F E AT U R E S
Patients’ Perspectives of Fast-Track Surgery and the Role of the Fast-Track Clinical Nurse Consultant in Gynecological Oncology ■ ■
Shannon Philp, MN(NP), RN, NP ■ J. Carter, MD (CGO) ■ C. Barnett, PhD ■ N. D’Abrew, BA S. Pather, MD (CGO) ■ K. White, PhD, RN This study examines the role of the fast-track nurse in gynecology from a patient perspective. The fast-track nurse is a specialist nursing role, which coordinates patient care, in addition to providing specialized clinical care. Semistructured interviews were conducted with women who had fast-track surgery for gynecological cancer. KEY WORDS: fast-track surgery, gynecological oncology, fast-track nurse, patient satisfaction, nurse-led follow-up Holist Nurs Pract 2015;29(3):158–166
Fast-track surgery (FTS) is a multimodal approach to the management of surgical patients and requires the successful organization of all members of the health care team. A key element of FTS is the nurse-led clinical coordination between acute and primary health sectors, in addition to the maintenance of quality clinical care. Nurses have increasingly become involved in the delivery of advanced technical care, triage, and coordination of care.1 This is in addition to patient education and psychosocial support from point of entry to the service, through surgery, initial recovery, and into the follow-up period where they provide ongoing support and appropriate referral. One area of nurses’ involvement is the development of nurse-led services in cancer care, including gynecological cancer. The establishment of a Author Affiliations: Lifehouse Gynaecologic Oncology Group, Chris O’Brien Lifehouse, Missenden Road, Camperdown, NSW, 2050, Australia (Ms Philp, Profs. Carter and Pather); Cancer Nursing Research Unit (MO2), Sydney Nursing School, University of Sydney, Sydney, NSW, Australia (Ms Philp, D’Abrew and Dr Barnett, Prof. White); Sydney Medical School, The University of Sydney (Profs. Carter and Pather); Sydney Cancer Network, Sydney Local Health Network, Sydney, NSW, Australia (Ms Philp and Prof. White); School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Joondalup WA Australia (Prof. White). The SGOG is now known as the Lifehouse Gynaecologic Oncology Group (LGOG) and is located at Chris O’Brien Lifehouse. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Cancer and Haematology Nursing, Sydney Nursing School, The University of Sydney, 88 Mallett St, Camperdown, NSW, 2050, Australia ([email protected]). DOI: 10.1097/HNP.0000000000000086
fast-track nurse (FTN), by the Sydney Gynaecological Oncology Group (SGOG) at Royal Prince Alfred Hospital (RPAH), Sydney, Australia, to coordinate patient care and communication before, during, and after FTS, is a new service, which was evaluated in this study from a patient perspective.
BACKGROUND Fast-track surgery aims to decrease the physical trauma of surgery and achieve a recovery outcome with no complications.2 Although reducing the patients’ stay in hospital forms part of these aims, the primary aim is to improve patients’ recovery after surgery, as well as reducing their morbidity.2,3 The elements of FTS occur at all stages of the surgical program. At the preoperative stage, the elements include commencing coordination of care, patient counseling, avoiding bowel preparation, minimizing fasting, and no premedications. Intraoperatively, they include patient warming, using short-acting anesthetics, analgesia, and transversus abdominis plane blocks while avoiding nasogastric tubes, fluid overloading, and drains. Finally, postoperatively, FTS elements include minimizing opioid analgesia and using nonsteroidal anti-inflammatory drugs, adhering to the postoperative nausea and vomiting protocol, and encouraging early mobilization, catheter removal, and oral feeding. More broadly, establishing care pathways and performing routine audits are also part of the FTS
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
process. For the purposes of this paper, a key feature of FTS is the introduction of the nurse-led follow-up clinic as part of patient care. The SGOG developed its fast-track protocol in 2008 and across several audits confirmed that FTS is safe and feasible in the gynecological oncology setting.3-5 In 2010, the SGOG established the role of the FTN, which was filled by an experienced clinical nurse consultant who provides expert coordination across the areas of gynecological cancer surgery. From a task perspective, the FTN provides day-to-day coordination, triage, clinical care (such as ensuring adequate analgesia, preventing postoperative nausea and vomiting, preventing constipation, and encouraging early mobilization), patient education, and psychosocial support including preoperative counseling, discharge planning, structured individualized advice, routine follow-up, and conduct of the nurse-led clinic, as well as appropriate referral. As part of the multidisciplinary health care team, the FTN is also able to consult with other clinical experts and refer to specialist services that the patient requires. More broadly, however, the role of the FTN, providing supportive and holistic care as it does across the entire process, benefits