Toward equitably high-quality cancer survivorship care.

Although models of cancer survivorship care are rapidly evolving, there is increasing evidence of health disparities among cancer survivors. In the current context, Canada's survivorship care systems privilege some and not others to receive high-quality care and optimize their health outcomes. The aim of this study was to improve survivorship care systems by helping clinicians and decision makers to a better understanding of how various psychosocial/political factors, survivors' health experiences and health management strategies might shape the development of and access to high-quality survivorship care for Canadians with cancer. Using a nursing epistemological approach informed by critical and intersectional perspectives, we conducted a three-phased Interpretive Description study. We engaged in critical textual analysis of documentary sources, a secondary analysis of interview transcripts from an existing database, and qualitative interviews with 34 survivors and 12 system stakeholders. On the basis of these data, we identified individual, group, and system factors that contributed to gaps between survivors' expected and actual survivorship care experiences. By understanding what shapes survivorship care systems and resources, we help illuminate and unravel the complex nature of the issue, supporting clinicians and decision makers to find multi-layered approaches for equitably high-quality survivorship care.

Building and sustaining a postgraduate student network: The experience of oncology nurses in Canada.

Networking with individuals on a similar journey through graduate studies has been identified as an important influence in the experience of doctoral and postdoctoral students. Through the Board of Directors of the Canadian Association of Nurses in Oncology/Association canadienne des infirmières en oncologie (CANO/ACIO), student members were encouraged to establish a Doctoral Student Network (DSN) that would enable a connection through education and common interest in oncology and cancer care. Since its inception, the DSN has been dynamic in how it has addressed the evolving needs of members and in providing development opportunities to group members. To uncover and describe key aspects of its evolution, a document analysis was undertaken to reveal themes pertaining to capacity development and leadership voice as paths to leadership for DSN members. The results of this study suggest that the DSN provides a supportive environment for postgraduate nurses across Canada to connect with others in their peer group to foster engagement in educational, professional, and scholarly activities, as well as highlighting opportunities for other professional organizations interested in establishing a support network for graduate student members.

Global perspectives on cancer survivorship: From lost in transition to leading into the future.

In the decade since the Institute of Medicine's 2006 landmark report, entitled From cancer patient to cancer survivor: Lost in transition, cancer survivorship increasingly has become a distinct phase in the cancer journey. While much progress has been made toward creating a system of care that optimally addresses survivors' needs, significant gaps remain. An international symposium to discuss and explore global challenges in cancer survivorship care was held at the Canadian Association of Nurses in Oncology (CANO/ACIO) conference in Calgary, Alberta, in October 2016. In this paper, we summarize presentations from that symposium, exploring cancer survivorship care from Canadian, American, and International perspectives, and describing challenges, issues and gaps. Strategies are also discussed for oncology nurses, individually and collectively, to provide future leadership in shaping survivorship care to be more person centered and equity oriented.

Qualitative assessment of information and decision support needs for managing menopausal symptoms after breast cancer.

PURPOSE: For breast cancer (BrCa) survivors, premature menopause can result from conventional cancer treatment. Due to limited treatment options, survivors often turn to complementary therapies (CTs), but struggle to make informed decisions. In this study, we identified BrCa survivors' CT and general information and decision-making needs related to menopausal symptoms. METHODS: The needs assessment was informed by interpretive descriptive methodology. Focus groups with survivors (n = 22) and interviews with conventional (n = 12) and CT (n = 5) healthcare professionals (HCPs) were conducted at two Canadian urban cancer centers. Thematic, inductive analysis was conducted on the data. RESULTS: Menopausal symptoms have significant negative impact on BrCa survivors. Close to 70 % of the sample were currently using CTs, including mind-body therapies (45.5 %), natural health products (NHPs) and dietary therapies (31.8 %), and lifestyle interventions (36.4 %). However, BrCa survivors reported inadequate access to information on the safety and efficacy of CT options. Survivors also struggled in their efforts to discuss CT with HCPs, who had limited time and information to support women in their CT decisions. Concise and credible information about CTs was required by BrCa survivors to support them in making informed and safe decisions about using CTs for menopausal symptom management. CONCLUSIONS: High quality research is needed on the efficacy and safety of CTs in managing menopausal symptoms following BrCa treatment. Decision support strategies, such as patient decision aids (DAs), may help synthesize and translate evidence on CTs and promote shared decision-making between BrCa survivors and HCPs about the role of CTs in coping with menopause following cancer treatment.

Building qualitative study design using nursing's disciplinary epistemology.

