Development of a national position statement on cancer patient navigation in Canada.

As the landscape of cancer care in Canada evolves, oncology nursing roles are developed to enhance the patient experience and address the changing needs of patients and families. Cancer Patient Navigation (CPN), an oncology nursing role focusing primarily on person-centred care coordination and system navigation, has become integral to providing high-quality cancer care in many Canadian jurisdictions. Since 2016, a national group of oncology nursing leaders have been engaged in convening and catalyzing our understanding of the role of patient navigation in the Canadian cancer context with the purpose of developing a national position statement on CPN. In this paper, we provide a historical analysis of the development of the forthcoming Canadian Association of Nurses in Oncology (CANO) position statement on CPN. We present an analysis of participant feedback from workshops at the 2016, 2017, and 2018 conferences, and meeting minutes from the National working group over this same time period. This paper serves as a concise historical summary of the evolution of CPN in Canada while providing a template for other groups looking to develop a consensus-based position statement.

Élaboration d'un énoncé de position national sur la navigation des patients atteints de cancer au Canada.

Au Canada, le paysage des soins du cancer évolue et les infirmières en oncologie sont appelées à jouer de nouveaux rôles afin d'améliorer l'expérience des patients et des familles et de répondre à leurs besoins toujours changeants. L'un de ces rôles, la navigation des patients atteints de cancer (NPC), vise principalement à coordonner les soins centrés sur la personne et à guider les patients dans le système de santé. Dans plusieurs provinces et territoires du Canada, la navigation est devenue essentielle pour offrir des soins de grande qualité aux patients cancéreux. Depuis 2016, des chefs de file des soins infirmiers oncologiques se réunissent au sein d'un groupe national pour synthétiser leur compréhension de la navigation des patients en contexte canadien afin d'élaborer un énoncé de position national sur la NPC. Dans le présent article, nous analyserons l'historique de l'élaboration de l'énoncé de position sur la NPC que publiera prochainement l'Association canadienne des infirmières en oncologie (ACIO/CANO). Nous analyserons également les commentaires des participants aux ateliers tenus dans le cadre des congrès de 2016, 2017 et 2018, de même que les comptes rendus des réunions du groupe de travail national qui ont eu lieu pendant cette même période. Le présent article se veut un sommaire historique concis de l'évolution de la NPC au Canada, ainsi qu'un modèle pour les autres groupes aspirant à rédiger un énoncé de position consensuel.

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.

Patient and family experiences with accessing telephone cancer treatment symptom support: a descriptive study.

PURPOSE: Assess patient and family member experiences with telephone cancer treatment symptom support. METHODS: Descriptive study guided by the Knowledge-to-Action Framework. Patients and family members who received telephone support for a cancer treatment symptom within the last month at one of three ambulatory cancer programs (Nova Scotia, Ontario, Quebec) were eligible. An adapted Short Questionnaire for Out-of-hours Care instrument was analyzed with univariate statistics. RESULTS: Of 105 participants, 83 % telephoned about themselves and 17 % for a family member. Participants received advice over the telephone (90 %) and were advised to go to emergency (13 %) and/or the clinic (9 %). Two left a message and were not called back. Participants were "very satisfied" with the manner of nurse or doctor (58 %), explanation about problem (56 %), treatment/advice given (54 %), way call was handled (48 %), getting through (40 %), and wait time to speak to a nurse or doctor (38 %). The proportion "dissatisfied" or "very dissatisfied" for the above items was 4, 5, 9, 11, 10, and 14 %, respectively. Suggestions were shorter call back time, weekend access to telephone support, more knowledgeable advice on self-care strategies, more education at discharge, and shared documentation on calls to avoid repetition and improve continuity. CONCLUSIONS: Most patients and family members who responded to the survey were satisfied with telephone-based cancer treatment symptom support. Programs could improve telephone support services by providing an estimated time for callback, ensuring that nurses have access to and use previous call documentation, and enhancing patient education on self-care strategies for managing and triaging treatment-related symptoms.

Training oncology nurses to use remote symptom support protocols: a retrospective pre-/post study.