patients in additional ways. Patients receive consistent information and care, which can be tailored to their individual needs. This may also translate into emotional care, thereby supporting a more holistic view of the patient. These psychological outcomes of the higher-level, structured care provided by the FTN are some of the benefits of the realignment of the way patient care is provided during FTS and nurse-led follow-up. Preoperatively, the effectiveness of a fast-track program depends on adjusting the patients’ expectations of their hospital stay.6 Psychological preparation has been linked to shortened hospital stay and a decreased need for analgesics, thus balancing patient expectations with actual clinical outcome.7 Postoperatively, successful FTS includes nurse follow-up, such as an FTS nurse clinic. The few early studies specifically examining this highlight that nurse follow-up can be a cost-effective way of addressing the increasing pressure on follow-up services and is also acceptable to consumers.8,9 For the fast-track gynecological surgical route to be cost-effective, routine medical follow-up care needs to be sustained. However, the time constraint of a medical follow-up appointment may inhibit adequate assessment of issues or concerns women wish to explore. This has been addressed through
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the establishment of a nurse-led clinic conducted by the FTN that is managed separately to the routine medical follow-up. The nurse-led clinic appointment for follow-up, approximately 1 week after surgery, provides an opportunity for patients to discuss physical, emotional, and psychological concerns and for nurses to utilize their specialist skills.8 These skills include advanced clinical assessment skills and psychosocial screening and counseling skills and reflect not only higher education and training in such areas as oncology nursing and advanced assessment, but also the commitment to holistic patient care across the surgical/clinical process and upon a patient’s return to home. In light of this, this study aimed at exploring the experiences of fast-tracked gynecological oncology patients on the care provided to them by the FTN. It is anticipated that FTS, relying on nurse coordinated care, education, and follow-up, is a satisfying experience for gynecological oncology patients.
METHOD Participants All women who were part of the fast-track program between January 2010 and July 2011 were invited to participate in a program of research being conducted by the SGOG. This included women with a gynecological cancer or a complex benign gynecological condition. Eleven women agreed to participate in an interview exploring patients’ experiences around the role of the FTN.
Materials A semistructured interview schedule was developed and used. Patients were given the choice of a face to face interview or a telephone interview. Interview questions revolved around the impact of early discharge, preparedness (physically/emotionally) for surgery, managing complications, and general satisfaction (see Appendix 1).
Procedure Patients who had completed the FTS program were invited to participate via a letter sent to them after they were discharged. A total of 207 patients were sent invitations as part of a larger quantitative study, with 106 agreeing to participate. Of these 106, the first 11 patients (N = 11) who responded agreeing to an
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interview were contacted by telephone and an interview time was arranged. The interviews were mostly conducted over the phone and, in a few cases, were conducted in person. Written consent was obtained prior to interviews being conducted. All interviews were subsequently transcribed verbatim with identifying information removed. The qualitative data obtained from the interviews were analyzed collectively using content analysis. Interviews were transcribed and transcripts were read thoroughly, coded, and then collapsed under higher-order categories (see Table 1). These higher-order categories were verified by a second person with experience in qualitative research and reporting.
Ethical considerations This study was approved by the Human Research Ethics Committee at RPAH. All participants were informed of the study and assured that participation was voluntary. Participants were also assured that refusal to participate would not affect their care in any way. Written consent for interviews was obtained prior to being conducted in accordance with ethical and hospital guidelines.
TABLE 2. Demographic Results (N = 11) Variable
Mean (SD)
Range Frequency
Age, y 55.69 (10.48) 43-76 Marital status Never married/single Married/de facto Widowed Divorced/separated Qualifications Year 10 and below Year 12/HSC Tafe certificate/diploma University Bachelor’s degree University postgraduate degree Medical/allied health training (eg, nursing, midwifery, and physiotherapy) Place of birth Australia Other Regular sexual partner Children Major life event (eg, job change, death, financial stress, and house renovations) Length of stay 3.4
1 6 1 3 2 1 1 4 3 5
10 1 6 6 4
Abbreviations: HSC, Higher School Certificate; SD, standard deviation.
