The Role of Researcher for Advanced Practice Nurses in Oncology: Challenges and Lessons Learned

OBJECTIVES

To reflect on current practice analyses regarding the role of advanced practice nurse (APN) researcher in oncology, and report on the challenges that were faced and lessons we have learned when intensively working with APNs on doing research within the domain of oncology.

METHODS

Discussions with APNs supervised by or who collaborated with academics in nursing science during the past 10 years on doing research within the domain of oncology.

RESULTS

Several misconceptions exist regarding the role of APNs as researchers. During the research process, APNs are confronted with a wide range of topics based on evidence gaps and unmet needs, challenges linked to specific research designs, and ethical issues. APNs also face challenges related to the dissemination of research. This step in the research process is often overlooked due to APNs' lack of time, limited financial resources, insufficient support for academic writing, or lower priority for APNs and other healthcare providers.

CONCLUSION

The APN role of researcher in oncology is fundamental for the advancement of oncology nursing care, implementation of evidence-based practice and innovations in oncology patient care, and further development of the nursing profession and nursing science. Participation in research is considered a main function that differentiates APNs from nurses in other clinical roles, such as specialized nurses. By embracing the role of researcher, oncology APNs can achieve professional growth that will stimulate them as an APN, open new opportunities, and keep them challenged.

IMPLICATIONS FOR NURSING PRACTICE

In addition to APN, organizational and structural related factors, support by relevant stakeholders, partnering with (nursing) research units and professional and patient organizations, and dedicated time for research can positively influence uptake of the APN researcher role.

Self-reported electronic symptom monitoring in older patients with multimorbidity treated for cancer: Development of a core dataset based on expert consensus, literature review, and quality of life questionnaires

INTRODUCTION

In cancer care, symptom monitoring during treatment results in improved clinical outcomes such as improved quality of life, longer survival, and fewer hospital admissions. However, as the majority of patients with cancer are older and have multimorbidity, they may benefit from monitoring of additional symptoms. The aim of this study was to identify a core set of symptoms to monitor in older patients with multimorbidity treated for cancer, including symptoms caused by treatment side effects, destabilization of comorbidities, and functional decline.

MATERIALS AND METHODS

During a scoping literature search, 17 quality of life questionnaires were used to select 53 possible symptoms to monitor. An expert panel of cancer and geriatrics specialists was asked to participate in multiple online surveys to indicate whether these symptoms were not relevant to monitor, only relevant to monitor in a specific patient group, or relevant to monitor in all patients. In a subsequent round the list was reduced and the panel indicated how frequently these symptoms should be monitored during cancer treatment and after cancer treatment completion. Finally, a digital consensus meeting was organised to decide when symptoms had to trigger a recommendation to the patient to get in touch with their medical team.

RESULTS

In total, 30 healthcare professionals participated in the online surveys. After two rounds, a dataset of 19 symptoms related to cancer, cancer treatment, functional decline, and destabilization of comorbidities was agreed upon for monitoring. Five symptoms were selected for daily monitoring during treatment, seven for weekly, and seven for monthly. After treatment completion, the panel agreed upon less frequent reporting. Additionally, nine symptoms to be monitored only in patients with specific cancer types or treatment types were chosen, such as "cough up blood" in lung cancer.

DISCUSSION

This study is the first to identify a core set of symptoms to monitor in older patients with multimorbidity treated for cancer. Future research is needed to investigate whether the monitoring of these symptoms is feasible and improves clinical outcomes in older patients with multimorbidity treated for cancer.

The use of electronic Patient Reported Outcomes in follow-up after palliative radiotherapy: A survey study in Belgium

Objective

Electronic Patient-Reported Outcome Measures (ePROMs) could be used to monitor patients' symptoms after treatment. However, ePROM implementation in clinical practice has been challenging, especially in (palliative) radiation oncology. The aim of this study was to explore the opinions of healthcare providers (HCP) active in radiation oncology in Belgium on the use of ePROMs for symptom follow-up after palliative radiotherapy.

