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Elsa Droog, PhD Claire Armstrong, PhD Sarah MacCurtain, PhD

Supporting Patients During Their Breast Cancer Journey The Informational Role of Clinical Nurse Specialists

K E Y

W O R D S

Background: Research evidence suggests that a multidisciplinary team approach

Breast cancer

improves the outcomes of patients with breast cancer. However, limited attention has

Clinical nurse specialists

examined the extent to which the clinical nurse specialist’s (CNS’s) role can impact Irish

Informational role

patients’ care, particularly given the novelty of this role in Ireland. Objective: The objective of this study was to examine the informational role of CNSs in supporting Irish patients during their breast cancer journey and the extent of its impact on their care. Methods: Three Irish breast cancer teams were investigated. A Picker questionnaire was administered to more than 100 patients per team who had completed treatment. Questions focused on the patients’ journey from diagnosis through to treatment completion. Follow-up interviews with the teams’ CNSs were conducted to achieve a deeper understanding of the care received. Results: While patients reported an overall positive impression of their care, they were least satisfied with the amount of information and emotional support they received during their chemotherapy. Clinical nurse specialists commented that there is insufficient staffing in medical oncology to address this need in part because the ill-defined job description makes it difficult to quantify the impact of this role. Conclusions: The informational role of the CNS is inadequately recognized and is thus not currently able to fully address patients’ care needs. Implications for Practice: Clarification of the

Author Affiliations: Department of Epidemiology & Public Health, University College Cork, Ireland (Dr Droog); HRM and Organisational Psychology Group, DCU Business School, Dublin City University, Ireland (Dr Armstrong); and Department of Personnel & Employment Relations, Kemmy Business School, University of Limerick, Ireland (Dr MacCurtain). The corresponding author would like to acknowledge that this PhD work was funded by the Irish Research Council for the Humanities and Social

Informational Role of CNSs

Sciences and was completed at the Department of Personnel & Employment Relations, Kemmy Business School, University of Limerick, Ireland. The authors have no conflicts of interest to disclose. Correspondence: Elsa Droog, PhD, Department of Epidemiology & Public Health, University College Cork, Western Gateway Bldg, Western Rd, Cork, Ireland ([email protected]). Accepted for publication September 19, 2013. DOI: 10.1097/NCC.0000000000000109

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CNS’s role description in oncology care in Ireland is needed as is sufficient CNS staffing to maintain the vital informational role of CNSs throughout the patients’ breast cancer journey.

E

vidence-based healthcare policy on breast cancer care in Western Europe includes the multidisciplinary team (MDT) approach as the standard structure of care.1Y3 The European Society of Mastology has published guidelines for ideal multidisciplinary clinics and has established a certification system for dedicated breast centers.4Y6 An essential prerequisite is that each breast unit has a core team consisting of health professionals from diverse disciplines who have undergone specialist training in breast cancer, beyond that provided in their general medical education.7 In Ireland, the MDT approach to the treatment of breast cancer is in its infancy. The origins of this arrangement date back to 1999 when the National Cancer Forum of academics and healthcare specialists was established for the purpose of reporting to the Department of Health & Children and making recommendations on the development of breast services for patients with breast cancer symptoms. Findings in the report on the Development of Services for Symptomatic Breast Disease revealed that the level of service provision varied throughout the 33 hospitals in the country.8 There was an absence of specific breast clinics. Instead, patients were seen as part of the general surgical clinic. An MDT structure did not exist. Following this report,8 a framework of national quality assurance guidelines for symptomatic breast disease services was proposed in a report on the National Quality Assurance Standards for Symptomatic Breast Disease Services,9 which also recommended that these services be delivered across 8 centers. From this, a major national policy initiative for multidisciplinary breast cancer care was launched in 2006/2007. However, coinciding with this initiative was the emergence of a number of false-positive and false-negative breast cancer diagnoses among women in 2 healthcare regions in Ireland. The reports10Y13 on the circumstances surrounding the misdiagnoses indicated systemic weaknesses in the coordination of the multiple professions involved in the diagnosis and treatment of each patient. Following the misdiagnoses, national policy focused on the immediate task of achieving a complete reorganization of the country’s breast cancer services into 8 regional specialized centers. It also established national quality assurance standards of clinical practice in symptomatic breast disease in each setting. In 2010, a national quality review of symptomatic breast disease services indicated significant progress to date in the transition from the variable application of a multidisciplinary approach to patient care throughout the 33 hospitals in the country, to all 8 centers now having clear staffing arrangements in place for the delivery of multidisciplinary care of all patients.14 Nonetheless, at the time of that review, comments were made regarding the lack of adequate personalized care and support during chemotherapy. Insufficient information and time made available to discuss adverse effects of chemotherapy and how 430 n Cancer NursingTM, Vol. 37, No. 6, 2014

these could be managed were highlighted. The absence of dietary advice was also noted. Based on these findings, the aim of this study was to examine the informational role of clinical nurse specialists (CNSs) in supporting patients during their breast cancer journey in Ireland and to understand the extent of its impact on their care. n

