare professionals [16-18]. Although the value of routine distress screening has been widely documented [9], there is still a lack of data regarding the skills needed to administer the screening, as well as an understanding of the complexity of its implementation in different clinical contexts. The objective of this study was to assess the impact of the training of nursing staff on the detection of distress and on the timely referral of patients for a Psycho-oncology consult.

2. Materials and Methods

2.1. Design

We conducted a blind, random, descriptive, monocentric pilot study.

2.2. Population and Setting

The sample was made up of patients recruited at the Day Hospital 1 (DH1) of the IFO, National Institute for Cancer Regina Elena of Rome (IRE), and nursing staff working in the DH. The criteria for inclusion of patients were being ≥ 18 years of age, having a diagnosis of histologically confirmed cancer, undergoing chemotherapy treatment at the DH1 of the aforementioned facility, being available for psychological counseling, and being willing to adhere to the study (informed written consent). Patients with cognitive impairment or pathological conditions that could be an obstacle to their active participation in the study were excluded. The inclusion criteria for nurses were to be employed at the DH1, to be available to participate in a one-month training course, and to have not participated in any training courses on communication skills in the last two years. The random assignment of nurses to a training group and not sharing information with the patients made it possible to evaluate if there were any behavioral biases of the nurses during the study, as well as avoiding that knowledge of this information could influence the patients during the interviews conducted by the nurses.

2.3. The Measurement Tools

The tools used were the following: a form for the collection of socio-demographic data (age, education, marital status, employment, family members) and clinical data of patients (previous oncological therapies, ongoing therapy, start date of therapy, follow-up in DH1, use of psychotropic drugs); the Distress Thermometer (DT) and its List of Problems (PL). The DT is a self-report tool used to detect distress levels and associated issues; it measures distress on a scale from 0 (no distress) to 10 (severe distress). Recommended cut-off scores for identifying clinically significant distress vary according to the objectives of the screening [19,20]. Boyes [21] identified a cut-off of 4 to identify patients with a significant degree of distress. The PL consists of a list of problems that patients can tick to identify which ones contribute to increasing their level of distress. The questions asked are related to physical health (e.g., constipation, pain, fatigue), emotions (e.g., concern, sadness), possible practical problems (e.g., transportation), family problems (e.g., caring for family/children), and spiritual/existential problems. A VAS scale of 1 to 10 was also used to evaluate whether the referral of the patient for a psychology consult by the nurse was appropriate or inappropriate. The cut-off in identifying an appropriate referral is 4 (appropriate referral if the VAS>4). At the end of the training program, a satisfaction survey was issued to the nurses to measure the quality of the training received.

2.4. Phases of the Study

2.4.1. PHASE 1°: Training

In the first phase, the DH1 nursing staff participating in the study were randomly divided into two groups, one that would be trained and the other that would not be trained. Group F was made up of nurses "trained" in communication and relational skills needed to properly detect the emotional distress in cancer patients. Group NF was made up of "untrained" nurses, those who did not receive the training. The training for group F was conducted by two qualified psycho-oncologists, who followed a theoretical and experiential methodology: the course was made up of two parts, a theoretical part lasting 3 hours and an experiential part consisting of 3 training sessions lasting 2 hours each. The theoretical part included an oral presentation where the trainers shared up-to-date scientific data related to the study itself. To allow for active participation and communication, the information was sent to the participants 5 days in advance of the training session. The experiential part included group discussions on clinical cases, role-playing, and gathering of feedback from the participants. The course was held over an entire month, on days scheduled in advance by the DH1 nursing coordinator and shared in advance with the nursing staff to ensure both the participation in the training event by those who had been selected and also to guarantee the continuity of patient care. Nurses from both groups were informed about the location of the meeting with the patients and the dates planned for the data collection. They were also taught how to assess the adequacy of the patient’s score on the Distress Thermometer (DT) and Trouble List (PL).