Methods

An anonymous online survey was conducted with different HCP in radiation oncology in Belgium. Participants were recruited through several professional organizations with approximately 390 members actively working in the field of radiation oncology. The survey used was a self-developed questionnaire, based on existing literature on implementation of (e)PROMs in cancer care, our previous research on this topic as well as our personal experience in the field of oncology and palliative care.

Results

Of the 128 respondents, 26% had experience with ePROMs in clinical practice. Eighty-four percent considered ePROMs beneficial for patients' health and symptom knowledge, symptom self-management and active participation in care. ePROMs could help HCP to focus on detection of relevant symptoms and improve their management. Almost 75% were willing to implement and use ePROMs. Assigning ePROM introduction and follow-up to a dedicated person, such as a nurse navigator, was suggested to promote ePROM implementation and use in clinical practice.

Conclusion

Despite limited experience with ePROMs in clinical care for palliative radiotherapy patients, the majority of respondents is willing to implement and use ePROMs for this particular patient population.

Innovation

This is one of the first studies specifically focusing on experiences and opinions of HCP in radiation oncology on the use of ePROMs for symptom follow-up in palliative radiotherapy. HCP should be actively involved in implementation of ePROMs after palliative radiotherapy, to translate their vision of their ideals in practice.

A randomized controlled trial of hand/foot-cooling by hilotherapy to prevent oxaliplatin-related peripheral neuropathy in patients with malignancies of the digestive system

BACKGROUND

Both acute and chronic symptoms of oxaliplatin-induced peripheral neuropathy (OIPN) affect patients' treatment dose and duration as well as quality-of-life. Hand/foot-cooling has been shown to reduce taxane-induced peripheral neuropathy but there is unclear evidence in the setting of oxaliplatin.

PATIENTS AND METHODS

In a monocentric, open-label phase II trial, patients with malignancies of the digestive system receiving oxaliplatin-based chemotherapy were randomly assigned to receive either continuous cooling of hands and feet using hilotherapy at 11°C during oxaliplatin infusion compared with usual care (no cooling). The primary endpoint was grade ≥2 neuropathy-free rate in 12 weeks after initiation of chemotherapy. Secondary endpoints included OIPN-related treatment alterations, acute OIPN symptoms and perceived comfort of the intervention.

RESULTS

The intention-to-treat population included 39 patients in the hilotherapy group and 38 in the control group. The grade ≥2 neuropathy-free rate at 12 weeks was 100% in the experimental group versus 80.5% in the control group (P = 0.006). This effect was persistent at 24 weeks (66.0% versus 49.2%, respectively) (P = 0.039). Next, treatment alterations-free rate at week 12 was 93.5% in the hilotherapy group compared with 83.3% in the control group (P = 0.131). Patients in the hilotherapy group experienced significantly less acute OIPN symptoms of numbness or tingling [odds ratio (OR) 0.05, 95% confidence interval (CI) 0.02-0.11, P < 0.0001], pain (OR 0.06, 95% CI 0.02-0.15, P < 0.0001) and/or cold sensitivity (OR 0.02, 95% CI 0.01-0.05, P < 0.0001) in fingers or toes as well as less pharyngeal cold sensitivity (OR 0.14, 95% CI 0.05-0.42, P = 0.0005). The majority of patients in the hilotherapy group rated the intervention as neutral, rather comfortable or very comfortable.

CONCLUSIONS

In this first study on hand/foot-cooling in oxaliplatin alone, hilotherapy significantly reduced the incidence of grade ≥2 OIPN at 12 and 24 weeks. Hilotherapy also reduced acute OIPN symptoms and was generally well tolerated.

Using ePROMs for follow-up after palliative radiotherapy: An exploratory study with patients and health care providers

OBJECTIVES

Patients treated with palliative radiotherapy may experience symptoms decreasing their quality of life. Electronic patient-reported outcome measures (ePROMs) could provide an opportunity to follow-up patients after treatment.

