Experiences and perspectives of colorectal cancer survivors and general practitioners on the delivery of survivorship care in general practice: a mixed methods study.

BACKGROUND: Many colorectal cancer (CRC) survivors experience ongoing sequelae from their cancer treatment. Limited evidence exists regarding how CRC survivors and general practitioners (GPs) manage these sequelae in the community. This study aimed to explore the experiences and perspectives of CRC survivors and GPs on current approaches to monitoring and managing sequelae of CRC treatment. METHODS: We conducted a mixed-methods study using cross-sectional national surveys and qualitative interviews with CRC survivors and GPs to explore: (1) treatment sequelae experienced by CRC survivors, (2) how these were monitored and managed by general practitioners, and (3) suggestions to improve ongoing management of the treatment sequelae. Survey responses were reported descriptively. Qualitative data were thematically analysed using an interpretive descriptive approach. RESULTS: Seventy participants completed surveys: 51 CRC survivors and 19 GPs, and four interviews were conducted with GPs. CRC survivors experienced a range of treatment sequelae, but often did not discuss these with their GPs (experienced vs discussed: 86% vs 47% for fatigue/lack of energy, 78% vs 27% for psychological/emotional concern, 63% vs 22% for impaired sleep, 69% vs 29% for weight loss/gain, 59% vs 16% for sexual and intimacy concerns). GPs reported inadequate information transfer from cancer services and workload as major barriers to optimal care. CONCLUSIONS: System-level changes that facilitate adequate information transfer from cancer services to GPs upon CRC treatment completion, as well as addressing time constraint issues essential for comprehensive monitoring and management of CRC treatment sequelae, could enhance the care of CRC survivors in the community setting.

Evaluating a shared care pathway intervention for people receiving chemotherapy to reduce post-treatment unplanned hospital presentations: a randomised controlled trial.

PURPOSE: The aim of this randomised controlled trial (RCT) was to explore whether a community nursing intervention for outpatients receiving systemic therapy reduced unplanned hospital presentations and improved physical and psychosocial health outcomes over the first three cycles of treatment compared to a control group receiving standard care. METHODS: The number of and reasons for unplanned presentations were obtained for 170 intervention and 176 control group adult patients with solid tumours starting outpatient chemotherapy. Poisson regression was used to compare the number of presentations between the intervention and control groups. Patients self-completed the Hospital Anxiety and Depression Scale, the Cancer Behavior Inventory and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire core 30 (EORTC QLQ-C30) at the start of the first four cycles. Linear regression techniques were used to compare quality of life outcomes. RESULTS: The reduction in unplanned presentations in the intervention group relative to the control group was 12% (95% CI, - 25%, 37%; P = 0.48). At the start of cycle 4, there was no difference in anxiety (difference = 0.47 (95% CI, - 0.28, 1.22; P = 0.22)), depression (difference = 0.57 (95% CI, - 0.18, 1.31; P = 0.13)) or EORTC QLQ-C30 summary score (difference = 0.16 (95% CI, - 2.67, 3.00; P = 0.91)). Scores for self-efficacy as measured by the Cancer Behavior Inventory were higher in the intervention group (difference = 4.3 (95% CI, 0.7, 7.9; P = 0.02)). CONCLUSION: This RCT did not demonstrate a benefit in reducing unplanned presentations to hospital. The trial identified improved cancer-based self-efficacy in patients receiving the intervention. TRIAL REGISTRATION: Registered at Australian and New Zealand Clinical Trials Registry: ACTRN12614001113640, registered 21/10/2014.

How consequences of colorectal cancer treatment are managed: a qualitative study of stakeholder experiences about supportive care and current practices.

PURPOSE: Colorectal cancer (CRC) survivors experience treatment-effects such as symptoms and functional impairments. There is limited evidence about how these are managed and what services or supports are available in the community. We aimed to identify current practice and available supports for managing consequences of treatment from clinician and CRC survivor perspectives. METHODS: This qualitative study, informed by an interpretivist constructionist paradigm, included semi-structured interviews. Clinicians with experience of treating CRC patients and adult CRC survivors were recruited across Australia. Interviews explored experiences about problems experienced after CRC treatment and how these were managed. Data collection and analysis, using thematic analysis, was iterative whereby emergent themes during analysis were incorporated into subsequent interviews. RESULTS: We interviewed 16 clinicians and 18 survivors. Survivors experienced a range of consequences of treatment amendable to support including allied health, information, and self-management. Barriers to support access included clinicians' worry about patient out-of-pocket expenses, long waitlists, lack of awareness about existing supports, and perception no therapeutic options were available. Healthcare professionals with expertise in CRC were often difficult to identify outside of cancer settings. Survivorship care could be improved with individualised timely information and identification of pathways to access healthcare providers with expertise in managing consequences of CRC treatment within primary care. CONCLUSIONS: To improve CRC survivor lives posttreatment, routine assessment of consequences of treatment, individualised care planning involving relevant healthcare professionals, access to supportive care when needed, and improved information provision and engagement of a range of health professionals in follow-up care are needed.

Experiences of colorectal cancer survivors in returning to primary coordinated healthcare following treatment.

