Identifying the concerns of women undergoing chemotherapy

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Abstract

This cross-sectional study aimed to identify key concerns of cancer patients receiving in-patient chemotherapy, determine the prevalence of anxiety and depression, and assess whether ward nurses could identify patients’ concerns. Thirty-three women on a chemotherapy ward in the northwest of England who had breast, ovarian, cervical or uterine cancer were interviewed using a Concerns Checklist and the Hospital Anxiety and Depression Scale. Patients expressed an average of 10.3 concerns (range: 2–27). Eighty percent of these were not identified by the nurses, who showed a clear bias towards physical symptoms and treatment-related concerns. The nurses were unable to identify the three main concerns in 70% of patients. Twenty-four percent of patients were found to be probable cases of anxiety and/or depression; there was a moderate correlation between the number of concerns and levels of anxiety and depression. Given the body of evidence that lack of identification of concerns leads to unmet needs, increased psychological distress, dissatisfaction with care and possible complaints, this study has provided clear evidence for the need to address this key area of care, and has highlighted the potential of the Concerns Checklist in busy clinical environments.

Introduction

Up to one-third of patients with cancer develop a depressive illness and/or anxiety disorder [1], [2]. A strong association has been found between the number and severity of patients’ concerns after diagnosis and the later development of anxiety and depression [2]. The number of concerns expressed by patients has also been linked to high levels of emotional distress [3], [4], [5]. If nurses are to provide better emotional support for patients, and promote emotional adjustment, then accurate identification of concerns is clearly essential.

The nature and severity of concerns experienced by cancer patients cannot be predicted by disease type, age or gender [4]. So, there is a need to assess patients’ concerns individually, particularly as patients have been shown to be highly selective in what they disclose to different health care professionals [6], [7]. Disparity in disclosure has been shown across professional groups, e.g. between doctors and nurses [6], [8], and, most importantly, between different professionals of the same discipline. In Heaven and Maguire’s study, for example, patients were shown to disclose different concerns to different nursing carers, depending on factors including perception of role and time, perception of emotional strength of the nurse and also the nurses’ communication skills [7].

The majority of patients’ concerns are not usually detected by nursing or medical staff [7], [8], [9]. Some studies suggest that as few as 20% of concerns are identified [7] whilst other would put the figure higher [10]. A number of possible reasons for this have been suggested. These include such things as professionals’ fear that psychological enquiry will in some way be damaging for the patients and make the situation worse [9], [11]; for example, a belief that asking about suicidal ideation may put the idea into a patient’s mind, or asking about fear of dying may put the patient in touch with intolerable fears which they have not considered. Professionals also fear that psychological enquiry may result in emotions which the professional will find difficult to handle [9], [11], and report other deterrents, for example lack of training in the relevant communication skills [12] and/or a lack of emotional support for staff [11], [13].

Chemotherapy is known to be associated with a high physical and psychiatric morbidity [12], [13], [14]. However, the extent to which patients undergoing chemotherapy disclose their concerns to their nursing carers has not been studied and there has been little research into the ability of nurses to identify these concerns. Whilst other research has looked at psychological morbidity during chemotherapy [14], the link between concerns and morbidity at this illness stage has not been established. We, therefore, studied individual concerns of patients receiving chemotherapy as in-patients and determined whether their concerns were identified by ward nurses and recorded in the nursing records. We also determined the prevalence of anxiety and depression and the potential link to levels of concern.

Section snippets

Methods

This was a cross-sectional study in which patients’ self-report, nurses perception and the written nursing records were compared to determine current concerns.

Study sample

Thirty-five women were asked to participate but one refused and one was excluded because she was admitted to a different ward. Of the remaining 33 female participants 11 had breast cancer, 14 ovarian cancer and 6 had cervical or uterine cancer. The remaining two patients had both breast and ovarian cancer, where cancer of the ovary was the second cancer to be diagnosed. Thirty women (91%) were scheduled to receive a platinum-based chemotherapy regime while three (9%) had a regime containing

Discussion and conclusion

This study has highlighted that women undergoing in-patient chemotherapy have many concerns that are not identified by the ward nurses caring for them.

The number of concerns in this cohort of patients was higher than that identified in oncology clinics with newly diagnosed patients [4] or palliative care patients [5], [8], [10]. This reflects the concern of Watson et al. [14] that receiving chemotherapy is a very distressing and concern-provoking stage of treatment. The stage of illness is also

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