AIM: To discuss the implications of drawing on core nursing knowledge as theoretical scaffolding for qualitative nursing enquiry. BACKGROUND: Although nurse scholars have been using qualitative methods for decades, much of their methodological direction derives from conventional approaches developed for answering questions in the social sciences. The quality of available knowledge to inform practice can be enhanced through the selection of study design options informed by an appreciation for the nature of nursing knowledge. DESIGN: Discussion paper. DATA SOURCES: Drawing on the body of extant literature dealing with nursing's theoretical and qualitative research traditions, we consider contextual factors that have shaped the application of qualitative research approaches in nursing, including prior attempts to align method with the structure and form of disciplinary knowledge. On this basis, we critically reflect on design considerations that would follow logically from core features associated with a nursing epistemology. IMPLICATIONS FOR NURSING: The substantive knowledge used by nurses to inform their practice includes both aspects developed at the level of the general and also that which pertains to application in the unique context of the particular. It must be contextually relevant to a fluid and dynamic healthcare environment and adaptable to distinctive patient conditions. Finally, it must align with nursing's moral mandate and action imperative. CONCLUSION: Qualitative research design components informed by nursing's disciplinary epistemology will help ensure a logical line of reasoning in our enquiries that remains true to the nature and structure of practice knowledge.

Implementation of Symptom Protocols for Nurses Providing Telephone-Based Cancer Symptom Management: A Comparative Case Study.

BACKGROUND: The pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) team developed 13 evidence-informed protocols for symptom management. AIM: To build an effective and sustainable approach for implementing the COSTaRS protocols for nurses providing telephone-based symptom support to cancer patients. METHODS: A comparative case study was guided by the Knowledge to Action Framework. Three cases were created for three Canadian oncology programs that have nurses providing telephone support. Teams of researchers and knowledge users: (a) assessed barriers and facilitators influencing protocol use, (b) adapted protocols for local use, (c) intervened to address barriers, (d) monitored use, and (e) assessed barriers and facilitators influencing sustained use. Analysis was within and across cases. RESULTS: At baseline, >85% nurses rated protocols positively but barriers were identified (64-80% needed training). Patients and families identified similar barriers and thought protocols would enhance consistency among nurses teaching self-management. Twenty-two COSTaRS workshops reached 85% to 97% of targeted nurses (N = 119). Nurses felt more confident with symptom management and using the COSTaRS protocols (p < .01). Protocol adaptations addressed barriers (e.g., health records approval, creating pocket versions, distributing with telephone messages). Chart audits revealed that protocols used were documented for 11% to 47% of patient calls. Sustained use requires organizational alignment and ongoing leadership support. LINKING EVIDENCE TO ACTION: Protocol uptake was similar to trials that have evaluated tailored interventions to improve professional practice by overcoming identified barriers. Collaborating with knowledge users facilitated interpretation of findings, aided protocol adaptation, and supported implementation. Protocol implementation in nursing requires a tailored approach. A multifaceted intervention approach increased nurses' use of evidence-informed protocols during telephone calls with patients about symptoms. Training and other interventions improved nurses' confidence with using COSTaRS protocols and their uptake was evident in some documented telephone calls. Protocols could be adapted for use by patients and nurses globally.

Evaluating the outcomes of complex nursing initiatives: Insights from the CANO/ACIO National Strategy for Chemotherapy Administration Project.

Because nursing interventions are typically complex and dynamic, evaluating their impact upon care and care systems is a notoriously daunting challenge. Nursing organizations seeking to evaluate the impact of their efforts are frequently frustrated by the gap between the evaluation research ideal and their available resources. In this paper, we describe a practical and manageable process developed to address such an evaluation challenge. Using a three-step inquiry approach, supported by modest organizational funding and a realistic level of voluntary member time, we were able to generate a meaningful understanding of intersecting outcomes arising from the implementation of CANO/ACIO's National Strategy for Chemotherapy Administration. On the basis of our experience, we see considerable merit in both process and outcomes of this form of targeted evaluation.

Breast cancer survivors' perspectives on a weight loss and physical activity lifestyle intervention.

PURPOSE: The purpose of this study is to qualitatively describe the experiences of breast cancer survivors who took part in a successful 24-week lifestyle intervention aimed at weight loss. The aim was to inform future study designs and lifestyle interventions. METHODS: Nine women who completed the lifestyle intervention took part in either a focus group or telephone interviews with trained facilitators who were not involved in the delivery of the intervention. Interviews were transcribed verbatim and thematic analysis was conducted. RESULTS: Women appreciated the group-based nature of the program, the presence of other breast cancer survivors, and the safe and supportive environment provided by program leaders. The intervention supported women in reframing their dietary habits, and the exercise component had unexpected benefits on their psychological wellbeing. The logistics of fitting the intervention into busy work and family schedules was a challenge experienced by most women. Recommendations for future programming included offering the intervention to all survivors immediately following adjuvant treatment, integrating participants' social networks into the program and including a maintenance phase for sustainability of healthy behaviors. CONCLUSION: This qualitative study provides insight into breast cancer survivors' experiences in a group-based lifestyle intervention and offers suggestions for the development of future lifestyle programming in cancer care.