RESULTS Demographic results for the 11 (N = 11) participants are shown in Table 2.
Qualitative interviews Eleven participants were interviewed about their experience and satisfaction with care as a patient whose surgery was fast tracked. Three broad categories emerged in relation to participants’ experiences, with subcategories revealing specific issues relevant to the fast-track program. The broad categories were preadmission, postoperative care, and the role of the FTN. These are described below in
major headings, with subheadings articulating more specific issues. Table 1 illustrates the categories and subcategories. Preadmission All interviewees, except 1, attended preadmission. They reported mostly positive comments about the service in respect of the usefulness of the information given and the reassurance it gave to participants who were anxious about forthcoming surgery. Some participants found the process quite involved with a lot of information to absorb.
TABLE 1. Main Categories and Subcategories From Qualitative Interviews With Patients Preadmission
Practical needs Emotional needs
Postoperative Care
Role of the Fast Track Nurse
Readiness for discharge Discharge information Support at home Management of complications and issues
Management of medical issues Emotional support and reassurance Nurse led follow-up clinic and the coordination role
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
The information was great but in myself personally I was in - a bit of a horror. I was just in a bit of shock. [Line 68: #15] . . . ah you’re given written information but you’re not given that information verbally. I didn’t feel, I mean I sort of felt ah that I had that in the, in the paperwork that I got given, but I’d probably in terms of verbal instructions for that, I think that I could have done with more there. [Line 75: #19]
One patient did not expect the day to be so long but nevertheless found it to be very informative, straightforward, clear, and helpful. Another perceived it as more about providing the hospital with information and less about being prepared personally for surgery. Practical needs Being able to speak to the FTN at preadmission was relevant for participants’ practical needs, and these needs fell into the following 3 specific categories: (1) expectations regarding surgery and length of stay in hospital, (2) contact information, and (3) medical information needs. 1. Expectations Participants appreciated having advance knowledge about the surgery and what to expect in a procedural sense. . . . the most helpful was [the FTN] . . . but I just remember thinking at the time that she was extremely thorough in terms of what I should expect. She went through . . . you know just all the steps of what was going to happen. [Line 163: #186]
Participants generally commented that their understanding of being “fast-tracked” meant that they stayed for a shorter time in hospital, but for some even this was better than they had expected. 2. Contact information Participants commented positively on having contact details for the FTN provided up front for 2 reasons. First, simply having access to the FTN, as part of a team, gave participants a sense of support and reassurance. Second, it allowed for easy follow-up and communication between the participant and the FTN after preadmission. 3. Medical information needs Most participants commented on how useful it was to have tests and administrative matters dealt with at
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preadmission and then to be given information about surgery at that point as well. Preadmission concentrated on the forthcoming surgery and less on after care. For some it was a “fairly quick” process because of the recent discovery of their condition, which had been a “shock” [Line 71: #37]. Two patients raised concerns in relation to the medical aspects of preadmission. One patient felt underprepared in terms of the location of a “port” for the administration of peritoneal chemotherapy but acknowledged that she should have asked more questions about it and that she had appreciated being shown a “port” by the nurse prior to surgery. Emotional needs Although practical needs were covered well during preadmission, “emotional needs” was an area where many participants reported that they had a lack of preparation. Interestingly, while participants reported feeling underprepared and sometimes in a state of shock over the need for surgery, a number of them acknowledged that it was not actually possible to be fully prepared in an emotional sense, and when asked what would help, some said that they did not think anything further would have helped at that stage. This was largely due to the bigger issue of a cancer diagnosis outweighing other relatively smaller emotional aspects to do with surgery and after care. One patient spoke of her concerns about not having enough information at preadmission and having already consented to surgery. Her comments highlighted the fear that was elicited once patients were at preadmission and an insight into the greater emotional support they may require at that time. The patient also noted—“There really needs to be counselling . . . in order to help someone sign the consent and go ahead and have surgery” [Line 144, #19]. Most participants reported being focused at preadmission on the practical aspects of the surgery and dealt with emotional aspects in the aftermath of surgery and when they had returned home. Because of this focus on practical aspects, emotional issues were often unexpected by the patient—“afterwards it [emotions] sort of just hits you, you know” [Line 311: #181]. However, some patients felt that having good information about the practical aspects helped them deal better with the emotional upset of having cancer and requiring surgery.