METHODS

A mixed-method study was performed using self-constructed questionnaires, focus groups and interviews with patients and health care professionals (HCP). A qualitative approach was used to code the data.

RESULTS

Forty-two patients, 21 radiation-oncologists, 15 general practitioners (GPs) and 24 home-care nurses completed a questionnaire. Ten patients, 6 radiation-oncologists, 14 GPs and 5 nurses were interviewed or participated in a focus group. Although patients and HCP are satisfied with current care, they believe ePROMs could improve follow-up, communication, continuity of care and self-management of symptoms. An easy to use, versatile ePROM platform seems to be important for successful implementation. Self-care tips and contact information should be added to relevant ePROM-questions, on both physical and psychological symptoms.

CONCLUSION

Patients and HCP agree that ePROMs could improve systematical clinical follow-up after palliative radiotherapy, with self-management support being the primary objective of such a system. Practice implications ePROMs after palliative radiotherapy seem feasible, the exact patient population that could benefit the most will need to be explored further; as the palliative population is very diverse.

A Narrative Review on the Collection and Use of Electronic Patient-Reported Outcomes in Cancer Survivorship Care with Emphasis on Symptom Monitoring

Electronic patient-reported outcome (ePRO) applications promise great added value for improving symptom management and health-related quality of life. The aim of this narrative review is to describe the collection and use of ePROs for cancer survivorship care, with an emphasis on ePRO-symptom monitoring. It offers many different perspectives from research settings, while current implementation in routine care is ongoing. ePRO collection optimizes survivorship care by providing insight into the patients' well-being and prioritizing their unmet needs during the whole trajectory from diagnosis to end-of-life. ePRO-symptom monitoring can contribute to timely health risk detection and subsequently allow earlier intervention. Detection is optimized by automatically generated alerts that vary from simple to complex and multilayered. Using ePRO-symptoms during in-hospital consultation enhances the patients' conversation with the health care provider before making informed decisions about treatments, other interventions, or self-management. ePRO(-symptoms) entail specific implementation issues and complementary ethics considerations. The latter is due to privacy concerns, digital divide, and scarcity of adequately representative data for particular groups of patients.

Preventing taxane-related peripheral neuropathy, pain and nail toxicity: a prospective self-controlled trial comparing hilotherapy with frozen gloves in early breast cancer

PURPOSE

The prevention of taxane-related toxicities at the extremities is highly important for patients' treatment and quality-of-life. Several studies endorse hand/foot-cooling using frozen gloves as a prophylactic intervention. Unlike frozen gloves, hilotherapy produces cooling at a constant temperature. Comparative data with frozen gloves are unavailable.

METHODS

This prospective self-controlled study explores the efficacy of hilotherapy at the right hand and foot compared to frozen gloves at the left in patients with early breast cancer treated with weekly paclitaxel 80 mg/m² or three-weekly docetaxel 75 mg/m². Patient-reported outcomes were collected at baseline, 6, 12, 18 and 24 weeks after the start of treatment. Primary and secondary endpoints were the incidence of any-grade and ≥ grade 2 side-effects (peripheral neuropathy, pain and nail toxicities), and perceived comfort of both interventions.

RESULTS

Sixty-two patients participated. The incidence of any-grade side-effects was similar on both sides, 85.5% with hilotherapy and 90.3% with frozen gloves (p = 1.000). The incidence of ≥ grade 2 side-effects at the extremities was significantly lower with hilotherapy: 43.6% compared to 61.3% with frozen gloves (p = 0.013). Perceived comfort was significantly better for hilotherapy than for frozen gloves (p < 0.0001).

CONCLUSIONS

Compared to frozen gloves, continuous cooling of hands and feet using hilotherapy produces better prevention of ≥ grade 2 patient-reported side-effects at the extremities (peripheral neuropathy, pain and nail toxicities). Perceived comfort was significantly better for hilotherapy. From a clinical and patient perspective, hilotherapy is a better alternative for preventing clinically significant taxane-related side-effects.