Informational Role of the CNS

The role of the breast care nurse specialist has become an established discipline in oncology since the work of Maguire et al,15 which drew attention to the high degree of psychiatric morbidity in patients undergoing breast surgery and the need for nursing intervention and support. Evaluations of this role have taken place in a wide range of settings, outside of Ireland, and evidence has demonstrated a strong link between the CNS role and the patients’ overall well-being.16 Studies show that specially trained CNSs in counseling and communication are primary members of the multidisciplinary breast cancer team and meet the healthcare needs of their cancer patients through psychosocial support, education, and information.17Y20 Indeed, the proportion of nurses on the multidisciplinary breast team can positively influence the team’s achievement of optimal clinical performance for newly diagnosed breast cancer patients.21 Moreover, this role has positively influenced the information and support received by women with breast cancer.22 It has improved their symptom management, emotional functioning, and quality of life; increased satisfaction with care; and decreased numbers of physical symptoms.23,24 Information seeking has been identified as a coping strategy of the breast cancer ‘‘survivor personality.’’25(p35) For example, in a study where women with breast cancer were surveyed about their counseling needs, a woman said, ‘‘Fact finding is the most important timeI. Information is the key to acceptance and help with anxiety and fears.’’26(p27) Information, given in everyday language,27 has been shown to reduce uncertainty and anxiety,28 help patients to gain control over their lives,29,30 and enhance self-care ability.31,32 However, although the CNS role is a major informational resource to patients,33Y35 it is difficult to confirm this through research.32 According to the literature, the informational role of the CNS can be very much a key unseen role.36 It is variable, sporadic, limited, and in some situations nonexistent.37 Commonly, when the CNS is off sick, on annual leave, or otherwise unavailable, there is no guaranteed fall back for covering this need.38 It has been found that the psychosocial aspects of cancer are not routinely covered.39,40 In particular, sexual well-being is a neglected area of discussion between patients and healthcare professionals,41Y43 not just in the surgical phase but often extending beyond the initial phase of treatment.44 Further investigation of the possible beneficial effect of the CNS on patients’ outcomes

Droog et al

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is required, especially given the fact that CNSs are at the top end of the nursing pay scale and are thus viewed as costly.45 n

Methods

Research Setting The aim of this study was to examine the informational role of CNSs in supporting patients during their breast cancer journey in Ireland and to understand the extent of its impact on their care. On this basis, the research was set in the country’s specialized breast cancer centers. Approval was received from the institutional ethics committees at 3 hospitals and the university to conduct the study. Following this, consent was obtained from the lead clinician in each breast team for the participation of patients who had completed treatment. Additional consent for participation was obtained from CNS participants working in the teams.

Data Collection Procedures The data collection time period began in January 2010 and was completed in December 2010. It involved 2 procedures. First, the Picker Ambulatory Oncology Survey Instrument46 was used to obtain information on the patients’ perceptions of the care they received from the breast cancer teams from the diagnosis to treatment completion. This instrument was standardized and validated in Canada in 2005 and had an average reliability of 0.93. In recent years, this survey has been used to measure the experiences of cancer care patients in British Columbia, Canada,47 New South Wales, Australia,48,49 and New Zealand.50 In this study, 10 items were added to the questionnaire based on issues raised in the literature, which did not appear in the Canadian Picker Questionnaire. These items were based on questions asked in the New South Wales Picker Questionnaire and reworded to suit the Irish health system context. It is a 5-page questionnaire comprising the following 10 main sections: (1) about your diagnosis, (2) planning your treatment, (3) about your tests, (4) about your surgery, (5) about your chemotherapy, (6) about your radiation therapy, (7) symptom management, (8) your healthcare providers, (9) your overall impression of your care, and (10) your background. There is also an open-ended question at the end of the questionnaire for patients to comment on their breast cancer journey. Second, based on findings emanating from the administration of the questionnaire, follow-up interviews were conducted with the teams’ CNSs in order to gain a deeper understanding of the care provided. Prior to the interview, the purpose of the study was explained to the CNS. The interview was semistructured and provided feedback from the patient questionnaire. Each CNS was asked the following: (1) to give an account of the nature of the patient-nurse relationship in breast cancer care; (2) to describe all aspects of the informational role of the CNS associated with supporting patients at each stage of their breast cancer journey, from making decisions on treatment, trial or otherwise, to managing the adverse effects of a given treatment; and (3) to comment on the challenges, if any, that face CNSs in fulfilling their role today, with particular reference to findings in the patient questionnaire

