Quality

Managing Chemotherapy Side Effects: Achieving Reliable and Equitable Outcomes

Clara C. Beaver

Morris A. Magnan

infusion nurse, treatment-related side effects, patient education
CJON 2016, 20(6), 589-591. DOI: 10.1188/16.CJON.589-591

Receiving information about treatment-related side effects is a high priority for patients receiving chemotherapy. Infusion nurses typically assume responsibility for teaching patients how to manage treatment-related side effects, but providing reliable and equitable information across visits and across different infusion centers can present a problem. Implementing a standardized, patient-centered, departure encounter checklist can help ensure that nurses consistently provide patients with targeted, timely, and regimen-specific information about treatment-related side effects.

At a Glance

  • A structured discharge and departure process can help nurses in delivering high-quality patient-centered care.
  • Providing nurses with a checklist with cues reinforces a standardized encounter with each patient.
  • Developing interventions that the nursing staff “own” allows for easier adoption.

Jump to a section

    The informational needs of patients with cancer are extensive, reflect a combination of personal and situational needs (Mills & Sullivan, 1999), and may vary during the course of their diseases (Hawkins et al., 2008). Consequently, informational support is needed from the time of diagnosis while making treatment decisions, undergoing treatment, and adjusting to survivorship (Skalla, Bakitas, Furstenberg, Ahles, & Henderson, 2004). Inadequate informational support has been associated with adverse outcomes, such as persistent anxiety and depression (Booth, Beaver, Kitchener, O’Neill, & Farrell, 2005), whereas adequate informational support has been associated with lower depression and anxiety (Booth et al., 2005), greater quality of life (Templeton & Coates, 2004), and greater satisfaction with care (Butow, Brindle, McConnell, Boakes, & Tattersall, 1998; Iconomou et al., 2006; Templeton & Coates, 2004). Although it is important to acknowledge and address the extensive and changing informational needs of patients with cancer, of equal importance is recognizing that quantitative and qualitative studies make it clear that receiving information about treatment-related side effects is a high priority among patients receiving chemotherapy (Hawkins et al., 2008; McCaughan & Thompson, 2000; Skalla, Bakitas, Furstenberg, Ahles, & Henderson, 2004).

    The staff at the authors’ National Cancer Institute-designated comprehensive cancer center regularly monitor patient education about treatment-related side effects using the PressGaney® indicator: “Nurses explained managing chemo side effects.” Staff also benchmark their percentage scores against the pooled mean percentage scores from all other Consortium of Comprehensive Cancer Centers for Quality Improvement (C4QI) members. An analysis of data trends over time suggested that an opportunity existed for quality improvement at the authors’ institution related to the PressGaney indicator. Specifically, trend lines showed variability within infusion centers, with wide swings from month to month— sometimes meeting the C4QI benchmark and sometimes falling short of the benchmark by a wide margin. This within-unit variability raised questions about the reliability of nursing interventions directed at teaching patients how to manage treatment-related side effects. Additional analyses of trend lines, comparing the two units, suggested that instruction about managing treatment-related side effects differed considerably across infusion centers within the same healthcare system. Based on a comparative analysis of data from two infusion centers, it became clear that, on average, during a five-month period, Infusion Center B scored 10.38 percentage points (range = 4.6–18.6) higher than Infusion Center A. This variation across infusion centers made it clear that equitable outcomes were not being achieved across the infusion centers. Leadership felt confident that nursing capabilities were comparable across infusion centers but speculated that variation in the departure process may account for the variability observed in the outcomes. Based on these observations, nurse leaders from the infusion centers determined that a need existed to create a standardized approach to ensure that all patients undergoing chemotherapy received targeted, timely, and regimen-specific information about treatment-related side effects.

    Developing the Checklist

    In August 2015, nurse leaders from the infusion centers developed and introduced into practice the Quality-Departure Encounter Checklist (Q-DEC). The Q-DEC was designed to ensure a standardized, high-quality nurse–patient interaction prior to patient discharge and departure from an infusion center. The Q-DEC has form and content. The Q-DEC form is that of an interpersonal, patient-centered nurse–patient interaction. The nurse–patient interaction is the therapeutic time/space dimension that nurses create as a safe place where important dialogues can occur. The content of the Q-DEC is comprised of four components: (a) engagement, (b) personalization, (c) review of omission-sensitive elements, and (d) a patient-centered closure. Engagement involves inviting the patient to enter an interaction by telling him or her who you are and what you intend to do. Personalization occurs when the nurse shifts the focus of the interaction to the patient by empathetically inviting the patient to share something about him or herself or the immediate experience or feeling state. A review of omission-sensitive elements is then conducted to verify that the patient has adequate knowledge, skills, and personal resources needed for self care. Omission-sensitive elements are reviewed and omissions are corrected before the patient leaves the department. Finally, a patient-centered closure occurs by asking the patient if he or she has any lingering concerns that have not yet been addressed. An example of the content elements of the Q-DEC is shown in Figure 1.