PURPOSE/OBJECTIVES: To evaluate the impact of training on nurses' satisfaction and perceived confidence using symptom protocols for remotely supporting patients undergoing cancer treatment. DESIGN: Retrospective pre-/post-study guided by the Knowledge-to-Action Framework. SETTING: Interactive workshops at three ambulatory oncology programs in Canada. SAMPLE: 107 RNs who provide remote support to patients with cancer. METHODS: Workshops included didactic presentation, role play with protocols, and group discussion. Post-training, a survey measured satisfaction with training and retrospective pre-/post-perceived confidence in the ability to provide symptom support using protocols. One-tailed, paired t-tests measured change. MAIN RESEARCH VARIABLES: Satisfaction with the workshop and perceived confidence in the ability to provide symptom support and use protocols. FINDINGS: Twenty-two workshops, 30-60 minutes each, were conducted with 107 participants. Ninety completed the survey. Compared to preworkshop, postworkshop nurses had improved self-confidence to assess, triage, and guide patients in self-care for cancer treatment-related symptoms, and use protocols to facilitate symptom assessment, triage, and care. Workshops were rated as easy to understand, comprehensive, and provided new information on remote symptom management. Some specified that the workshop did not provide enough time for role play, but most said they would recommend it to others. CONCLUSIONS: The workshop increased nurses' perceived confidence with providing remote symptom support and was well received. IMPLICATIONS FOR NURSING: Subsequent workshops should ensure adequate time for role play to enhance nurses' skills in using protocols and documenting symptom support.

Perceived factors influencing nurses' use of evidence-informed protocols for remote cancer treatment-related symptom management: A mixed methods study.

PURPOSE: To assess factors perceived to influence nurses' use of symptom protocols when providing remote management for oncology patients. METHOD: A mixed methods descriptive study was guided by the Knowledge-to-Action Framework. In 2013, 8 focus groups and 7 interviews were conducted with 49 nurses or patients/family members in three ambulatory oncology programs within different provincial healthcare systems. Role-play with a protocol was used during nurse focus groups/interviews. Nurses who provided remote symptom support received a survey. Data was triangulated using thematic analysis guided by the Ottawa Model of Research Use. RESULTS: Over 90% of nurses provide telephone support during regular hours only. These symptom protocols were being used by 14% of nurses at one program. Nurses rated the protocols positively for content and format (>85%) but 20% indicated too complex. Protocol facilitators were systematic approach, comprehensive, and evidence-based. Protocol barriers were too long, not for symptom clusters, and inadequate space for documenting. To facilitate use, nurses need to enhance their knowledge (73%) and skills (58%), get access to resources, and obtain performance feedback. Nurse barriers included the learning curve, being unaware of protocols, and feeling tied to a script. Organizational barriers were communication challenges with patients, lack of electronic charting, and no clear direction to use them (54%). CONCLUSIONS: Several barriers and facilitators were perceived to influence the use of symptom protocols. Nurses and patients/family members identified similar factors. Interventions are needed to overcome barriers to nurses using the protocols such as education, clear organizational mandate, and integration with documentation.

Remote symptom support training programs for oncology nurses in Canada: an environmental scan.

The overall aim of this study was to explore current remote symptom support training programs provided to nurses in ambulatory oncology programs across Canada, using a survey-methods environmental scan. Of 36 delivered invitations, 28 programs responded (77.8%) representing 10 provinces. Of 25 programs that offer telephone symptom support, 17 provide symptom support training, seven do not, and one did not say. Seven programs shared training materials with the investigators and elements of training included: symptom management guidelines (n = 6), telephone triage process/principles (n = 5), competent telephone practices (n = 4), documentation (n = 4), professional standards (n = 3), role-play (n = 3), communication skills/etiquette (n = 3), and monitoring quality (n = 1). Formats included: presentations (n = 3), paper-based resources (n = 3), or e-learning modules (n = 1). No training programs were rigorously evaluated. Training in telephone nursing symptom support across oncology programs is variable. Opportunities exist to identify core competencies and evaluate if training programs enhance delivery of remote cancer symptom support.

Managing symptoms during cancer treatments: evaluating the implementation of evidence-informed remote support protocols.

BACKGROUND: Management of cancer treatment-related symptoms is an important safety issue given that symptoms can become life-threatening and often occur when patients are at home. With funding from the Canadian Partnership Against Cancer, a pan-Canadian steering committee was established with representation from eight provinces to develop symptom protocols using a rigorous methodology (CAN-IMPLEMENT©). Each protocol is based on a systematic review of the literature to identify relevant clinical practice guidelines. Protocols were validated by cancer nurses from across Canada. The aim of this study is to build an effective and sustainable approach for implementing evidence-informed protocols for nurses to use when providing remote symptom assessment, triage, and guidance in self-management for patients experiencing symptoms while undergoing cancer treatments. METHODS: A prospective mixed-methods study design will be used. Guided by the Knowledge to Action Framework, the study will involve (a) establishing an advisory knowledge user team in each of three targeted settings; (b) assessing factors influencing nurses' use of protocols using interviews/focus groups and a standardized survey instrument; (c) adapting protocols for local use, ensuring fidelity of the content; (d) selecting intervention strategies to overcome known barriers and implementing the protocols; (e) conducting think-aloud usability testing; (f) evaluating protocol use and outcomes by conducting an audit of 100 randomly selected charts at each of the three settings; and (g) assessing satisfaction with remote support using symptom protocols and change in nurses' barriers to use using survey instruments. The primary outcome is sustained use of the protocols, defined as use in 75% of the calls. Descriptive analysis will be conducted for the barriers, use of protocols, and chart audit outcomes. Content analysis will be conducted on interviews/focus groups and usability testing with comparisons across settings. DISCUSSION: Given the importance of patient safety, patient-centered care, and delivery of quality services, learning how to effectively implement evidence-informed symptom protocols in oncology healthcare services is essential for ensuring safe, consistent, and effective care for individuals with cancer. This study is likely to have a significant contribution to the delivery of remote oncology services, as well as influence symptom management by patients at home.