Scalp cooling in breast cancer patients treated with docetaxel-cyclophosphamide: patient- and nurse-reported results

PURPOSE

Recent evidence supports the efficacy of scalp cooling in preventing chemotherapy-induced alopecia in breast cancer treatments. However, efficacy largely varies between treatment regimens. The aim of this study was to explore the patient- and nurse-reported results of scalp cooling in terms of hair loss and need for a wig/head cover in patients with breast cancer treated with 3-weekly docetaxel 75 mg/m²- cyclophosphamide 600 mg/m².

METHODS

We studied nurse-reported efficacy as noted in the electronic patient files of 85 patients treated with docetaxel 75 mg/m²- cyclophosphamide 600 mg/m² between 1/1/2017 and 1/1/2020. Sixty-nine of them also self-reported on their scalp cooling results up to one year after adjuvant chemotherapy in a retrospective way.

RESULTS

Nurse- and patient-reported data showed that scalp cooling was successful (i.e., hair loss < 50%) in 47.1 and 44.9% of patients, respectively, and 55% of patients were (very) satisfied with the result of scalp cooling. Scalp cooling was perceived as (very) uncomfortable in 36.2% of patients. Regarding hair status one year after treatment, 47 patients (55.3%) reported no changes compared to their hair status before treatment.

CONCLUSIONS

Scalp cooling is successful in preventing severe chemotherapy-induced alopecia in almost half of the patients with breast cancer treated with docetaxel 75 mg/m²- cyclophosphamide 600 mg/m². Better understanding of the success rate of scalp cooling enables correct patient information and decision-making support.

Caregiver distress and quality of life in primary caregivers of oncology patients in active treatment and follow-up

OBJECTIVE

As the number of informal caregivers and their caregiving responsibilities increase, this study aims at evaluating caregiver distress, quality of life (QoL) and their predictors in informal caregivers of cancer patients during active treatment and follow-up.

METHODS

This cross-sectional descriptive study targeted primary caregivers of patients with different cancer diagnoses. Caregiver-reported outcomes were measured by the Caregiver Risk Screen (CRS), Distress Thermometer (DT) and Caregiver Quality of Life Index-Cancer (CQOLC).

RESULTS

Caregivers (n = 1580) experienced a low-to-moderate risk of caregiver distress and a moderate QoL during both treatment and follow-up. About 13% reported a high caregiver risk and 20% reported severe distress. There was a strong and significant correlation between caregiver distress and caregivers' QoL (0.793). Predictive factors for higher distress and poorer QoL were: fewer emotional and practical resources, being female, non-spousal relationship or not living together (p < 0.05). Caregivers of patients with head-and-neck, skin, lung and brain cancers reported the highest distress and lowest QoL.

CONCLUSION

Caregiver distress is highly variable, but a minority of caregivers is at high risk for caregiver distress. Professional caregivers play an important role at supporting caregivers and detecting high-risk caregivers.

The added value of geriatric assessment in evaluating a patient's Health-Related Quality-of-Life: A study in ≥70-year-old early-stage invasive breast cancer patients

OBJECTIVE

The objective of this study was to assess the relationship between geriatric assessment (GA) and health-related Quality-of-Life (HRQOL) in older patients with breast cancer.

METHODS

Patients were assigned either to adjuvant chemotherapy (CTG) or to a control group (CG). Spearman rank coefficients (ρ) calculated correlations between HRQOL and GA at baseline, 3 months and 1 year. Multivariate regressions modelled the prognostic value of GA in evaluating of a patient's HRQOL and the accuracy of baseline GA in predicting HRQOL decline (change of ≥10 points).

RESULTS

The analysis included 57 patients in the CTG and 52 in the CG. Strong correlations (ρ ≥ 0.5) were reported between the EORTC QLQ-C30 Physical Functioning Scale and Activities of Daily Living (ADL), Instrumental ADL (iADL) and Leuven Oncogeriatric Frailty Score Scale (LOFS). Multivariate models demonstrated that poor iADL, ADL and LOFS (CG) and ADL and iADL (CTG) contributed to a statistically (all p < .05) worse HRQOL. The relative gain in predicting 3-month and 1-year HRQOL decline was 24.1% and 4.7% (CG) and 6.1% and 18.3% (CTG).