    Conceptually, the Q-DEC is based on a synthesis of ideas about (a) patient-centered, relationship-based care; (b) limitations of the established quality improvement (QI) process; (c) high-reliability organizations; (d) the nature of nursing errors; and (e) the challenges associated with managing complex situations. With respect to patient-centered, relationship-based care, the authors agreed that caring needed to be captured in moments of caring exchanged between the patient and the nurse during their interaction (Koloroutis, 2004). Limitations of the established QI process were identified. At the authors’ institution, the management team typically reviews QI indicators on a monthly basis, identifies corrective action needed, and then directs staff to implement the corrective action. Limitations of this process are self-evident. The process is reactive, focused on correction rather than prevention, and separates the problem identifier (management) from the problem fixer (staff). It was clear to the Q-DEC developers that a more proactive, dynamic, and preventive approach was needed that allowed staff to identify and correct problems immediately and on their own authority. This new dynamic approach would be more consistent with what happens in high-reliability organizations where staff are empowered to recognize problems and take corrective action immediately (Chassin & Loeb, 2013). Not providing patients with instruction about managing treatment-related side effects constitutes an error of omission. As suggested by Gawande (2009), it was suspected that omissions may be a consequence of ineptitude in managing the complexity inherent in providing nursing care in a busy environment where nurses may feel the pressure of time scarcity, erroneously believe that someone else has already instructed the patient, and/or feel overwhelmed by the competing demands of managing multiple patients and events. Developers of the Q-DEC thought that implementing the Q-DEC as a checklist may be helpful.

    The authors expected that implementing the Q-DEC program would lead to substantial improvement in the PressGaney nursing-sensitive indicator and hoped that effective implementation of the Q-DEC would (a) decrease within-unit variability observed in trend line, (b) yield greater reliability in meeting or exceeding the C4QI benchmark, and (c) lead to greater equity of care across units as evidenced by having the trend lines from different infusion centers converge toward a common percentage point.

    Implementing the Checklist

    To implement the Q-DEC, each infusion nurse received individual instruction about principles and insights underlying the development of the Q-DEC, a review of the Q-DEC form and content, and instruction about expectations for use with every patient receiving chemotherapy on every visit. To facilitate memory, each nurse received a pocket card that summarized instructions for use and listed Q-DEC content. To ensure application of the Q-DEC, nurses were reminded periodically to use the Q-DEC. In addition, nurses were encouraged to use key words to link the patient symptom experience to the idea that they were experiencing a side effect if that, in fact, was the case.

    Impact of the Checklist

    As shown in Figure 2, during a one-year period (March 2015 to March 2016), the authors monitored and plotted percentage scores for the PressGaney indicator for two of the infusion centers. From March 2015 to October 2015, the trend lines for both units show marked peaks and valleys, with Infusion Center A scores frequently falling short of the C4QI benchmark. In August 2015, staff were trained in the use of Q-DEC and started implementing it into practice. Because PressGaney reports typically have a lag time of about eight weeks, the authors did not expect to see an impact from the Q-DEC intervention until October or November 2015. However, since November 2015, both infusion centers have consistently met or exceeded the C4QI benchmark, which suggests that more reliable measures are being achieved on the PressGaney indicator. In addition, the trend lines for each unit are now converging toward a common percentage, which suggests greater equity of care across infusion centers. A comparative analysis of data from the two participating units showed that average difference in percentage scores during a four-month period was 3.8% after implementing the Q-DEC, which is down from the previously reported average difference of 10.4% observed before implementing the Q-DEC.

    Discussion

    Based on an analysis of quality data, the authors identified an opportunity to improve the quality of care related to nurses explaining management of chemotherapy side effects to patients. The authors focused narrowly on trying to improve scores on a single PressGaney indicator but deliberated broadly to find a solution. The authors’ experiences suggest that, by formalizing the structure of the patient departure process, nurses are able to exercise greater control in delivering reliable and equitable patient-centered care. There was little resistance to Q-DEC implementation. The nurses’ acceptance of the program and willingness to implement it can be attributed, in part, to the fact that they received information about the conceptual and philosophical underpinnings of the Q-DEC, which was congruent with a nursing ethos.

    Conclusion

    After implementing Q-DEC, quality monitoring data revealed substantial improvement in meeting or exceeding benchmark for the PressGaney indicator. This experience exemplifies how a thoughtful analysis of benchmarking data can lead to the development and implementation of a process improvement initiative.

    References

    Booth, K., Beaver, K., Kitchener, H., O’Neill, J., & Farrell, C. (2005). Women’s experiences of information, psychological distress and worry after treatment for gynaecological cancer. Patient Education and Counseling, 56, 225–232.

