Article

eHealth Education: Methods to Enhance Oncology Nurse, Patient, and Caregiver Teaching

Ardith Z. Doorenbos

Min K. Jang

Hongjin Li

Robin Lally

eHealth, telehealth, mHealth applications, web-based education, videoconferencing
CJON 2020, 24(3), 42-48. DOI: 10.1188/20.CJON.S1.42-48

Background: eHealth can enhance the delivery of clinical cancer care by offering unique education opportunities for oncology nurses, patients, and family caregivers throughout the cancer trajectory.

Objectives: This article reviews eHealth technology that can be applied to oncology education, such as mobile health applications, text messaging, web-based education, and audio- and videoconferencing.

Methods: Case studies provide exemplars of eHealth technologies used for delivering oncology education to nurses, patients, and caregivers.

Findings: By using eHealth technologies to obtain and provide education, oncology nurses are well positioned to improve the lives of patients and caregivers.

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    Improved oncology nurse, patient, and caregiver education is essential to caring for and meeting the needs of the ever-growing population of individuals with cancer. However, despite increased attention to the challenges of cancer care and the establishment of clinical guidelines for symptom management, previous studies indicate that patients with cancer and their caregivers often express dissatisfaction with their health care and the information provided to them during the cancer trajectory. In an international survey of women with metastatic breast cancer, 41% of women expressed the need for more easily accessible patient education (Cardoso et al., 2016). Insufficient education on supportive care can also increase challenges related to the cancer experience. Patients with cancer and their caregivers who lack the necessary education are tasked with adopting a more autonomous role in information seeking and self-education to manage day-to-day life during their cancer journey. Addressing unmet education needs on a variety of topics (e.g., healthcare system/information, patient care, supportive needs) has been found to lessen the impact of increased symptom burden on quality of life among women with breast cancer (Cheng et al., 2016). The evolution of the Internet and other digital technology has driven a rapid expansion of communication, and widespread adoption of this technology has expanded healthcare education by enabling efficient delivery via multimodal communication platforms (Curran et al., 2019).

    Background

    eHealth refers to all electronic and digital processes related to health (Triberti et al., 2019). A variety of eHealth technologies are available for use by healthcare providers to improve communication and patient care. These technologies include the Internet, intranet, telephone, videoconferencing, email, and text messaging. Telehealth, which is one facet of eHealth, is comprised of all health activities that use technology to connect individuals virtually instead of in person to provide health-related education. Telehealth is often used to describe education provided either over a telephone call or through videoconferencing technology. Additional eHealth technologies that can be applied to education include web-based, self-guided programs that can be delivered through a website (Barak et al., 2009) and mobile health (mHealth) applications or text messaging services that deliver health education through mobile devices, such as smartphones or tablets (Olla & Shimskey, 2015).

    Advancements in eHealth have also provided important methods for improved communication and education among healthcare professionals. eHealth can support oncology nurses, keeping them up to date on rapid changes in cancer treatment and management, which can be a challenge for nurses providing comprehensive cancer care in community, nonacademic, or rural settings. The majority of nurses in these settings are primary care specialists who provide a broad range of services and are often isolated from interaction with oncology specialists. For these nurses, education on cancer care is essential to the provision of quality clinical care, but providing education to nurses in community and rural settings can be particularly challenging (Curran et al., 2010). Mobile applications on smartphones and tablets, which provide real-time information and resources at the bedside, can be used to enhance oncology nursing education in these settings. Access to information through mHealth applications has resulted in increased knowledge, skills, productivity, and confidence among nurses (Raman, 2015; Wittmann-Price et al., 2012).

    This article provides an overview of the following eHealth methods that are being used to provide cancer-related education to patients with cancer, their families, caregivers, and oncology nurses: (a) mHealth applications and text messaging, (b) web-based on-demand education, and (c) audio- and videoconferencing. Case studies are also presented as exemplars of how to implement eHealth in oncology clinical practice.

    eHealth Technologies

    mHealth Applications

    One effective method to enhance patient and clinical oncology nursing education is mHealth (Curran et al., 2019). For oncology nurses, mHealth applications can provide training on physical assessment, adult and pediatric patient education, patient monitoring guidelines, drug dosing, and many other topics.

    The use of mHealth technology to provide effective education to patients and family caregivers is increasing (Curran et al., 2019; Doyle et al., 2014; Doyle-Lindrud, 2014; O’Connor & Andrews, 2015). In a randomized controlled trial of 64 patients with breast cancer who received endocrine therapy, evidence-based information was delivered through an mHealth application to the experimental group during a three-month period. Following the intervention, patients in the experimental group reported statistically higher quality-of-life scores and lower distress scores compared to patients in the control group who received standard care. In addition, 87% of patients in the experimental group reported that the mHealth information they received was useful and informative (Çinar et al., 2019). Similarly, in their systematic review of 29 empirical studies that described the use of mHealth applications for breast cancer care, Jongerius et al. (2019) found that mHealth applications positively influenced care for patients with breast cancer, particularly in promoting education regarding weight loss and decreasing stress. Oncology healthcare providers who have used mHealth applications to provide patient education have also reported that such applications help to engage patients with cancer, promote general health, and ensure that symptoms are properly monitored and managed (Berkowitz et al., 2017).