Informational Role of CNSs

on the coordination and continuity of the patient-nurse relationship beyond the surgical phase of treatment.

Sample Size In this study, the patient questionnaire was administered to a sample of at least 100 patients per team who were attending the review clinics for treatment that they had received since 2006/2007. The reason for this year was that it was at that time when the national cancer control forum first launched a major national policy initiative for multidisciplinary breast cancer care. A total of 81 items were asked and did not include questions that might uniquely identify individuals. In 2 of the teams investigated, the questionnaire was administered face-to-face to patients. In the third team, the questionnaire was completed over the telephone for practical reasons. In total, 54 review clinics were attended and 101 telephone calls were made, and of the 323 unique patient questionnaires, 302 were usable. Furthermore, only 2 of these questionnaires were completed by male patients. A follow-up interview was then conducted with each of the teams’ CNSs. The sample size per team ranged from 3 to 6 CNSs and included team 1, 3 breast cancerYspecific CNSs; team 2, 2 breast cancerYspecific CNSs, 1 clinical nurse manager acting as a breast cancerYspecific CNS, and 2 oncology liaison nurses, whose responsibility was for patients presenting with breast cancer only; team 3, 4 breast cancerYspecific CNSs and 2 oncology liaison nurses, whose responsibility was for patients presenting with all cancers. Despite the small sample size in terms of absolute numbers per team, there was a 100% response rate for CNS participation, and in total, 14 interviews were completed.

Data Analysis The patient questionnaire comprised 8 dimensions: (1) access to care, (2) coordination and continuity of care, (3) surgery specific issues, (4) physical comfort, (5) information, communication and education, (6) emotional support, (7) respect for patient preferences, and (8) overall impression of visit. Positive response (P) scores for each dimension of care were calculated. Positive scores for the dimensions are the proportion of positive responses across all the questions in the dimension relative to the total number of responses across all the questions in the dimension. In a separate analysis, positive scores were calculated for all items affiliated with each dimension of care. Quotations from breast cancer patients about their breast cancer journey were used to add further explanation to the respective positive scores. In addition, all transcripts from the CNS interviews were imported into NVIVO (version 8; QSR International (UK) Limited, United Kingdom), and all quotations were transferred into nodes to analyze the data. n

Results

Overview of Findings From the Patient Questionnaire In general, all patients across the 3 breast cancer teams reported a high level of satisfaction (95%) with their overall care in terms of the following: patients’ care providers did everything they could Cancer NursingTM, Vol. 37, No. 6, 2014

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to treat their cancer, patients highly rated the quality of care they received during their cancer treatment, patients highly rated the quality of all of their care overall, and patients recommended their healthcare providers to their family and friends. Moreover, this rating of care was reflected in an overall positive hospital rating, where patients reported a mean value of 9.13 of 10.0. Quotations below sum up the patients’ overall impression of their care delivered by the 3 teams examined. Excellent care and very caring breast care nurses and a very caring surgeon and team. (I.D. 82) The team was exceptional! They made the journey as easy as possible. (I.D. 309) In addition, all patients across the 3 breast cancer teams reported high levels of satisfaction in the 7 remaining dimensions of care (Table).

