Nursing Care Delivery Redesign: Using the Right Data to Make the Right Decisions.

BACKGROUND: In British Columbia, the Nursing Policy Secretariat of the Ministry of Health recently issued a series of priority nursing recommendations, including team-based care delivery models. AIM: This paper will describe the data collection and analysis phase of a quality improvement initiative focused on care delivery redesign within three healthcare organizations. The focus of the care delivery redesign was a transition from total nursing care to team-based nursing care. METHODS: Our leadership-academic partnership used the Canadian Nurses Association's "Staff Mix Decision-Making Framework for Quality Nursing Care" to guide data collection and analysis on patient, nurse and organizational factors. Data were collected by nurse-led project teams using a patient needs assessment tool, surveys of nurses' scope of practice and teamwork and an environmental profile tool with nurse demographics and unit/facility-level characteristics. RESULTS: Findings from one organization's pediatric medicine and surgery units are presented in this paper. CONCLUSION: Quality improvement data provide multiple opportunities for proactive human resource planning and professional development. Resources and examples are provided to guide others' redesign efforts.

Easier Said Than Done: Keys to Successful Implementation of the Distress Assessment and Response Tool (DART) Program.

PURPOSE: Systematic screening for distress in oncology clinics has gained increasing acceptance as a means to improve cancer care, but its implementation poses enormous challenges. We describe the development and implementation of the Distress Assessment and Response Tool (DART) program in a large urban comprehensive cancer center. METHOD: DART is an electronic screening tool used to detect physical and emotional distress and practical concerns and is linked to triaged interprofessional collaborative care pathways. The implementation of DART depended on clinician education, technological innovation, transparent communication, and an evaluation framework based on principles of change management and quality improvement. RESULTS: There have been 364,378 DART surveys completed since 2010, with a sustained screening rate of > 70% for the past 3 years. High staff satisfaction, increased perception of teamwork, greater clinical attention to the psychosocial needs of patients, patient-clinician communication, and patient satisfaction with care were demonstrated without a resultant increase in referrals to specialized psychosocial services. DART is now a standard of care for all patients attending the cancer center and a quality performance indicator for the organization. CONCLUSION: Key factors in the success of DART implementation were the adoption of a programmatic approach, strong institutional commitment, and a primary focus on clinic-based response. We have demonstrated that large-scale routine screening for distress in a cancer center is achievable and has the potential to enhance the cancer care experience for both patients and staff.

Piloting an integrated education pathway as a strategy to prepare for and encourage oncology specialty certification.

Although continuing nursing education is crucial to improve professional and patient outcomes, programs in oncology nursing remain scarce, piecemeal, and focused on one modality of treatment, which limits the effectiveness of education interventions. The objectives of this paper are to describe the development and implementation of a longitudinal specialized oncology nursing education pathway program, and the evaluation results of a year-long pilot of the first stage of the program at a large university-affiliated cancer centre. Preliminary findings indicated that participants' perceived competence in health assessment and symptom management was improved after one year of enrolment in the education pathway. Next steps following this pilot, including implications for participants with regards to attaining oncology certification are also discussed.

Using Audience Response System technology and PRITE questions to improve psychiatric residents' medical knowledge.

OBJECTIVE: Interactive educational tools are thought to convey material effectively. Audience Response Systems (ARSs), in particular, have been shown to improve written test scores in several residency fields but have not been previously reported in psychiatry. Such an approach may prove a valuable tool in improving test performance and medical knowledge. METHODS: Psychiatry residents were required to attend 12 90-min review sessions throughout the summer that utilized previous Psychiatry Residency In-Training Exam (PRITE) questions and an ARS to provide immediate feedback and a stimulus for discussion. Preparation for these sessions was either unsupervised (phase I) or involved a personalized reading program for residents who scored below the 50th percentile. Data were evaluated with ANOVA and unpaired 2-tail tests. RESULTS: Overall performance on the PRITE examination improved significantly as compared to pre-intervention controls (change in score 17.0 ± SD 16.6 vs 6.4 ± 12.6, P = 0.0068). The addition of a personalized reading program did not improve raw score performance significantly beyond the improvement seen with ARS alone but did slightly improve percentile rank and STD score. CONCLUSIONS: Utilization of the interactive ARS may improve performance on PRITE examination for residents.