    Butow, P., Brindle, E., McConnell, D., Boakes, R., & Tattersall, M. (1998). Information booklets about cancer: Factors influencing patient satisfaction and utilization. Patient Education and Counseling, 33, 129–141.

    Chassin, M.R., & Loeb, J.M. (2013). High‐reliability health care: Getting there from here. Milbank Quarterly, 91, 459–490. doi:10.1111/1468-0009.12023

    Gawande, A. (2009). The checklist manifesto: How to get things right. New York, NY: Henry Holt and Company.

    Hawkins, N.A., Pollack, L.A., Leadbetter, S., Steele, W.R., Carroll, J., Dolan, J.G., . . . Morrow, G.R. (2008). Informational needs of patients and perceived adequacy of information available before and after treatment of cancer. Journal of Psychosocial Oncology, 26(2), 1–16.

    Iconomou, G., Viha, A., Koutras, A., Koukourikou, I., Mega, V., Makatsoris, T., . . . Kalofonos, H.P. (2006). Impact of providing booklets about chemotherapy to newly presenting patients with cancer: A randomized controlled trial. Annals of Oncology, 17, 515–520.

    Koloroutis, M. (Ed.) (2004). Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management.

    McCaughan, E.M., & Thompson, K.A. (2000). Information needs of cancer patients receiving chemotherapy at a day-case unit in Northern Ireland. Journal of Clinical Nursing, 9, 851–858. doi:10.1046/j.1365-2702.2000.00434.x

    Mills, M.E., & Sullivan, K. (1999). The importance of information giving for patients newly diagnosed with cancer: A review of the literature. Journal of Clinical Nursing, 8, 631–642.

    Skalla, K.A., Bakitas, M., Furstenberg, C.T., Ahles, T., & Henderson, J.V. (2004). Patients’ need for information about cancer therapy. Oncology Nursing Forum, 31, 313–319.

    Templeton, H., & Coates, V. (2004). Evaluation of an evidence-based education package for men with prostate cancer on hormonal manipulation therapy. Patient Education and Counseling, 55, 55–61.

    About the Author(s)

    Clara C. Beaver, MSN, RN, AOCNS®, ACNS-BC, is a manager and Morris A. Magnan, PhD, RN, is a clinical nurse specialist, both in ambulatory operations at Barbara Ann Karmanos Cancer Institute in Detroit, MI. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. Beaver can be reached at beaverc@karmanos.org, with copy to editor at CJONEditor@ons.org.

     

    References

    Booth, K., Beaver, K., Kitchener, H., O’Neill, J., & Farrell, C. (2005). Women’s experiences of information, psychological distress and worry after treatment for gynaecological cancer. Patient Education and Counseling, 56, 225–232.
    Butow, P., Brindle, E., McConnell, D., Boakes, R., & Tattersall, M. (1998). Information booklets about cancer: Factors influencing patient satisfaction and utilization. Patient Education and Counseling, 33, 129–141.
    Chassin, M.R., & Loeb, J.M. (2013). High‐reliability health care: Getting there from here. Milbank Quarterly, 91, 459–490. doi:10.1111/1468-0009.12023
    Gawande, A. (2009). The checklist manifesto: How to get things right. New York, NY: Henry Holt and Company.
    Hawkins, N.A., Pollack, L.A., Leadbetter, S., Steele, W.R., Carroll, J., Dolan, J.G., . . . Morrow, G.R. (2008). Informational needs of patients and perceived adequacy of information available before and after treatment of cancer. Journal of Psychosocial Oncology, 26(2), 1–16.
    Iconomou, G., Viha, A., Koutras, A., Koukourikou, I., Mega, V., Makatsoris, T., . . . Kalofonos, H.P. (2006). Impact of providing booklets about chemotherapy to newly presenting patients with cancer: A randomized controlled trial. Annals of Oncology, 17, 515–520.
    Koloroutis, M. (Ed.) (2004). Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management.
    McCaughan, E.M., & Thompson, K.A. (2000). Information needs of cancer patients receiving chemotherapy at a day-case unit in Northern Ireland. Journal of Clinical Nursing, 9, 851–858. doi:10.1046/j.1365-2702.2000.00434.x
    Mills, M.E., & Sullivan, K. (1999). The importance of information giving for patients newly diagnosed with cancer: A review of the literature. Journal of Clinical Nursing, 8, 631–642.
    Skalla, K.A., Bakitas, M., Furstenberg, C.T., Ahles, T., & Henderson, J.V. (2004). Patients’ need for information about cancer therapy. Oncology Nursing Forum, 31, 313–319.
    Templeton, H., & Coates, V. (2004). Evaluation of an evidence-based education package for men with prostate cancer on hormonal manipulation therapy. Patient Education and Counseling, 55, 55–61.