Emotional Support The dimension of care that received the lowest score rating across all 3 teams was ‘‘emotional support.’’ In particular, female patients significantly commented on a lack of information received regarding possible changes in their emotions during their care. I felt that I didn’t get enough information about possible changes in my emotions. Chemo affects the brain, your whole personality. I lost my confidence. (I.D. 298) I felt that there was no one for my partner to talk to, to give us that family support we needed. (I.D. 283)

Information, Communication, and Education In the dimension entitled ‘‘information, communication, and education,’’ patients across all 3 teams reported a low rating of 59% for the dimensional item on ‘‘getting enough information about their nutritional needs.’’ Quotations listed below from some female patients highlight the following: the lack of nutritional information received during their care, the anxiety this caused them in their efforts to boost their immune system during chemo and then finding out that what they were taking could affect their treatment, and now their constant endeavor to

Table & Patients’ Positive Scores Across the Dimensions of Care

Dimensions of Care

Patients’ Positive Scores, %

Access to care Coordination and continuity of care Surgery-specific issues relating to waiting time until day of surgery and understanding results of surgery Physical comfort Information, communication, and education Emotional support Respect for patient preferences

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81 84 92

90 80 75 87

combat the weight gained from being on steroids after treatment in an effort to achieve a better mental control of their illness and to build a healthier lifestyle. I should have received information on dietary support. I had to research the whole thing myself. I found out that eating pineapples are good for treating mouth blisters and eating marshmallows are good for getting rid of the nausea. (I.D. 292) On one of my chemo visits, I happened to say to the nurse that I was taking soya products. She said to me that she would recommend that I stop taking them as they could affect the chemo. If I had only been made aware of it earlierI (I.D. 310) I was in work one day, and a colleague of mine had a cold. I was afraid I would get it being on chemo. I took RUBEXVa vitamin C boosterVfor 5 days. I told one of the oncology nurses about this on my next visit just to check to see if it was OK. She said to me to take fresh oranges instead, that RUBEX could nullify the effect of the chemo. I really didn’t know what to think after that! (I.D. 143) A more balanced diet would have given me better control over my weight and therefore more mental control over my illness. (I.D. 196)

Coordination and Continuity of Care A final finding in the patient questionnaire was that female patients significantly commented on the coordination and continuity of their care, particularly in terms of not knowing whom to ask when they had questions about their health problems. They were quoted as saying that, while they had their breast care nurse that they could call to ask questions about their health problems during their surgical care, this one-to-one patientnurse relationship did not exist in their oncology care. Because of this lack of liaison/personal contact, patients felt that they were forgotten about during their chemotherapy treatment and were left second guessing themselves with their symptoms. Some patients felt that they could not go back to their breast care nurse for help as they believed it was not her job. The transition in my care from surgery to oncology was very different. You get such a hand holding in surgical care. But, there is no all-inclusive-type transfer in oncology care. The patient and breast care nurse relationship in surgical care does not exist in oncology care. My breast care nurse gave me great information about my surgery and somewhat touched upon the oncology side of my care. However, my oncology nurseVwho was usually not the same person on each of my visits to the oncology unitVdid not give me sufficient information about my oncology care. I was given no understanding of the various adverse effects of the chemotherapy and radiotherapy treatment to the extent that I second guessed myself at times with my symptoms. (I.D. 119) After your surgery, you have no backup. No one is ringing you to see how you are doing with the chemo or the

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radiation. You think at times that you’re the only one experiencing such symptoms! I couldn’t call my breast care nurse as her job is to look after patients before and after surgery. You’re kind of left to learn as you go along. (I.D. 305)

Overview of Findings From the CNS Interviews On further examination of the patient questionnaire findings through interviews conducted with the teams’ CNSs, however, CNSs reported that all 3 teams were significantly understaffed, particularly liaison nursing in medical oncology: ‘‘We just don’t have enough hands’’ (I.D. 1). The significance of the role of an oncology liaison nurse is as ‘‘Ian education link person’’ for patients undergoing chemotherapy (I.D. 31). Because oncology deals with all cancers, colon, brain, and lung, the patient tends to lose that doctor-nurse relationship that they experienced in breast surgery, which is a specialty on its own and therefore ‘‘Ithe way to rectify it is with a liaison person’’ (I.D. 15). Two reasons were given for the lack of sufficient oncology liaison nurses: (1) the staff embargo and (2) the definition of the CNS role.