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. . . there’s always the, I suppose the . . . fear of the unknown but you know that was something that I was prepared I had as much information I think as I could have been given so I was relieved. [Line 76: #22]
Finally, timely support from family, friends, and the hospital team seemed to counter the negative effects of the emotional aspects. One patient commented that having follow-up at home, over the phone from the FTN, fortunately coincided with the time when she felt vulnerable and emotional. Patients consistently reported that where they had such support, this alleviated fears and anxieties helped them cope better with surgery and aided recovery at home. Well I have a great support network . . . by having all of my questions answered if I had concerns I think emotionally that, that made me feel a lot better. I wasn’t stressed, I wasn’t concerned . . . having the support of the hospital and then having people able to ask, answer questions helped and I also had the support of family and friends. [Line 88: #2]
health care professional who was able to give me advice and that basically is all you need when you’re at home. I think you just need to talk to someone who knows what they’re talking about . . . the fast track nurse was able to do that . . . . . . they are able to sort of look at files and know me as a person and know what I’ve gone through so I really don’t know how it [the service] could be improved because I just found that it suited . . . my needs. [Line 175: #2]
One patient who was not able to have someone at home on the original day they were due for discharge valued the hospital’s flexibility in keeping them in for an extra day until they had support at home. This indicates that while early discharge/fast-track is a worthwhile aim, some level of flexibility is required, and the support a patient has at home is important for the service to consider before early discharge occurs. Discharge information
Participants wanted to get home as soon as possible, and being discharged early was welcomed in most circumstances. Participants acknowledged 2 related reasons for wanting to be discharged early (or “fast-tracked”)—first, they did not enjoy being in hospital because of issues such as food, noise, lack of sleep, and risk of infection. Second, they reported the belief that getting home sooner would aid their physical, as well as emotional recovery. There was an important qualification to this, which was that participants believed that being discharged early required having appropriate and timely support, both at home and from the hospital. The participant below summarizes the all-encompassing nature of the fast-track service and why the role of the FTN was crucial in the success of the program for this patient.
The majority of participants reported that they were given sufficient information on discharge to feel confident about going home early. Information generally related to wound and pain management and how to avoid complications like constipation. However, some participants did suggest the issue of whether information could be tailored for individual patients. For example, 1 participant, commenting philosophically in relation to the placement of her “port,” suggested that it is possible to have too much information because this can mean dwelling on the “negatives” of surgery. On the contrary, while patients received an information sheet to take home with them, a couple of patients would have liked more information, or a chance to clarify the information before they left hospital. To assist with this, 1 patient suggested being provided with a “discharge pack” giving information such as what a normal wound should look like, an appropriate exercise regimen, and do’s and don’ts postsurgery. Another patient suggested the use of a “prompt sheet” of questions for patients to rely on when the medical team is visiting them prior to discharge. This participant referred to a whole range of issues (eg, being affected by chemotherapy, not having family around, new technologies, and feeling anxious) that confronted him or her and affected his or her ability to process information postsurgery:
I was actually quite impressed by the service itself . . . the short amount of time that you’re in hospital that you need some sort of support network. Now I found that that . . . was excellent for the fact that with a phone call . . . , I was able to contact a
. . . I guess in a sense because you’re just, you’re worrying or . . . you’re spending too much time thinking about it so maybe just a little, a prompt sheet you know would be helpful. [Line 603: #186]
Postoperative care A number of subcategories with respect to postoperative care emerged from the interviews. These were readiness for discharge and evaluation of the fast-track program, information given at time of discharge, support at home, and management of issues/complications (pain, wound, and emotional). Readiness for discharge
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