    However, although mHealth is recognized as an effective method for delivering clinical cancer care and patient education, mHealth applications require patients to take responsibility to master handheld technology and safely access data, which may be a potential barrier for some patients (Berkowitz et al., 2017). Carelessness by patients while using these applications can also create risks for data privacy, reduce communication efficacy, lead to inadequate provider follow-up, and weaken the scientific rigor of the data provided (Doyle-Lindrud, 2014).

    mHealth Applications Case Study

    Lee et al. (2017) developed an mHealth application to increase mammography screening participation among Korean American women. In Lee et al.’s (2017) study, 120 women aged 40–77 years were randomly assigned to either use an mHealth application (n = 60) or receive a printed informational brochure (n = 60). The group who used the mHealth application reported a significantly greater change in scores on their knowledge of breast cancer and screening guidelines compared to those women who only received the printed brochure. In addition, at the six-month follow-up, 45 women in the mHealth application group had received a mammogram compared to only 18 women in the printed brochure group (Lee et al., 2017). The following case study, based on Lee et al.’s (2017) study, illustrates the benefits of using an mHealth application in patients with breast cancer.

    M.K., a 42-year-old Korean American woman with a family history of breast cancer, emigrated from South Korea 12 years ago. She attends a healthcare education presentation at her local church where an mHealth application is introduced. M.K. reports that she has not received a mammogram, and she is encouraged to use the application, which provides culturally tailored education on breast cancer screening in Korean language. The application uses an artificial intelligence logarithm to provide individualized messaging (via text and video) to M.K. to increase her knowledge of cancer risks, risk factors, and the benefits of screening. The application also provides hyperlinks for the websites of clinics located near M.K.’s home, including their contact information, to help her schedule appointments. The mHealth application encourages M.K. to complete her breast cancer screening and schedule a mammogram.

    Text Messaging

    Text messaging, or short message service (SMS), is a popular intervention aimed at improving self-efficacy and behavior changes by providing education and motivational information. The advancements of logarithms to schedule and deliver text messages are a convenient method for providing health information to many individuals (Burn et al., 2017). Accessibility to mobile phones with text messaging capabilities has rapidly increased, with accessibility rates of about 90%–96% in the United States. About 98% of U.S. smartphone users send text messages regularly (Techjury, 2020). Previous studies have indicated that text messaging systems can help to improve breast cancer screening rates, monitor adherence to endocrine therapy for breast cancer, and support weight loss and physical activity behavior change among women with breast cancer (Alipour et al., 2014; Job et al., 2017; Mougalian et al., 2017). Singleton et al. (2019) developed a text messaging intervention (EMPOWER-SMS) to support women’s physical and mental health following treatment for breast cancer. EMPOWER-SMS provided educational, motivational, and supportive information to these women to help improve their health status (Singleton et al., 2019). Tailored and patient-centered text messaging can provide timely education to improve patient outcomes. However, some limitations of text messaging have been reported, such as security, confidentiality, and misinterpretation of information (Abaza & Marschollek, 2017; Aranda-Jan et al., 2014).

    Text Messaging Case Study

    An mHealth text messaging program was designed by a team of urologists at the University of California San Francisco (Balakrishnan et al., 2019). This text messaging–based program consisted of seven reminders that were sent at certain time points prior to and following a prostate biopsy. Messages contained educational content, reminders, and readiness questionnaires (Balakrishnan et al., 2019). The following case study is an exemplar of this text messaging program.

    D.W. is a 72-year-old man who is scheduled for a transrectal prostate biopsy. Beginning 14 days prior to his procedure, he is sent a series of text messages that contain information that is related to his responsibilities in preparation for the procedure (e.g., antibiotic use, discontinuation of anticoagulant, enema reminders). Text messages regarding recovery are also sent for two days following the procedure (e.g., complete symptom check questionnaires, follow-up appointment reminders). Educational content includes step-by-step descriptions of the biopsy procedure, the importance of adherence to antibiotics and enemas, and information on the importance of getting a prostate biopsy. Several of the text messages also contain hyperlinks to online, supplemental, patient-focused education information on the specific planned procedure, biopsy, and its relevance to prostate cancer. The frequency of the text messages increases as the scheduled appointment date for the procedure approaches and then decreases following the procedure. D.W. reports that the text message reminders help him to remember and prepare for his appointments. He also expresses high levels of satisfaction with the text messaging system and feels that it supplements his care.

