SAUSALITO, CA (ASRN.ORG) --A Nurse plays a major role in cancer care. The nurse care in cancer care focus is not only on the medical aspect but also on the emotional aspect of care. Studies investigating the nurse patient interactions have shown that such interactions involve a complex process of knowing the patient (Skilbeck et.al, 2003).Studies on the nurse experiences with cancer patients have shown the challenging nature of the cancer care highlighting the emotional nature of the care, with many nurses affected by patient situations. Studies have also brought out many factors like communication, family, symptom management and the cost of caring that strongly influence cancer care (Dunne et.al, 2005). The experience of nurses with patients receiving a cancer diagnosis based on a semi structured interviews has revealed that the nurse’s response to cancer care differs based on nurse’s attitudes and professional experience (Dunniece et al, 2000).

The psychological cancer care

The psychological care of the terminally ill cancer patients is important to address their needs.  This is because of the fact that at least a quarter of patients with advanced cancer will have a symptom of depression. The psychological symptoms includes dejection, unhappy mood, anxiety, irritability, lack of interest in everyday life, withdrawal from outside world, slow mental activity, feeling of guilt, hypochondria, loss of libido, restlessness and thoughts of suicide. Biological symptoms include sleeplessness, lack of appetite, constipation, fatigue and listlessness. However, care being focused on chemotherapy and other invasive procedures, 80% of the psychological and psychiatric morbidity goes untreated (Beadle, 2004). The awareness about the depression, the identification of symptoms, like ‘appropriate sadness’ due to the patient’s approach to death and initiation of treatment is essential for optimum nurse care. Again here, the nurse’s perception of the patient’s expressions is an important aspect of the care process.

The Communication web

The National Cancer Institute has compiled a review of the literature published from 1979 to 1990 on information, education and communication needs of patients with cancer and their families in U.S.A. The review points to the need on maximizing patient comprehension, minimising apprehension, encouraging patient participation and retention of information. The review focuses on the fact that information should be tailored to suit patient’s educational background, cultural orientation and level of comprehension. The review recommends that steps should be taken to ensure informational needs assessment as being a regular part of the comprehensive care.  The article goes to further point out that health care providers should be aware of the fact that these informational needs change in due course of the care and give scope for the patient to play an active role in his end-of-life care. But, a  study carried out with 41 breast cancer patients with qualitative grounded theory methods triangulated with the findings to the couple communication scale and state trait anxiety inventory has shown the effect of information on illness in anxiety has little effect on the anxiety relief unless reframing and empowering interventions are employed (Teasdale, 1993). Only a nurse who understands these informational needs can effectively provide comfort and care (Harris, 1998).

Nurses are ideally suited for communication about prognosis and hospice referral among patients in the advanced stage of cancer.  But there seems to be some obstacles to nurse’s communication of prognosis and referral to hospice. In a study of a total of 174 staff nurses working with such patients, the most common obstacles were found to be unwillingness of a patients of the family to accept the prognosis and hospice, non-communicative status of the patients, belief of doctor’s hesitance, nurse’s discomfort and desire on part of nurses to maintain hope among patient and patient’s families (Green et. al, 2005).  Thus, improved skills on communication of prognosis will result in more referrals and a smooth transition to hospice, according to the study.  A study on the level of awareness of prognosis in a group of cancer patients has revealed a low level of prognosis awareness (Chochinov, 2000) with 9.5% to 17% of the patients having either no awareness or partial awareness. This bring to light that all terminally ill patients are not properly communicated. A correlation analysis on the level of depression and awareness of prognosis has shown that depression is three times more in patients who have no awareness of prognosis then those who have awareness of prognosis. A comparative study of communication in end of life cancer care in three European countries has identified factors associated with problematic communication. The three components of communication evaluated in the last week of the patient’s life, viz communication between the patient and his family, communication between the patient and health care team and communication between health care professionals has shown that communication between patient and family is a more serious problem in the last week of life than the other two components (Irene et.al, 2002). A recent study has also brought to light the nursing difficulties that exist in satisfying individual requirements for information about treatment options and progress (krujver et. al 2001). An exploration of the communication between nurses and patients when cancer chemotherapy is administrated has indicated the importance of the communication that should take place during specific nursing procedures to assess patients understanding, apprehensions or feelings (Dennision, 1995).

The role of reflective practice in cancer care

Recent studies on cancer care have elucidated the role of reflective practice in cancer palliative nursing care. A reflective nurse practice based on John’s model of structured reflection with a series of questions which assists in the practice and learning through reflection has been documented (Preston, 2001). This model includes questions on why a particular health care giver responds in a particular way , consequence of the response, how he/she feels in the situation, the knowledge base of the action and the connective links to previous such situations. The study also elucidates how a caring communication with the cancer patient and family can make a difference in the comfort level of the terminally ill patient.  The importance of emotional expressions like a caring smile  that  gives the tired patient a face full of life, prompting the patient to speak about their feelings about their illness and symptoms and a loving eye contact which elicits a response of tears from the patient have been shown to relieve distress. This reflective practice model has also highlighted the importance of listening to the cancer patients and these patients have been shown to be grateful to the caring nurses for listening (Preston, 2001). The model explains the evolution of a ‘connected relationship’ from a ‘clinical relationship’ as a result of this nurse-patient communication.

Conclusions

Care for the cancer patients should have a patient centred approach considering the patients as still active dignified individuals, who can plan, manage and create some meaning out of their end life situation. Interpersonal connectedness helps in nurse’s commitment to the patient’s cause and the nurse should use her instinctive sense to decide on what is right for the cancer patient. Active listening skills helps nurse to establish a relationship and giving hope helps coping of patient distress (Green et. al, 2005). Awareness about depression, the identification of symptoms like ‘appropriate sadness’ due to the patient’s approach to death and initiation of treatment is essential for optimum cancer care. Thus, a nurse needs insight, sensitivity, effective communication skills and strategies to give what the patient needs and uphold the values of nursing care.

References 

• Dena Schulman Green et.al (2005). Nurses communication of prognosis and indications for hospice referral. American Journal of Critical Care 14: 64-70.
• Dennison S (1995).An exploration of the communication that takes place between nurse and patients, whilst cancer chemotherapy is administrated. Journal of Advanced Nursing 4(4): 227-33.
• Jill Preston (2001).Using reflective practice in palliative care. JCN online.
• Irene J. Higginson et. al (2002).Communication in End-of-life Cancer care: A comparison of Team Assessments in three European countries. Journal of Clinical Oncology.20 (17):3674-82.
• Kruijver Irma P.M. et.al (2001). Communication skills of nurse during interactions with simulated cancer patients. Journal of Advanced Nursing, 34(6); 772.
• Chochinov Harvey Max et.al (2000).Prognostic awareness and the terminally ill. Psychosomatics 41, 500-504.
• Teasdale K (1993).Information and anxiety - a critical reappraisal. J Advanced Nursing. 18(7); 1125-32.
• Dunniece et. al (2000). Nurse’s experiences of being present with a patient receiving a diagnosis of cancer. Journal of Adv. Nurs. 32 (3); 611-618.
• Skilbeck et. al (2003).Emotional support and the role of Clinical Nurse Specialists in Palliative care. Journal of Adv. Nurs 43 (5).
• Beadle (2004). Illusions in advances cancer: The effect of belief systems and attitudes on quality of life. Psychology of Oncology, 13 (1); 26-36.
• Kathleen Dunne et.al (2005).Palliative care for patients with cancer: district nurses experiences.  Journal of Adv. Nurs .50 (4); 372.

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