CONCLUSION

Our results show that the functional measures in the GA are strongly correlated with patient self-reported functioning. Poor baseline GA has a modest probability of predicting HRQOL deterioration.

Systematic development of CHEMO-SUPPORT, a nursing intervention to support adult patients with cancer in dealing with chemotherapy-related symptoms at home

Background

Given the great symptom burden associated with chemotherapy on the one hand and generally poor self-management of symptoms by cancer patients on the other hand, our aim was to develop a nursing intervention to reduce symptom burden in adult cancer patients treated with chemotherapy and to support them in dealing with their various symptoms at home.

Methods

Development of the intervention was guided by the Intervention Mapping Approach and included following steps: needs assessment, formulation of proximal programme objectives, selection of methods and strategies, production of programme components, and planning for implementation and evaluation of the intervention. A panel of multidisciplinary healthcare professionals (n = 12) and a panel of patients and family caregivers (n = 7) were actively involved developing the intervention at each stage.

Results

For the intervention, four patient performance objectives relating to self-management were advanced. Self-efficacy and outcome expectations were selected as key determinants of dealing with chemotherapy-related symptoms. As methods for supporting patients, motivational interviewing and tailoring were found to fit best with the change objectives and determinants. Existing patient information materials were re-designed after panel input to reinforce the new intervention approach.

Conclusion

The intervention mapping approach, including active involvement of the intervention providers and receivers, informed the design of this nursing intervention with two or more contacts. Further evaluation is needed to gain insight into the potential effects, feasibility and mechanisms of this complex intervention.

Electronic supplementary material

The online version of this article (10.1186/s12912-018-0297-8) contains supplementary material, which is available to authorized users.

Implementation and Use of a Patient Symptom Diary During Chemotherapy: A Mixed-Methods Evaluation of the Nurse Perspective

PURPOSE/OBJECTIVES

To gain a deeper understanding of nurses' experience working with a patient diary for tracking and treating side effects during chemotherapy.
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DESIGN

A mixed-methods design was used to learn about oncology nurses' use and perceptions of a symptom diary. 
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SETTING

Six oncology wards and two outpatient clinics at the University Hospitals Leuven, Belgium.
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SAMPLE

79 nurses completed a survey, and 14 nurses participated in focus group discussions.
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METHODS

First, a survey sampled nurses' use and perceptions of the diary. Next, focus group discussions were held with the aim of arriving at a deeper understanding of the survey results.
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MAIN RESEARCH VARIABLES

Use and perceptions of a symptom diary.
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FINDINGS

Most nurses reported performing diary-related behavior to some extent. The survey and focus groups indicated that many nurses strongly believed in the value of the diary, but some were still hesitant or had concerns about patients' perceptions of the diary. The focus group results showed that nurses' use of the diary in daily practice was influenced by their personal beliefs about the value of the diary, the team's, and those of their patients.
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CONCLUSIONS

Although a positive trend was noted, nurses' use of the symptom diary was suboptimal six months after its implementation.
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IMPLICATIONS FOR NURSING

This study highlights important issues that need to be addressed to advance the successful implementation of the symptom diary.

Adherence to oral cancer therapy in older adults: The International Society of Geriatric Oncology (SIOG) taskforce recommendations

There is an increasing trend towards using oral systemic therapy in patients with cancer. Compared to parenteral therapy, oral cancer agents offer convenience, have similar efficacy, and are preferred by patients, consequently making its use appealing in older adults. However, adherence is required to ensure its efficacy and to avoid compromising treatment outcomes, especially when the treatment goal is curative, or in case of symptomatic/rapidly progressing disease, where dose-intensity is important. This opens a new challenge for clinicians, as optimizing patient adherence is challenging, particularly due to lack of consensus and scarcity of available clinical evidence. This manuscript aims to review the impact of age-related factors on adherence, summarize the evidence on adherence, recommend methods for selecting patients suitable for oral cancer agents, and advise monitoring interventions to promote adherence to treatment.