Model of care and pattern of nursing practice in ambulatory oncology.

BACKGROUND: The worldwide burden of cancer warrants more effective and efficient cancer care management strategies (World Health Organization, 2003). Model of ambulatory care, in particular, has tremendous implications on patient and administrative outcomes (Knight, 2007; Lynch, Marcone & Kagan, 2007; Moore, Johnson, Fortner & Houts, 2008). Nevertheless, little is known about the pattern of practices and the clinic operations in this setting. As part of the hospital's ambulatory redesign program, this survey aims to: a) review and describe existing models of ambulatory care employed by key national and international cancer centres; b) identify models or elements within the models that are appropriate to be adopted for best practice. METHODS: Semi-structured interviews with 10 senior management members at 10 centres (N = 10) were conducted. Participants were asked to describe: a) model of ambulatory care employed by their institution (e.g., scope and model of ambulatory nursing practice); and b) strategies used to manage common patient care related issues in their institutions. Interviews were recorded and analyzed according to the objectives of this survey. RESULTS: A majority of cancer centres employed models of care similar to the existing Hospital model of ambulatory care and are encountering similar challenges in care delivery. Therefore, it was not deemed appropriate to adopt any models from participating centres. CONCLUSION: It is crucial for administrators to report and share best practices to ensure high-quality care. The survey of current practice did not yield sufficient data to adequately support the implementation of any specific models at the hospital's ambulatory care settings. Nevertheless, findings from the present review support the principles proposed for the new hospital model of ambulatory care.

Exercise behaviour and attitudes among fourth-year medical students at the University of British Columbia.

OBJECTIVE: To describe the physical activity (PA) levels and counseling attitudes of Canadian undergraduate medical students. DESIGN: Online or paper survey. SETTING: The University of British Columbia (UBC). PARTICIPANTS: Fourth-year medical students at UBC from 2007 to 2010. MAIN OUTCOME MEASURES: Physical activity levels, relationship between exercise behaviour and attitudes toward counseling, and student perception of training in the area of exercise prescription. RESULTS: A total of 546 out of 883 students participated in the survey (62% response rate). Sixty-four percent of students met the Canadian Society for Exercise Physiology 2011 recommendations for PA. Attitudes toward healthy living were related to PA levels, but the rate of counseling patients about exercise was not; however, students who engaged in more strenuous PA were more likely to perceive exercise counseling as being highly relevant to future clinical practice (P = .018). Overall, 69% of students perceived exercise counseling to be highly relevant to clinical practice, but 86% thought that their training in this area was less than extensive. CONCLUSION: Fourth-year UBC medical students engage in more strenuous PA than average age-matched Canadians, which affects their attitudes toward perceived future counseling practices. Encouraging more student participation in strenuous PA and encouraging academic training in the area of exercise counseling might be important next steps in preparing future physicians to effectively prescribe exercise to their patients.

Travelling on parallel tracks: patient and physician perspectives on why women delay seeking care for breast cancer symptoms.

In the breast cancer literature, "delayed presentation" is defined as a delay of > 3 months from the self-detection of a new breast cancer symptom until presentation to a health care provider. It has been established that early detection of breast cancer is associated with better health outcomes. The purpose of this qualitative study was to explore reasons why women delay seeking care for their breast cancer symptoms by asking both women and family physicians for their perspectives. Narrative analysis was used to reveal the ways in which people make sense of their experiences and which parts of their stories are most important to them. We found differences in the explanatory narratives of women versus those of family physicians when it came to understanding delay. Suggestions to promote earlier presentation include improving physician-patient communication and encouraging physician and health care professional neutrality in making attributions about women's delay.

Models of care in outpatient cancer centers.