    Web-Based On-Demand Education

    Web-based education provides valuable and accessible information, training, and resources to patients, caregivers, and oncology nurses. Web-based on-demand education can be particularly convenient for clinical oncology nurses who have ongoing education needs. In a study of the development of an effective online education program for palliative oncology healthcare professionals, 91% of healthcare professionals reported that the online education program partially or entirely met their needs, and 75% of participants planned to review or change their practice based on what they learned during the web-based education program (Koczwara et al., 2010).

    In addition, web-based on-demand education has been an effective method for relaying patient education. In a randomized controlled trial of 273 disease-free cancer survivors with cancer-related fatigue, survivors in the intervention group who participated in a tailored web-based education program reported higher quality-of-life scores and lower anxiety and fatigue scores than the control group (Yun et al., 2012). In a systematic review of 16 studies that examined the feasibility, acceptability, or efficacy of online education interventions designed to improve supportive care outcomes for patients with prostate cancer, Forbes et al. (2019) found that participants in all studies reported satisfaction with their cancer care and improved quality of life and sexual and mental health. Similarly, in their integrative review of 15 studies examining web-based survivorship education interventions for patients with breast cancer, Post and Flanagan (2016) found that outcomes based on targeted interventions showed improvement, and patients reported that they were satisfied with the web-based interventions overall. Web-based on-demand education is advantageous because of its convenience, low cost, and minimal staffing requirements; however, challenges associated with web-based education can include limited accessibility and difficulties in meeting requirements to maintain content and software updates (Moody et al., 2015).

    Web-Based Education Case Study

    CaringGuidance™ After Breast Cancer Diagnosis is a web-based psychoeducational program for distress self-management that was designed by a nurse scientist–led team (Lally et al., 2018, 2019). The following case study is based on a patient who received web-based education using the CaringGuidance program.

    B.K., a 61-year old White woman who lives in a rural community in the United States, was diagnosed with stage I breast cancer. At diagnosis, she was given access to the CaringGuidance After Breast Cancer Diagnosis web-based psychoeducational program. B.K. has been aware of her diagnosis for fewer than 30 days and is undergoing clinical consultation for her cancer treatment. She indicates that she usually spends four to seven hours per day on the Internet, and she has a laptop and an iPad on which she can access the CaringGuidance program.

    Before receiving access to the CaringGuidance program, B.K. completes the National Comprehensive Cancer Network Distress Thermometer and Problem List and receives a baseline score of 9 on a scale ranging from 0 (no distress) to 10 (extreme distress); a score greater than 4 is clinically significant. She also receives a baseline score of 41 for intrusive/avoidant thinking on the Impact of Event Scale, with a total score of 26 or greater indicating a clinically significant possibility of post-traumatic stress symptoms. By her one-month follow-up assessment, B.K. had accessed the CaringGuidance program for 101 minutes (1.7 hours). Her Distress Thermometer score decreased to 6, and her score for intrusive/avoidant thinking on the Impact of Event Scale decreased to 18 (mild impact).

    During a telephone interview at the end of the study, B.K. shares that her only concern about the program was that she feared missing content and found it difficult to recall which components she had previously accessed. In particular, B.K. found the cognitive behavior–based homework exercises, psychologist-led audio recordings, and videos from survivors within CaringGuidance to be the most helpful components. According to B.K., these components made her think about and explore her reactions to her breast cancer diagnosis in comparison to other survivors. During the three-month period, B.K. used CaringGuidance for a total of 263 minutes (4.4 hours) and accessed the learning modules 34 times and the homework exercises 43 times.

    Audio- and Videoconferencing

    Videoconferencing is the use of video technology to transmit images, voice, and data between two or more locations (Tuckson et al., 2017). Videoconferencing allows for real-time interaction between individuals, can be used to deliver education to a large number of individuals across different sites at a reasonable cost, and is well-accepted by learners. It has been widely used in continuing nursing education (Gonzalez-Espada et al., 2009).

    Quality cancer education can be delivered to providers via videoconferencing (Doorenbos, Demiris, et al., 2011; Doorenbos, Kundu, et al., 2011; Haozous et al., 2012). Conducting case reviews via videoconferencing or presenting to virtual tumor boards can allow oncology experts to connect to one another or to a community healthcare provider. Patient cases can be presented by one clinician and reviewed and discussed virtually by a panel of experts. In addition to patient case reviews, didactic education content can be included in videoconferences, which can extend learning beyond a single patient case and provide content for and applicability to clinical practice. This multiplier effect broadens the educational impact, not only for nurses but for community providers of various specialties (e.g., physicians, dentists, pharmacists, physician assistants, social workers, homecare workers, physical therapists), enabling community healthcare providers to share in the knowledge of experts. Challenges for maximizing the use of videoconferencing can include availability of videoconferencing equipment in community settings, poor Internet connection speeds, and difficulty scheduling a time that would allow for all oncology nurses and other healthcare providers to attend.

