Skrutkowski, M., Saucier, A., Eades, M., Swidzinski, M., Ritchie, J., Marchionni, C., & Ladouceur, M. (2008). Impact of a pivot nurse in oncology on patients with lung or breast cancer: Symptom distress, fatigue, quality of life, and use of healthcare resources. Oncology Nursing Forum, 35, 948–954.

To determine whether patients followed by a pivot nurse/nurse coordinator would have less symptom distress and less healthcare resource utilization as evidenced by fewer unscheduled clinic visits, fewer emergency room visits, and hospitalizations than a control group

Patients were randomly assigned to a pivot nurse in addition to usual care (experimental group) or usual care only. The pivot nurse (PNO) was a baccalaureate-prepared palliative care nurse with experience and additional training in cancer symptom management. The PNO met with patients and caregivers in the ambulatory setting to review understanding of the diagnosis, expected side effects of treatment, and resources available to the patient. Patients were taught ways to identify and cope with systems and offered education and support as needed. The PNO advocated for patients in interdisciplinary rounds, developed care plans and referrals, and provided support, information, coaching, etc., via follow-up telephone calls. Usual care included symptom assessment and teaching for management, but not in a formally coordinated manner. With usual care, patients did not necessarily see the same nurse at each appointment, and telephone follow-up was usually patient initiated. The study was conducted over a six-month period. Data were collected at each clinic visit, about every three weeks, for a maximum of eight measurements.

• The study reported on a total sample of 113 patients.
• Mean patient age in the control group was 60.5 years ± 11.1; mean patient age in the experimental group was 59.3 years ± 10.7.
• Patients were diagnosed with breast or lung cancer.
• The sample was 67%–71% female and 29%–33% male.
• Of the total sample, 67%–72% were married; 36% in the control group and 51% in the experimental group had stage III or IV cancer, and 19% in the control group and 23% in the experimental group had metastatic disease; 75%–83% were deemed as having adequate financial resources; and more than 70% in both groups had sufficient help at home.

• Outpatient setting
• Canada

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

• McCorkle Symptom Distress Scale (SDS)
• Functional Assessment of Cancer Therapy Scale–General (FACT-G), version 4
• Brief Fatigue Inventory (BFI)
• Hospital records

There were no differences in SDS scores over time between groups. Over time, patients in the lung cancer groups had more distress than patients with breast cancer (p = 0.023). There were no significant differences between groups for BFI findings. Patients with lung cancer reported more fatigue (p = 0.002). There were no differences between groups in FACT scores. Significantly lower quality-of-life score were reported by patients with lung cancer (p = 0.0024). There were no differences between groups in healthcare resource utilization data included in this study. Over time, patients with breast cancer were less likely to have hospitalizations shorter than 72 hours than those with lung cancer (p = 0.001).

Care provided by a PNO did not result in any difference in symptom distress or healthcare resource utilization. Patients with lung cancer had higher symptom distress, had more fatigue, and used more healthcare resources, which is in concert with differences in the disease trajectories between lung and breast cancer.

A higher proportion of patients in the intervention group had presence of metastases, and a slightly higher proportion had disease recurrence. It was not stated whether these differences were statistically significant, and these differences could have influenced results in terms of symptoms and resource usage needs. No information was provided in terms of any other chronic healthcare conditions that may have also influenced the results. Authors reported overall SDS results but did not identify actual symptoms experienced or differences at that level between groups. Clinically, different symptoms can be expected to yield different degrees of distress and needs for medical intervention and associated healthcare use. The authors reported a final sample of 113 and results in these, but provided baseline characteristics in 190 patients. One cannot evaluate actual final differences between groups in these characteristics. No power analysis was provided in order to determine if the sample size had sufficient power to detect differences. The study assumes that all practitioners in a given role should be expected to achieve standard results, while this may not be the case. The PNO in this study was not an advanced practice nurse, with associated advanced education. Nurses in the usual care group were highly experienced, and more than 75% were oncology certified. This factor may have caused there to be no substantial clinical difference in the actual nursing care provided for symptom management. The study only lasted six months—effect of better care coordination and symptom management may be more effective over a longer term. No information was provided regarding the time since diagnosis or the phase of care for patients studied, factors that could be expected to influence these aspects of care and patient needs.

This study did not provide any supportive findings for the role of a PNO as implemented in the study. Further research in this area needs to provide the ability to directly contrast this type of intervention with the nursing care provided in usual care. Research in the impact of various roles such as this, navigators, clinical nurse specialists, etc., need to provide better structure, consistency, and definition of these responsibilities and patient interactions. Inclusion of findings related to patient satisfaction with care in this type of research may be helpful.