Staff Embargo First, the embargo on staff recruitment, because of budgetary deficits in the healthcare service, has resulted in instances whereby maternity leave is being covered by part-time CNS staff only. This has required these liaison nurses to work harder to care for the volume of breast cancer patients, particularly in medical oncology. We have to really work at communicationI. We have a communication book, but we also have a lot of phone contactI that would include me being phoned at home or (the other liaison nurse) being phoned at home because that’s what we need to doI sometimes it’s not enough to write something because it wouldn’t give you an impression of what’s going on with the person psychologically or any other issues that are hugeI. Circumstances are so individual with each patient. You have to be able to completely try to make it as transparent as possible the flow between the two of us as to where we are at with the patient. (I.D. 38) Clinical nurse specialists commented that the job would be better served by full-time breast cancerYspecific liaison nurses ‘‘Ifor cohesion, for continuity’’ (I.D. 38). This is because they would have their own list of patients, unlike having to share the list because of part-time commitments and therefore ending up knowing only half of the patients really well, because they would have educated them on the day of their first consultation visit with the oncologist. Iwhen you don’t have that first consult and you don’t educate them, you are kind of going back and you are gathering. You haven’t that same relationship with themI. I don’t think it breaks down communication but it hinders their care. (I.D. 36) In addition, this part-time arrangement in 1 medical oncology team has had a further impact on the functioning of the breast cancer team ‘‘Ibecause the likes of (the medical oncol-

Informational Role of CNSs

ogist) or any of the surgeons just never know whether they are going to get me or (the other liaison nurse) or if either of us was to be around if they were to look for one of us anyway, so it’s a bit less ideal’’ (I.D. 38). Going forward, CNSs commented that this part-time arrangement in liaison nursing ‘‘Iwouldn’t be very sustainable’’ (I.D. 38). A further, and more significant, consequence of the staff embargo is the absence of liaison nurses in 1 medical oncology team to address the care needs of breast cancer patients. The result of this is that, when the patients have their first consultation visit with the oncologist after their surgery, they are not educated on their specific line of treatment until their first chemotherapy visit in the day ward. It is then when they can talk to the chemotherapy nurses if they have any queries ‘‘Ibut that’s a long time to wait with all those questions’’ (I.D. 14). Current efforts are being made to ensure that the patients have the same chemotherapy nurses from their first chemotherapy visit through to the end of their care. However, this continuity of contact for the patient is not always feasible because of the rotation of chemotherapy nurses between the day ward and the inpatient ward. Iwe do make an effort if they have connected with somebody that they would continue with that personI but that can’t always happen. (I.D. 14) At presently, this ‘‘Ideficit of life support’’ is ‘‘dangerous’’ (I.D. 23). For example: I had a lady yesterday who contacted me. She couldn’t get through to the chemo ward because they were incredibly busy there, but that’s where she had her chemo 2 weeks agoI. The woman had a massive abscessI. She was a diabetic. She was incredibly unwell, but it all worked out well. She was brought in. But if that was left unaidedI she could be incredibly unwell. (I.D. 23)

Role Definition of the CNS Despite consideration given to the staff embargo, however, a more grave explanation for the lack of sufficient liaison nurses is the description of their role. In short, it is ‘‘Ivery airy fairy’’ (I.D. 40). There are just huge areas that you could say, right, that’s youI every liaison nurse in the country nearly has a slightly different element to the rolesI and management can push it into what (it) wants. (I.D. 40) Clinical nurse specialists commented on the fact that, recently, their role has had to change because of the fact that the increase in patient numbers has not been met with an increase in oncology liaison nurses. In 1 team setting, the oncology liaison nurses only now see the patients in the outpatient clinic when the patients have their first consultation visit with the medical oncologist or when they are in for a review halfway during their treatment. Particularly after the patients have had their first consult with the oncologist, what is happening now is that the liaison nurse has to seat them in a ‘‘Ibusy corridor’’ (I.D. 40) to educate them on their treatment and gives them written information Cancer NursingTM, Vol. 37, No. 6, 2014

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about it. She is not supposed to leave the clinic because ‘‘Iyou have only 3 hours to see x amount of patients, and if you spend 1 hour with one, the others are missing out as well on your time’’ (I.D. 40). At this stage, the liaison nurse ‘‘Ikind of feels more that (the patients) don’t want to feel they are being rushed, and I’m just throwing information at them and giving them a folder’’ and ‘‘Ionce somebody gets upset in the corridorI you’re constantly apologizing to them that you don’t have a room’’ (I.D. 40). However, the liaison nurse does point out that she will allocate a time to ring the patients back over the next 2 days and offer to meet them again in a quieter area. Nonetheless, after that meeting, the patients do not see the liaison nurse until halfway through their treatment when they are reviewed by the oncologist in the clinic. Rather, the patients go into the day ward for treatment for 3 or 4 months where they meet a number of different chemotherapy nurses. Ideally it would be nice to offer them all a chemotherapy nurse, but we don’t have the facility to do that. (I.D. 32) Patients are given the phone number for the liaison nurse and the number for the day ward should they have a problem. However, the patients who do not call the liaison nurse are the ones with problems. Ithey are the ones who could actually be forgotten about, and they are just being seen in the day ward and deemed as no problem, but when you actually got the opportunity to contact them, arrange to meet them, they had loads of social problems but didn’t want to ring us because they knew we were so busy. (I.D. 40). And although the CNS role is recognized by the consultants and management, it is very difficult to quantify its importance in order to justify an increase in oncology liaison nurses. A large portion of the time is spent on the phone talking to patients and, if there is a problem, talking to their primary care team such as the general practitioner or the home care nurse in order to avoid having the patient come into the day ward or being admitted. The hallmark of this role is early intervention. I am always so passionate about liaison. I would always be putting in the numbers, the calls, but it’s very hard to quantify itI because (the patients) haven’t had to clock into the hospital, there’s no recordI and putting it into a database it might be just one line, and it doesn’t reflect back on the amount of work that went into it. (I.D. 40)