    Audio- and videoconferencing are effective and convenient methods to enhance education and social support among patients with cancer and their caregivers (Doorenbos et al., 2010). In a study of newly diagnosed women with breast cancer by Tan et al. (2018), a video-based education intervention was shown to be effective in improving breast cancer knowledge levels among participants. Morrison et al. (2018) developed a nursing telephone education intervention using a structured needs assessment for women with gynecologic cancer (TOPCAT-G) to improve patient education and empowerment, which was found to be feasible among participants. However, in a study of cancer survivors by Sprague and Holschuh (2019), no significant difference was found in satisfaction between survivors who received diet and exercise recommendations from a survivorship care plan over the telephone and those who received that same information in the clinic.

    Videoconferencing Case Study

    Videoconferencing was used in a previous study to provide patient and caregiver education to remote American Indian/Alaskan Native cancer support groups (Doorenbos et al., 2010). The following case study is based on an interview with a woman who attended one of these video-based support groups.

    H.Z. is a 54-year-old American Indian breast cancer survivor. She lives in a rural area with very few tribal cancer survivors and travels for a day to get to the cancer center where she receives her care. During a follow-up appointment at the reservation clinic, her nurse tells her about a support group for American Indians that is being delivered via videoconference and can be attended virtually from the reservation clinic. H.Z. begins to attend monthly virtual support group sessions lasting for two hours at the clinic. The support group sessions also consist of other cancer survivors and family caregivers. The video support group sessions begin with a dinner that is followed by an education presentation. Extra time is allotted following the presentation for any questions or sharing from participants.

    Education content presented during the videoconference consists of modules from Cancer 101: A Cancer Education and Training Program for American Indians and Alaska Natives. The modules cover the following topics: (a) an overview of cancer concerns among the American Indian/Alaska Native population, (b) a basic explanation of cancer, (c) cancer screening and early detection, (d) cancer diagnosis and staging, (e) cancer risks and risk-reduction strategies, (f) the basics of cancer treatment, and (g) support for patients and caregivers.

    Although the video transmission is delayed at times and the audio sometimes echoes, H.Z. reports that she is satisfied with the videoconference support group sessions overall. By seeing and hearing from other American Indian/Alaskan Native cancer survivors, H.Z. realizes she is not alone in her cancer journey.

    Implications for Nursing

    Clinical cancer care is a hands-on field, but with rapid advancements in technology, oncology nurses are uniquely positioned to investigate ways to harness that technology to deliver healthcare information and improve the effectiveness and appropriateness of technology-supported education. Adapting current education processes to be amenable to eHealth technologies remains an opportunity-rich environment for education research and increases the capacity to deliver effective healthcare education to nurses, patients, and family caregivers who cannot physically access traditional in-person care education.

    mHealth applications, text messaging, web-based on demand education, telehealth, and audio- and videoconferencing have all been demonstrated to be viable methods for facilitating education for patients with cancer and family caregivers. eHealth methods should be considered when planning education offerings for patients with cancer and their caregivers, particularly those who are unable to easily attend in-person education offerings because of geographic isolation. In addition, eHealth is a feasible and cost-effective method for delivering real-time, interactive cancer education to multiple sites, providing a practical solution to the barriers faced by community oncology nurses who are obtaining continuing education.

    Conclusion

    eHealth is increasingly being used to enhance clinical oncology nurse education, as well as patient and family caregiver education. Technological innovations, such as smartphones and tablets, web-based education, and videoconferencing, allow for easy access to information in any location at any time. These eHealth innovations offer a unique method for providing ongoing clinical oncology nursing education and nursing education for patients with cancer and family caregivers during their cancer journey. Embracing opportunities to implement eHealth strategies in education can enhance oncology nurses’ ability to improve the quality and reach of cancer care.

    About the Author(s)

    Ardith Z. Doorenbos, PhD, RN, FAAN, is a professor in the College of Nursing at the University of Illinois and the director of palliative care at the University of Illinois Cancer Center, both in Chicago; Min Kyeong Jang, PhD, RN, and Hongjin Li, PhD, RN, are postdoctoral fellows in the College of Nursing at the University of Illinois and the University of Illinois Cancer Center; and Robin M. Lally, PhD, MS, BA, RN, AOCN®, FAAN, is a professor in the College of Nursing at the University of Nebraska Medical Center and Fred and Pamela Buffett Cancer Center in Omaha. The authors take full responsibility for this content. This article was supported by a grant (No. K24NR015340) from the National Institute of Nursing Research of the National Institutes of Health. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Doorenbos can be reached at ardith@uic.edu, with copy to CJONEditor@ons.org. (Submitted December 2020. Accepted February 19, 2020.)

     

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