BACKGROUND: Advances in screening and treatments for colorectal cancer (CRC) have improved survival rates, leading to a large population of CRC survivors. Treatment for CRC can cause long-term side-effects and functioning impairments. General practitioners (GPs) have a role in meeting survivorship care needs of this group of survivors. We explored CRC survivors' experiences of managing the consequences of treatment in the community and their perspective on the GP's role in post-treatment care. METHODS: This was a qualitative study using an interpretive descriptive approach. Adult participants no longer actively receiving treatment for CRC were asked about: side-effects post-treatment; experiences of GP-coordinated care; perceived care gaps; and perceived GP role in post-treatment care. Thematic analysis was used for data analysis. RESULTS: A total of 19 interviews were conducted. Participants experienced side-effects that significantly impacted their lives; many they felt ill-prepared for. Disappointment and frustration was expressed with the healthcare system when expectations about preparation for post-treatment effects were not met. The GP was considered vital in survivorship care. Participants' unmet needs led to self-management, self-directed information seeking and sourcing referral options, leaving them feeling like their own care coordinator. Disparities in post-treatment care between metropolitan and rural participants were observed. CONCLUSION: There is a need for improved discharge preparation and information for GPs, and earlier recognition of concerns following CRC treatment to ensure timely management and access to services in the community, supported by system-level initiatives and appropriate interventions.

Patient perceptions of a community-based intervention designed to provide support post administration of anti-cancer systemic treatments: A qualitative evaluation.

PURPOSE: This paper reports on patient participant experiences of a larger randomised controlled trial evaluating a shared-care pathway intervention designed to support outpatients at home during their first three cycles of systemic anti-cancer therapies delivered in two large tertiary hospitals in Sydney, Australia. This qualitative study explores the perspectives of patient participants who received the intervention, which involved targeted home visits by community nurses post treatment administration. METHODS: A qualitative inductive thematic analysis was used to examine data from semi-structured interviews with patients who received the intervention. RESULTS: Twenty-five patient participants were interviewed. We identified four themes: Stepping into the unknown; Impact of availability of health and social care support; Building confidence to manage self-care; Uncertainty, frailty and co-morbidities. Targeted support at home is seen to be effective and welcomed by patients as early stages of each treatment cycle can be extremely challenging, particularly for those who are elderly, frail or with co-morbidities, and for those with limited health and social support. CONCLUSION: Regular contact with community nursing services can, at least for some patients, support the development of patient self-efficacy in managing aspects of their own care. Some patients are sufficiently confident to self-manage some treatment side effects by treatment cycle four.

Introducing solution-focussed brief therapy to mental health nurses across a local health district in Australia.

Solution-focussed brief therapy (SFBT) can be applied to effectively address a broad range of mental health-, alcohol-, and substance-related challenges. The compatibility that SFBT has with mental health nursing practice has been widely recognized. The aim of the present mixed-methods study was to introduce and evaluate the utility of SFBT principles, strategies, and techniques to the clinical work of mental health nurses from a local health district in Sydney, Australia. Following a 4-hour introductory SFBT workshop, participants were invited to complete a one-page evaluation and undertake a follow-up individual telephone interview with a research assistant. Participants (n = 65) were positive about the workshop content and recognized the potential benefits of SFBT in clinical practice. Interviewed participants (n = 14) were enthusiastic about SFBT. However, they also identified that using SFBT was challenging, particularly as the approach was considered different to current practices in mental health services. A lack of confidence with incorporating SFBT in their clinical work was also acknowledged, and participants expressed interest in additional training, including more time to practise SFBT strategies and techniques. Widespread training for mental health nurses in SFBT is indicated, including opportunities for supervision and to observe SFBT being employed by experienced clinicians.

Evaluating a new model of nurse-led emergency department mental health care in Australia; perspectives of key informants.

BACKGROUND: Mental health nurse services have existed in Emergency Departments (ED) for many years. However, there is considerable variation in the way these services operate, and no standardised model of care has been articulated. AIM: To evaluate an extended hours nurse practitioner-led mental health liaison nurse (MHLN) service based in an ED in Sydney Australia. METHODS: As part of a larger mixed-methods study, semi-structured interviews were conducted with a sample of ED patients and nursing, medical and psychiatry staff (N = 46). Newly recruited MHLNs were interviewed at the commencement and conclusion of the study period. This paper presents the qualitative component from the evaluation. RESULTS: The new service was met with high levels of approval by patients and staff. MHLN team members were challenged by their new role but considered the service reduced waiting times, provided therapeutic benefits, and enhanced communication and support for emergency staff. CONCLUSION: A nurse practitioner-led extended hours MHLN service embedded within the ED team structure provides prompt and effective access to specialised mental health care for people with 'undifferentiated health problems' and removes a significant workload from nursing and medical staff.

Evaluation of a nurse practitioner-led extended hours mental health liaison nurse service based in the emergency department.

OBJECTIVE: To evaluate a nurse practitioner (NP)-led extended hours mental health liaison nurse (MHLN) service based in the emergency department (ED) of an inner city teaching hospital in Sydney and to explicate a model of care that is transferable across a broad range of ED settings, both in metropolitan and rural contexts. METHODS: This mixed-methods evaluation encompassed descriptive data on ED mental health presentations, quantifying waiting times for MHLN involvement and interviews with MHLN team members at the commencement of the evaluation and 12 months later. Interviews were also conducted with a snapshot of ED patients, and a sample of ED and psychiatry staff. RESULTS: The expanded MHLN service was rapidly incorporated into the ED structure, enthusiastically endorsed by ED patients and highly valued by staff and the organisation. The MHLN team saw 55% of referred patients within the first hour of arrival (frequently before medical assessment), thereby initiating and expediting co-ordination of care at an early stage of the ED process. CONCLUSIONS: An NP-led extended hours MHLN team based in the ED provides prompt and effective access to specialised mental health care for people with 'undifferentiated health problems', and removes a significant workload from nursing and medical staff. Embedding the NP-led MHLN service within the ED structure was pivotal to the success and sustainability of this model of care.