professionals,41Y43 not just in the surgical phase but often extending beyond the initial phase of treatment.44 In this study, however, it is a nurse-perceived concern that there is a major problem of understaffing in the area of liaison nursing in medical oncology. One team examined does not have a liaison nurse to look after its breast cancer patients when they have their chemotherapy. Indeed, it was during the administration of the questionnaire that patients significantly commented on the lack of a one-to-one nurse contact that they could call on if they had any questions about their health problems during their chemotherapy. The result of this was that patients felt that they did not receive sufficient emotional support and information about their nutritional needs in all 3 teams concerned. As mentioned earlier, this qualitative finding has already been highlighted in a national quality review of symptomatic breast disease services in Ireland.14 While the embargo on staff recruitment was given in this study as a common reason for this understaffing, grave concern was also raised over the fact that the job description of a liaison nurse in medical oncology is ill defined. This is evidenced by the large areas the job covers and the fact that each CNS has slightly different elements to their role and that there is a difficulty in quantifying the importance of this role in order to justify an increase in oncology liaison nurses. Indeed, this finding has been highlighted in the literature, which has found the informational role of the CNS to be variable, sporadic, limited,37 and very much unseen.36 Nonetheless, this study builds on the evidence that ultimately supports the unique role of CNSs in cancer care provision, particularly from the patients’ perspective. Moreover, the findings of this study support the call for a clarification of the role description of the CNS in oncology care in Ireland matched with sufficient CNS staffing in the MDT, in order to maintain the informational role of CNSs throughout the patients’ breast cancer journey. Although it was possible to investigate only 3 teams of a possible 8, the number of patients in our sample (302) and the 100% response rate of the CNSs in the 3 teams provide us with some confidence that these findings are valid. However, because of the limitation of the Picker instrument, in terms of its general questions about care and nursing, further investigation of the effect of the CNS on patient outcomes would be welcome through the use of a more sensitive indicator of the CNS role.

References n

Discussion

This study has found that patients are not receiving enough educational support in relation to their nutritional needs as well as enough emotional support. The latter is particularly evident in the informational areas about possible changes in patients’ emotions, their sexual activity, and in their relationship with their spouse or partner. This finding is reflected in the literature where it has been cited that the psychosocial aspects of cancer are not routinely covered.39,40 Moreover, sexual well-being is a neglected area of discussion between patients and healthcare 434 n Cancer NursingTM, Vol. 37, No. 6, 2014

1. Fleissig A, Jenkins V, Catt S. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol. 2006;7(11):935Y943. 2. Houssami N, Sainsbury R. Breast cancer: multidisciplinary care and clinical outcomes. Eur J Cancer. 2006;42(15):2480Y2491. 3. Whelan JM, Griffith CD, Archer T. Breast cancer multidisciplinary teams in England: much achieved but still more to be done. Breast J. 2006;15(1): 119Y122. 4. Blamey RW, Cataliotti L. EUSOMA accreditation of breast units. Eur J Cancer. 2006;42(10):1331Y1337. 5. EUSOMA. The requirements of a specialist breast unit. Eur J Cancer. 2000;36(18):2288Y2293. 6. Greco M, Marotti L. Background to EUSOMA guidelines and statements. Eur J Cancer. 2006;42(14):2200Y2204.

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Cancer NursingTM, Vol. 37, No. 6, 2014

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Supporting patients during their breast cancer journey: the informational role of clinical nurse specialists.

Research evidence suggests that a multidisciplinary team approach improves the outcomes of patients with breast cancer. However, limited attention has...
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