The Leuven questionnaire on patient knowledge of chemotherapy (L-PaKC): instrument development and psychometric evaluation

PURPOSE

Evidence suggests that patients who gain knowledge perform better self-care, cope better and are more satisfied. Today, up-to-date and valid instruments for evaluating patient knowledge on chemotherapy are unavailable. Hence, our aim was to develop a valid instrument to assess patients' knowledge on chemotherapy.

METHOD

We performed a literature review to develop a topic list for the construct. Using a triple Delphi procedure, an expert panel of nine oncologists and oncology nurses evaluated the face and content validity of the topic list and the generated items. A preliminary psychometric evaluation of 144 patients allowed to identify and remediate items having limited applicability and item validity. A convenience sample of 440 patients was used to evaluate item statistics (item difficulty), reliability (Cronbach alpha) and construct validity (exploratory factor analysis) of the final instrument.

RESULTS

We developed a 20-item instrument reflecting 14 relevant themes of patient knowledge on chemotherapy in 13 questions. Twelve items cover general chemotherapy aspects, eight items cover treatment-specific knowledge. Three questions are facultative and address oral chemotherapy. Content validity was excellent (CVI = 0.78-1.00). Item difficulty ranged from 0.25 to 0.95. Internal consistency was acceptable (Cronbach's alpha = 0.67). Exploratory factor analysis defined four underlying factors: general aspects of chemotherapy treatment, negative treatment-related events, information resources and intake of oral chemotherapy.

CONCLUSIONS

The Leuven Questionnaire on Patient Knowledge of Chemotherapy (L-PaKC) demonstrated good content validity and psychometric properties, permitting application in both research and practice for evaluating patient knowledge on chemotherapy.

Researching lived experience in health care: Significance for care ethics

The aim of this article is to demonstrate the usefulness of qualitative research for studying the ethics of care, bringing to light the lived experience of health care recipients, together with the importance of methods that allow reconstruction of the processes underlying this lived experience. Lived experiences of families being approached for organ donation, parents facing the imminent death of their child and patients being treated using stem cell transplantation are used to illustrate how ethical principles are differentiated, modified or contradicted by the narrative context of persons concerned. The integration of empirical data into ethics will help caregivers in their ethical decision making and may enrich care ethics as a narrative and interpretative field.

Immediate versus delayed self-reporting of symptoms and side effects during chemotherapy: does timing matter?

PURPOSE

The aim of this study was to examine how patients recall symptoms at a delayed self-report. Accurate insight into toxicity symptoms during chemotherapy is essential so that nurses and doctors can assess therapeutic tolerance and adjust supportive care accordingly.

METHOD

A non-experimental, longitudinal design was employed. Using the Therapy-Related Symptoms Checklist (TRSC), respondents (n = 142) reported their initial symptoms during the first 7 days of the chemotherapy cycle at two different times: (1) each day of the first seven days after the chemotherapy administration (immediate self-report), and (2) at their next hospital visit for chemotherapy (delayed self-report). We compared the number and severity of symptoms and side effects reported in the immediate and delayed self-reports.

RESULTS

Respondents reported significantly fewer symptoms and fewer severe symptoms in the delayed self-report. For 22 out of 25 symptoms the delayed-reported grade was significantly lower than the immediate-reported maximum grade. Compared to the immediate-reported median grade, significant differences occurred in only 10 out of the 25 symptoms. In all cases, except fatigue, the delayed-reported grade was significantly higher than the immediate-reported median grade.

CONCLUSIONS

This study indicates that delayed self-report of chemotherapy side effects is not an appropriate measure of actual symptoms and side effects experienced by patients. Delayed self-report gives a weaker insight into actual symptom burden. Fatigue is at particular risk to be minimized at the delayed self-report. Therefore it is recommended to assess chemotherapy-related symptoms and side effects by means of immediate self-report.