Support at home As reported above, patients were pleased to be discharged early as long as they had sufficient support at home or from the hospital. A couple of patients commented that if they had not had family support at home they would have preferred to stay in hospital for an extra day or so, and in the case of 1 patient referred to above, flexibility existed so that that patient could stay in an extra day. Patients felt additionally supported because they had access to the FTN as 1 patient reported: . . . when I came home . . . there were several questions that I needed to ask and I was able to contact [Name] who is the fast track nurse and as I say I was, that alleviated a lot of my concern. [Line 80: #2]
Patients were also asked about whether they were offered or accessed home community services, and while it was offered to all patients, none of the interviewees required support from community care. Management of complications Participants were able to return to hospital to see their doctor and attend the nurse-led clinic. However, sometimes participants referred to complications arising from the surgery that they had to deal with at home. These complications commonly related to wound care, management of pain, side effects, and emotional issues. As mentioned earlier, most participants had sufficient information to be able to deal with the practical issues, such as wound care, at home. But when complications arose, participants reported needing specific support from the hospital or the health care team, which included the FTN, their general practitioner, or the surgical team. . . . I experienced a couple [side effects] that I wasn’t, that hadn’t been spoken about. I rang [FTN]. [The FTN] kept in contact with me, gave me the procedure to go through and what I should be doing so I you know I was pretty well taken care of. [Line 135: #2]
The role of the fast-track nurse The interviews highlighted that the FTN assisted and supported patients in 3 ways. First, the FTN was able to assist patients in the management of any medical complications, such as wound and pain management. Second, they offered emotional support to patients in the preadmission process, as the provider of information about aspects of surgery, and in the postoperative stage, by giving reassurance and
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information to patients about their recovery. Finally, the FTN had overall coordination of patients in the fast-track program, which gave additional support to patients, by specifically offering the nurse-led follow-up clinic postsurgery and, more generally, by managing patient care across the entire fast-track program. Management of medical issues Patients were able to contact the FTN about any problems that arose after surgery. These problems mostly related to wound and pain management as outlined above. In addition, regardless of any issues, patients received follow-up calls from the FTN to check on their progress. . . . [the FTN] called me so she answered any questions I had about anything ‘cause I was, . . . I was getting a lot of diarrhoea . . . . [Line 245: #181]
Emotional support and reassurance The FTN provided emotional support to patients related to the practical aspects around care. In the preadmission stage, this was about providing additional information to patients about the surgery. . . . The bit [of preadmission] that was good was that I waited and I spoke to the nurse clinician . . . and that was really good. That was the best part because she explained more about what was going to happen and, and that was very valuable. [Line 34: #40]
In the postoperative stage, the FTN was able to provide patients with reassurance about their recovery. One participant even surmised that having this positive emotional support and reassurance was linked to improvements in their health. . . . the fast track service was excellent . . . being able to contact someone virtually immediately and have whatever concern I had eased rapidly rather than sit and you know worry about it, stew about it. I felt that that actually . . . I suppose let me . . . I suppose improve and my health improved, I think a lot quicker by knowing that support was there. [Line 192: #2]
The nurse-led follow-up clinic and coordination role The FTN offered a clinic to patients a week or so postsurgery so they could visit the nurse and have problems addressed prior to visiting with the doctor. Most patients reported visiting the clinic, with 1 patient reporting that it was “good to have an, have an interim sort of appointment” [Line 413: #181] before
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seeing the doctor “cause sometimes it seems a long time til you get to see the specialist after” [Line 415: #181]. Finally, the FTN was able to provide coordination across the fast-track program and provide patients with information when other members of the health care team were unavailable. . . . [FTN] was very very good at saying to ring anytime and if you know if I had any questions . . . yeah she in particular seemed to be the, link person . . . you know so it was nice, it was nice to have her there as the, the go between and she was, she has been terrific in, in that respect . . . to ring anytime with questions and concerns. [Line 369: #186]
DISCUSSION The aim of this study was to describe women’s experience and satisfaction with a fast-track surgical program for gynecological cancer, coordinated by the FTN. The qualitative data provide important details about the FTS program and the FTN who coordinates it, with the results showing strong patient satisfaction with their positive experiences of FTS and the beneficial support provided to them by the FTN.