The breast cancer patient navigation kit: development and user feedback.

Our interdisciplinary team developed a written cancer patient education tool, the Breast Cancer Navigation Kit, to respond to the information needs of patients and family members and that meet patient literacy levels. A literature review and a focus group provided content development for four modules: "About Breast Cancer," "Body-Mind-Spirit," "After Treatment Ends," and "Practical Information." An evaluation by 31 women showed the kit to be easy to understand, very useful, and informative. However, all agreed that it could not replace the dialogue with health care professionals. An interdisciplinary approach involving patient feedback is key to develop appropriate patient education tools.

Intervention patterns of pivot nurses in oncology.

The Pivot Nurse in Oncology (PNO) is a health care professional dedicated to providing patients with cancer and their families with continuing and consistent supportive care throughout the care trajectory. The purpose of this paper is to describe the variation and frequency of nursing interventions delivered by 12 PNOs at our health centre. An administrative analysis over a three-year period revealed a total of 43,906 interventions that were grouped into 10 categories. This analysis provided a description of the intervention frequency and these interventions were further collapsed into the four role functions of the PNO. Coordination/continuity of care and the assessment of needs and symptoms were identified as the dominant practice domains of the PNO in the professional cancer navigator role.

Impact of a pivot nurse in oncology on patients with lung or breast cancer: symptom distress, fatigue, quality of life, and use of healthcare resources.

PURPOSE/OBJECTIVES: To examine the impact on continuity of nursing care delivered by a pivot nurse in oncology to improve symptom relief and outcomes for patients with lung or breast cancer. DESIGN: Randomized controlled trial in which participants were randomly assigned to an intervention group (n = 93) with care by a pivot nurse in oncology and usual care by clinic nurses or to a control group (n = 97) with usual care only. SETTING: Three outpatient ambulatory oncology clinics in a large university health center in Quebec, Canada. SAMPLE: 113 patients with lung cancer and 77 patients with breast cancer. METHODS: Participants in both groups completed the Symptom Distress Scale, Brief Fatigue Inventory, and Functional Assessment of Cancer Therapy Scale-General version 4 at eight intervals over six months. Healthcare usage was evaluated through a review of hospital records. MAIN RESEARCH VARIABLES: Symptom distress, fatigue level, quality of life, and healthcare usage. FINDINGS: Researchers found no significant differences in symptom distress, fatigue, quality of life, and healthcare usage between groups. CONCLUSIONS: The new nursing role did not have an impact on the patient outcomes under study. IMPLICATIONS FOR NURSING: Experienced nurses with specialized knowledge of oncology symptom assessment and management may reduce the symptom burden experienced by ambulatory patients with breast or lung cancer during active treatment.

Translating instruments into other languages: development and testing processes.

Cross-cultural influences affect perceptions and health practices, which are 2 areas of nursing concern. Culturally sensitive assessment instruments are needed, but many challenges exist in obtaining valid and reliable measurement. Translating questionnaires for cross-cultural research is fraught with methodological pitfalls related to colloquial phrases, jargon, idiomatic expressions, word clarity, and word meanings. It cannot be assumed that a particular concept has the same relevance across cultures. Simply translating an English version word-for-word into another language is not adequate to account for linguistic and cultural differences. Ideally, the perspectives of people from the culture about the concept of interest should be studied first, but often a practical alternative is to find and translate a tool developed in another culture. The purpose of this article is to describe important considerations in conducting translation for equivalence, types of equivalence, and strategies to translate instruments that promote equivalence and how to test the translated version for equivalence. These concepts and strategies are illustrated by describing the translation process of Hilton's Uncertainty Stress Scale into French and the use and testing of the French version with a French Canadian sample in Skrutkowski's study of perceived uncertainty in adult survivors of cancer.