While rapid changes in the treatment of cancer have been driven by research-based evidence, innovations in cancer care delivery have lagged behind that seen in cancer treatment. A literature review and ten semi-structured interviews were conducted to identify models of care in the ambulatory oncology setting to be adopted by a comprehensive cancer center. Four models were identified from the literature review but none were widely recognized or adopted by administrators. Findings suggested some common themes that should be included in an optimal model of care. These themes are in support of the burgeoning efforts seen in the promotion of interprofessional education and practice for quality improvement. Unique challenges related to the contextual factors in the ambulatory oncology settings suggest quality improvement interventions should be tailored to meet the specific needs of the care facility and its workforce.

The symptom appraisal of breast cancer in the context of an intimate relationship.

The purpose of this qualitative investigation was to understand how a self-detected breast abnormality is experienced within the context of an intimate relationship. Of specific interest were spousal interactions that influenced (facilitated or impeded) timely presentation for medical evaluation. Fourteen women who were in a relationship at the time of symptom discovery and seven of their male partners were interviewed. Interview transcripts were analyzed using the grounded theory method. Tenuous Knowing and Spiral of Disclosure defined two main processes that a woman negotiated within herself in relation to her partner upon discovery of a breast change.

Cancer-related pain management: a report of evidence-based recommendations to guide practice.

OBJECTIVES: Cancer may be associated with many symptoms, but pain is the one most feared by patients. Pain is experienced by one-third of patients receiving treatment for cancer and about two-thirds of those with advanced cancers. To aid in providing quality care and pain relief for cancer patients, Cancer Care Ontario's Cancer-related Pain Management Guideline Panel conducted a systematic review of guidelines to provide evidence-based and consensus recommendations for the management of cancer-related pain to guide the practice of healthcare providers. METHODS: Published and unpublished cancer-related pain management guidelines were sought by conducting an Internet search, which included health organizations and the National Guidelines Clearinghouse, the Guideline International Network, and the McMillan Group. Also, MEDLINE searches were conducted for guidelines published between the years 2000 and May 2006. RESULTS: Twenty-five guidelines were found and the quality of each guideline was evaluated using the Appraisal of Guideline Research and Evaluation Instrument and the utility of the guideline for recommendations was assessed. Using these 2 criteria, 8 relevant and high-quality pain guidelines were identified. From these guidelines, the Panel articulated core principles of the management of cancer pain and selected or adapted specific recommendations through consensus to become a part of the cancer-related pain guide for practice. DISCUSSION: The domains on which recommendations were drafted include: assessment of pain; assessors of pain; time and frequency of assessment; components of pain assessment; assessment of pain in special populations; plan of care; pharmacologic intervention; nonpharmacologic intervention; documentation; education; and outcome measures of cancer-pain management.

Why women delay seeking assistance for locally advanced breast cancer.

Locally advanced breast cancer (LABC) occurs in 10% to 30% of all new primary breast cancer diagnoses. For reasons that are not well-understood, 20% to 30% of women with breast cancer (at all stages) wait eight weeks or more from the time they notice the breast symptom(s) to when they seek assistance from a health care provider. Comprehending the mechanisms that support the health appraisal and health seeking behaviour is paramount and not well understood, particularly for women with LABC. The purpose of this study was to qualitatively explore the cognitive, emotional, and contextual experience of women with locally advanced breast cancer in the time between symptom discovery and seeking health care. In-depth qualitative interviews and a cross-case, content analysis revealed that the participants delayed their search for assistance because they did not perceive themselves to be at risk for developing breast cancer, had a symptom other than a lump, and so misattributed or minimized the gravity of the symptom, had a previous experience with a benign tumour, and/or were experiencing concurrent stressful life events. These participants were motivated to seek attention if they had an already scheduled appointment with a health professional for another matter, felt the symptom worsen over time, or were motivated by a loved one to seek help. Implications for health promotion and for education with women with benign breast disease, as well as the general public, are discussed.

Association of low tumor RNA integrity with response to chemotherapy in breast cancer patients.