Experience and satisfaction with fast-track surgery and the fast-track nurse The results of the qualitative interviews with patients who participated in the fast-track program highlighted important issues around emotional and practical needs at the time of preadmission, but more particularly during the postoperative care phase and after discharge. The FTN has an important role to play across the continuum but, more crucially, seems to have had a significant role once the patient has left hospital after an early discharge. The role that the FTN has in the later stages of the fast-track program coincides with the greater needs expressed by these patients. There were obvious individual differences among the patients in terms of the level of support that they needed, but all interviewed patients valued their interaction with the FTN and the range of support she offered. The data from the qualitative interviews highlighted the importance around the patients’ emotional needs as part of the fast-track program. The mixture of responses around emotional needs suggests that this is 1 area where patient care and satisfaction can be enhanced. A small group of patients highlighted that their emotional needs were more complex and would
like to have had additional support and understanding to help them move through the process. For example, a mother of a young child found herself getting quite depressed out of frustration at not being able to do things at home for the family or her daughter. She had higher expectations of her recovery and would have liked more support at home with practical aspects of running a home and being a mum. Another patient had never had any surgery before and was daunted by that particular aspect of what she needed to go through. She would have liked more information around this. However, most patients felt that the support received from the hospital, friends, and family was sufficient. Fast-track surgery might impact on a patient’s emotional needs in a number of ways. Within the fast-track program, patients spend less time in hospital. The focus at preadmission is on preparing patients for surgery and then they are discharged in a relatively short space of time (usually on day 3). Combined with the delay in emotional reaction reported by some patients, emotional needs are then understandably an area of less immediate concern while the patient is being preadmitted and in hospital. Nevertheless, research shows that healthy emotional responses to surgery aid with recovery and healing.10 Given that patients did report a delay in their emotional response to having surgery, the FTN was seen to be an important support person to the patient after discharge. The ability to contact the FTN, as well as to attend a nurse-led clinic a week after discharge, provided an opportunity for emotional responses to be addressed and reassurance given. Having nursing follow-up is 1 way to help allay fears or to pick up on any delayed emotional reactions/responses. A recent initiative of the SGOG is for “distress screening” of all patients so as to better understand likely emotional reactions at different time points. Patients are assessed prior to surgery in relation to their distress/anxiety levels and how they are likely to respond in different situations. Their answers to questions help identify potential problem areas and allow the medical team to put appropriate resources in place if and when issues arise. The other related issue is the possible link between information and emotional needs. Information needs was viewed in this research as a practical need of the patient. However, the comments by some patients suggest that the provision of adequate information also satisfied an emotional need on some level. The provision of good information at preadmission, along with the ability to contact the FTN throughout the
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
process, supported a number of patients emotionally and gave them reassurance. This suggests that emotional reactions can be anticipated to some extent and supported by the provision of quality information from the outset. Although patients were generally happy with the amount of information given to them on discharge, it was apparent that some patients would have liked more information around practical issues after surgery. It is clear that individual patients have different information needs, and the use of the Web and other avenues for providing patients with ready access to an appropriately tailored level of information is being explored. Interestingly, some patients commented that there could be too much information provided, so the decision on level of information will also depend to some extent on an understanding of the patient and how information is likely to affect them emotionally. The FTN is ideally placed to give patients timely and tailored information, and their role in doing this is integral to the success of the FTS program. The introduction of distress screening referred to above may further assist in this understanding and would be a useful evaluative tool for future research in this area. At preadmission, patients generally reported wanting their practical needs met, and the findings suggest that this was done well. Medical preparation, such as tests and administration, took place at this stage and was a fairly streamlined process. Other patient needs included information about what to expect in terms of the surgery as well as their length of stay. Patients were pleased to have direct contact information for the FTN, which remained relevant to the patients right the way through the fast-track program. Managing patient expectations throughout the fast-track program is a key role of the FTN and requires someone with the requisite experience to coordinate this. An advanced practice nursing role, the FTN, is not only a specialist gynecological oncology nurse with advanced skills, expertise and knowledge in gynecological cancer, surgical care and adjuvant cancer treatments, but also has the ability to provide patient education and counseling, and thus practice in a truly holistic manner. However, there is such a focus on practical, medical, and information needs at this early stage that emotional preparation may not have been a priority. Given that emotional preparation was not a focus of the medical staff, it appears that patients also “took their lead” from this and generally reported a lack of preparation in this area. As mentioned above, this is an