2.4.2. 2°. PHASE: Enrollment/Patient Management

In the second phase of the study, the nurses involved enrolled the patients who met the inclusion criteria, explaining both the objectives of the survey and how the data would be collected. The patients were asked to carefully read the informed consent form to ensure that they had all the information needed when deciding if to participate in the study or not. The patients were also randomly divided into two groups (group A and Group B), the randomized list was generated electronically and with a ratio of 1:1. Group A was made up of patients who were given the questionnaires by the trained nurses; Group B was made up of patients who were given the questionnaires by untrained nurses. Indicative days were identified for the enrollment of patients, ensuring the presence on the shift of both the trained and non-trained nurses so that they could properly explain the objectives of the study and facilitate the meeting with the nurse in the dedicated room in DH1. As previously pointed out, the patients were not told if the nurse they would be dealing with had been trained or not to avoid that this information could influence them during the interview. Patients were given the DT and the socio-demographic and clinical data collection form, which they were asked to fill out in a dedicated quiet room of the DH1, far from any disturbing elements. Once the questionnaires had been filled in, the tools were collected by the nurse, who then studied the DT questionnaire and had a brief meeting with the patient (in the dedicated room) to evaluate the congruity of the score given by the patient and then based on their interpretation of the results they labeled the questionnaire with either "AP" (appropriate) or "NAP" (not appropriate), to differentiate between those patients that according to them needed to be sent to Psychology for a consult or not.

2.4.3. 3°. PHASE: Interview with the Psycho-Oncologist

In the last phase of the study, all patients, regardless of the nurse’s assessment, were interviewed by the psycho-oncologist. The interview was scheduled based on the availability of both the patient and the psycho-oncologist. The psycho-oncologist used a VAS scale (from 1 to 10) to determine if the referral made by the nurse was appropriate or not. The psycho-oncologists were also kept in the dark on whether the nurse referring the patient had been trained or not. Before the questionnaires were administered, each nurse and patient participating in the study was assigned an identification code to allow the researchers to trace the data collection/analysis back to the relevant group.

2.5. Statistical Analysis

According to the study design methodology, descriptive statistics were used to summarize relevant information about the study and presented as mean and relative standard deviation (SD) for continuous variables and as frequencies and percentage values for categorical variables. Concordance between psycho-oncologist and nurse choice regarding the referral of patients for a psychological consult was evaluated by using Cohen’s K Statistic (K). A p-value <0.05 was considered statistically significant. Statistical analyses were performed with SPSS 29.0 software (SPSS, Chicago, IL).

3. Results

Twenty (20) patients were recruited, ten (10) of whom were randomly assigned to the group of trained nurses and ten (10) to the group of untrained nurses. Four (4) nursing units were involved, two (2) for each group, to limit the variability in the evaluation. The sample of patients consisted predominantly of men (60%), married (50%), with a medium-high level of education (55%) who work as employees (35%) (Table 1).

The patients had different oncological pathologies and underwent both surgical treatments (70%) as well as chemotherapy (60%) (Table 1). The patients had an average score of 5 on the DT and emotional problems mainly related to fear and concern (55%), nervousness (50%), and sadness (40%), and the physical problems were main issues of fatigue (75%), memory (40%), tingling hands and feet and low self-esteem (35%) (Table 2).

The rough correlation between psycho-oncologist and nurse in identifying patients in need of a psychological consult shows that for 12 out of 20 patients examined (60%), the two professionals equally understood their real needs, indicating for 9 of them the need for a referral and three no referral. Despite this, Cohen’s K statistic shows a poor overall correlation (Table 3, K=0.12, p=0.539).

We evaluated the correlation by overlaying the training status of the nurses. For trained nurses, we observed that for seven patients out of 10 (70%), the two professionals identified their real needs in the same way; however, the correlation was only slight, with a K value equal to 0.35 (p= 0.260) (Table 4).