The CAN-NCIC-MA22 phase I/II clinical trial evaluated women with locally advanced or inflammatory breast cancer treated with epirubicin and docetaxel at 2 or 3 weekly intervals in sequential cohorts. The relationship between various biomarkers and treatment response was assessed. Breast biopsy cores were obtained from 50 patients pre-, mid-, and post-treatment. Immunohistochemical staining was performed to determine baseline levels of estrogen receptor (ER), progesterone receptor (PR), Her2/Neu protein (HER2), and topoisomerase II (Topo 2),expressed as percent positive stain. Tumor RNA integrity(RIN) and tumor cellularity were measured pre-, mid- and post-treatment by capillary electrophoresis and light microscopy after hematoxylin/eosin staining, respectively.Associations between 1) maximum RIN and 2) tumor cellularity at the three time points with baseline levels of ER,PR, Her2, and topo II were assessed using Spearman and Pearson correlation coefficients. Associations between RIN and tumor cellularity with chemotherapy dose level orpathologic response were assessed using one-way ANOVA.In this study, we observed that low mid-treatment maximum RIN (but not tumor cellularity) was associated with high chemotherapy drug dose level (P = 0.05) and eventual pathologic complete response (pCR) (P = 0.01). Posttreatment,low maximum RIN was found to be associated with low tumor cellularity (P = 0.004), and low tumor cellularity with pCR (P = 0.01). Post-treatment tumor cellularity was lowest in patients with tumors having high baseline PR levels (P = 0.05). The association of midtreatment RIN with drug dose level and with pCR suggests that tumor RIN may represent an important new biomarker for measuring response to chemotherapy in breast cancer patients.

Approach to inflammatory breast cancer.

OBJECTIVE: To review the definition, clinical presentation, and management of inflammatory breast cancer in primary care. SOURCES OF INFORMATION: Relevant research and review articles, as well as personal experience of the authors practising in a specialized locally advanced breast cancer program at a comprehensive cancer centre. Evidence is levels II and III. MAIN MESSAGE: Inflammatory breast cancer is a rare disease that typically presents with a rapidly enlarging erythematous breast, often with no discernable breast mass. Identification of warning signs and recognition of clinical symptoms are crucial to prompt diagnosis and appropriate referral. Management in the primary care setting includes treatment of symptoms, psychosocial support, regular surveillance and follow-up, as well as palliative care. CONCLUSION: Family physicians are usually the entry point to the health care system and are well positioned to assess inflammation of the breast and recognize the warning signs of an underlying inflammatory breast cancer. They are also important members of the team that provides support for breast cancer patients and their families during treatment, follow-up, and end-of-life care.

The use of complementary and alternative medicines among patients with locally advanced breast cancer--a descriptive study.

BACKGROUND: Complementary and alternative medicine (CAM) use is common among cancer patients. This paper reviews the use of CAM in a series of patients with locally advanced breast cancer (LABC). METHODS: Women with LABC attending a specialist clinic at a single Canadian cancer centre were identified and approached. Participants completed a self-administered survey regarding CAM usage, beliefs associated with CAM usage, views of their risks of developing recurrent cancer and of dying of breast cancer. Responses were scored and compared between CAM users and non-users. RESULTS: Thirty-six patients were approached, 32 completed the questionnaire (response rate 89%). Forty-seven percent of LABC patients were identified as CAM users. CAM users were more likely to be younger, married, in a higher socioeconomic class and of Asian ethnicity than non-users. CAM users were likely to use multiple modalities simultaneously (median 4) with vitamins being the most popular (60%). Motivation for CAM therapy was described as, "assisting their body to heal" (75%), to 'boost the immune system' (56%) and to "give a feeling of control with respect to their treatment" (56%). CAM therapy was used concurrently with conventional treatment in 88% of cases, however, 12% of patients felt that CAM could replace their conventional therapy. Psychological evaluation suggests CAM users perceived their risk of dying of breast cancer was similar to that of the non-Cam group (33% vs. 35%), however the CAM group had less severe anxiety and depression. CONCLUSION: The motivation, objectives and benefits of CAM therapy in a selected population of women with LABC are similar to those reported for women diagnosed with early stage breast cancer. CAM users display less anxiety and depression and are less likely to believe they will die of their breast cancer. However the actual benefit to overall and disease free survival has yet to be demonstrated, as well as the possible interactions with conventional therapy. Consequently more research is needed in this ever-growing field.