Response to "Rethinking assumptions about cancer survivorship": a nursing disciplinary perspective.

In response to our social science and humanities colleagues' paper, Rethinking Assumptions about Cancer Survivorship (Ristovski-Slijepcevic & Bell. [2014]. CONJ, 24(3), p. 166), we offer a nursing disciplinary perspective on some of the dominant messages purported to underpin cancer survivorship. We illuminate points of disjuncture within their paper, using nursing's disciplinary lens to describe and explain the complexities inherent in the cancer survivorship experience and its implications for clinical practice. Opportunities for collaboration with our social science and humanities colleagues are outlined to foster synergistic knowledge development that will, ultimately, improve the care of those living with, through, and beyond cancer.

"I can't sleep!": gathering the evidence for an innovative intervention for insomnia in cancer patients.

Sleep-wake disturbances, in particular insomnia, are experienced by 30%-75% of oncology patients, yet no effective interventions have been designed to address this distressing symptom in the ambulatory setting. In response to an identified gap in care, I share the development and evaluation of an innovative sleep intervention designed specifically for the ambulatory setting. Preliminary findings, as well as an informative blueprint for conducting point-of-care research, are described. As a "bedside" nurse it is possible and within our moral imperative and social justice mandate to take action to find evidence-informed solutions to improve care for populations of patients experiencing gaps in care. The "I" used throughout the article refers to the lead author Surya.

Complementary and alternative medicine (CAM) use in advanced cancer: a systematic review.

This systematic review synthesizes knowledge about the use of complementary and alternative medicine (CAM) among advanced cancer patients. EBSCO and Ovid databases were searched using core concepts, including advanced cancer, CAM, integrative medicine, and decision-making. Articles included in the final review were analyzed using narrative synthesis methods, including thematic analysis, concept mapping, and critical reflection on the synthesis process. Results demonstrate that advanced cancer patients who are younger, female, more educated, have longer duration of disease, and have previously used CAM are more likely to use CAM during this stage of illness. Key themes identified include patterns of and reasons for use; and barriers and facilitators to informed CAM decision-making. Knowledge regarding the use of CAM in advanced cancer remains in its nascent stages. Findings suggest a need for more research on understanding the dynamic process of CAM decision-making in the advanced cancer population from the patients' perspective.

Addressing Complementary and Alternative Medicine Use Among Individuals With Cancer: An Integrative Review and Clinical Practice Guideline.

Complementary and alternative medicine (CAM) use is common among individuals with cancer, but many choose not to discuss CAM with health-care providers (HCPs). Moreover, there is variability in the provision of evidence-informed decision making about CAM use. A clinical practice guideline was developed to standardize how oncology HCPs address CAM use as well as to inform how individuals with cancer can be supported in making evidence-informed decisions about CAM. An integrative review of the literature, from inception to December 31, 2018, was conducted in MEDLINE, EMBASE, PsychINFO, CINAHL, and AMED databases. Eligible articles included oncology HCPs' practice related to discussing, assessing, documenting, providing decision support, or offering information about CAM. Two authors independently searched the literature, and selected articles were summarized. Recommendations for clinical practice were formulated from the appraised evidence and clinical experiences of the research team. An expert panel reviewed the guideline for usability and appropriateness and recommendations were finalized. The majority of the 30 studies eligible for inclusion were either observational or qualitative, with only 3 being reviews and 3 being experimental. From the literature, 7 practice recommendations were formulated for oncology HCPs regarding how to address CAM use by individuals with cancer, including communicating, assessing, educating, decision coaching, documenting, active monitoring, and adverse event reporting. It is imperative for safe and comprehensive care that oncology HCPs address CAM use as part of standard practice. This clinical practice guideline offers directions on how to support evidence-informed decision making about CAM among individuals with cancer.

Interprofessional education about patient decision support in specialty care.

Specialty care involves services provided by health professionals who focus on treating diseases affecting one body system. In contrast to primary care - aimed at providing continuous, comprehensive care - specialty care often involves intermittent episodes of care focused around specific medical conditions. In addition, it typically includes multiple providers who have unique areas of expertise that are important in supporting patients' care. Interprofessional care involves multiple professionals from different disciplines collaborating to provide an integrated approach to patient care. For patients to experience continuity of care across interprofessional providers, providers need to communicate and maintain a shared sense of responsibility to their patients. In this article, we describe challenges inherent in providing interprofessional patient decision support in specialty care. We propose ways for providers to engage in interprofessional decision support and discuss promising approaches to teaching an interprofessional decision support to specialty care providers. Additional evaluation and empirical research are required before further recommendations can be made about education for interprofessional decision support in specialty care.