Finally, with regards to the group of untrained nurses, only five patients (50%) of the two professionals agreed on their need for a psychology consult: in fact, the correlation assessed with K was even lower than would have been expected for the case at hand, with a value of -0.09 (p= 0,778) (Table 5)

In general, although the K statistic was never statistically significant and showed a weak overall correlation, our findings seemed to indicate that the introduction of a training course for nurses generated a greater awareness of the needs of patients, optimizing the support service of the psycho-oncologist given that they would only be sent those who were really in need of a consult.

The nurses participating in the training expressed a high level of satisfaction (Table 6).

4. Discussion

The objective of the study was to assess the impact of the training of nursing staff in the detection of distress and the appropriateness of the patient’s referral for a Psycho-oncology consult. The Nurse has an important role in the patient’s care, as they are constantly in contact with them at all stages of their journey, and therefore, they are more accessible to patients than other healthcare professionals. The nurse plays a central role in the humanization of care. Through specialized training, the nurse can help detect psychological distress and psycho-social needs of patients on time [22]. Nurses, however, often experience discomfort in treating psycho-social issues because they do not know how to deal with these topics with patients [23]. Previous studies have shown that specific and ongoing training of health workers improves the rate of success of the screening [9,24-27]. The results of our pilot study suggest that specialized training ensures appropriate referral of patients for Psycho-oncological consults. A greater success rate in referring patients for consults by trained nurses versus untrained nurses confirms the effectiveness of training in improving the skills and awareness of health workers. Early and appropriate detection of Distress can reduce the level of anxiety in cancer patients as well as the overall cost of health care [28,29]; it can also improve adherence to chemotherapy treatment [30], hormone therapy [31], quality of life [32] , and survival time [33]. Targeted training becomes the key element in acquiring the skills necessary for the screening of Distress and to enable nurses to know what to look for to refer patients for a Psycho-oncology consult when appropriate. The results of our study also showed that the participating nurses expressed a high level of satisfaction with the training program itself. This can be attributed to the fact that the content of the training met the needs of the nurses, both from a cognitive and clinical perspective, by dealing with common problems related to psychological distress in cancer patients. In addition, the experiential part of the course, which included group discussions and role-playing, [34] allowed participants to share their experiences and elaborate their emotions with the support of experienced psycho-oncologists [35-37]. Patients involved in our study showed an average level of psychological distress of (5), reflecting similar results to those of recent literature [38]. A significant percentage of the sample showed emotional as well as physical problems, emphasizing the influence that psycho-social issues can have on cancer treatment. The ability of nurses to make appropriate referrals could increase the number of patients referred on time for a psycho-oncological consult. The psycho-social problems of patients must be recognized and managed as early on in treatment as possible, and with the right referrals on behalf of the nurses, this is possible. The DT can help nurses with this task, but the implementation of the tool alone is not enough, it is essential to properly train health professionals, as demonstrated also by our findings and by other existing studies [26,39,40]. These findings suggest that training on the psychological aspects of cancer patients can significantly improve the care they receive. However, further studies are needed to assess the long-term effectiveness of the training. Future research, besides studying the effects of the screening for detecting distress, should also study the desire of patients to be sent for the consult and the use of the treatment versus those that do not follow it. Qualitative studies could deepen the understanding as to why some patients do not accept the referral for a psycho-oncological consult.

Limitations of the Study

The pilot study has some limitations. The monocentricity and the small size of the sample make the results non-generalizable. Moreover, the absence of a control group reduces the ability to attribute results solely to the training received. In order to measure the effectiveness of implementing the training, a randomized and controlled trial could provide greater methodology robustness.

5. Conclusions

The results of this pilot study highlight the importance of investing in psycho-oncology training courses for nurses to ensure advanced competence. Such training not only improves nurses' professional skills but also helps reduce discrepancies in patient assessments and referrals to psycho-oncology consultations. The implementation of this training model would favor an overall improvement in the psychological well-being of patients and optimize the effectiveness of cancer treatment, thus ensuring greater help for the patient.