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area where more is being done to assist patients and future research will assess whether patient satisfaction, with improved emotional support, is increased as a result. In contrast, some patients stated that they were not sure that much could ever be done that early on to assist them emotionally, and that their emotional response to surgery and being “fast-tracked” was part of a “larger” response to being diagnosed with cancer. Nevertheless, the FTS program operates in the context of this “larger” emotional response and for an FTS program to be successful; it must acknowledge and understand all the emotional needs of the patient at this time. This highlights the importance of tailored information on a practical and an emotional level. As patients moved through the FTS program, practical needs were more than adequately met by the FTN whose role assumed a greater importance as they managed the ongoing needs of their patients. Patients reported being keen to go home, and therefore responded favorably to the option of an early discharge from hospital. They also appreciated the flexibility of the hospital when it was not possible to go home on their designated day. Knowledge about the patient’s support situation at home was coordinated by the FTN and was essential to ensuring the success of the surgery and the fast-track program. For all 11 patients interviewed, no extra support was required from community services, indicating that they were comfortable with the forms of support that they had from the hospital and the fast-track program. Information on wound management and possible complications was provided to patients by the FTN on discharge. The main issues that arose here were those referred to above, that is, some patients would have liked more information or information presented in a different way. For example, a discharge pack or prompt sheet of questions; at the time of writing, additional information is now being provided to patients. It is possible that due to pain medication or delayed emotional responses, some patients could not adequately process discharge information which is why being able to contact the FTN, being followed up by her, and attending the nurse-led clinic (to discuss wound and pain management, alleviate any concerns, and assess all aspects of recovery) a week or so after discharge are essential components of the fast-track surgical program run by SGOG at RPAH. Having the FTN available to assist with information provision, management of medical issues, emotional support, and reassurance clearly becomes important in these later stages of an FTS program. The coordinated
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support that is provided throughout the FTS program, as well as the provision of extra services such as the nurse-led clinic and follow-up phone calls to patients, is indicative of the high levels of patient satisfaction highlighted in the qualitative data. An area for future research would be to examine patients’ quality of life as a result of early discharge in conjunction with the coordinated support provided by the FTN. The qualitative results form part of a larger program of research examining patient satisfaction with FTS, and future directions include the development of a patient satisfaction measure of FTS, with specific examination of the role of the coordinated care provided by the FTN.
CONCLUSIONS This study supports a high level of satisfaction for the unique service provided by the FTN. Patients were generally satisfied with their overall experience in hospital for the duration of their stay and reported clear additional benefits offered through the nurse-led clinic and follow-up by the FTN. The FTN has a unique role in being able to provide timely and tailored support to patients, in addition to coordination of their care. Possible future steps to improving the service would be ways to better support patients’ emotional needs, which might be accommodated through more detailed understanding of their individual information requirements. This study
suggests that the advantages of a fast-track program far outweigh any potential negatives and supports the idea of nurse coordination of treatment throughout FTS program and in the postdischarge phase for gynecological oncology patients.
REFERENCES 1. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005;18(2):Art No: CD001271. 2. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189-198. 3. Carter J, Szabo R, Sim WW, et al. Fast track surgery: a clinical audit. Aust N Z J Obstet Gynaecol. 2010;50:159-163. 4. Carter J, Philp S, Arora V. Fast track gynaecologic surgery in the overweight and obese patient. Int J Clin Med. 2010;1:64-69. 5. Carter J, Philp S. Development and extended experience with a fast track surgery program in a gynaecological oncology service. Open Women’s Health J. 2011;5:22-25. 6. Zonca P, Stigler J, Maly T, Neoral C, Hajek M, Stiglerova S. Do we really apply fast-track surgery? Bratisl Lek Listy. 2008;109(2):61-65. 7. Chase DM, Lopez S, Nguyen C, Pugmire GA, Monk BJ. A clinical pathway for postoperative management and early patient discharge: does it work in gynecologic oncology? Am J Obstet Gynecol. 2008;199(5):541.e1-7. 8. Cox A, Bull E, Cockle-Hearne J, Knibb W, Potter C, Faithfull S. Nurse led telephone follow up in ovarian cancer: a psychosocial perspective. Eur J Oncol Nurs. 2008;12(5):412-417. 9. Faithfull S, Corner J, Meyer L, Huddart R, Dearnaley D. Evaluation of nurse-led follow up for patients undergoing pelvic radiotherapy. Brit J Cancer. 2001;85:1853-1864. 10. National Breast Cancer Centre and National Cancer Control Initiative. Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer. Camperdown, Sydney, Australia: National Breast Cancer Centre; 2003.
APPENDIX 1. Fast-Track Surgery in Gynecological Oncology—Patient Experience and Satisfaction Interview Schedule 1. Did you attend the preadmission clinic prior to your surgery? 2. How long was your hospital stay? 3. How well prepared for surgery did you feel in relation to: • Preadmission information • What to expect • How long you would be in hospital for • The support you would require at home after your surgery • Emotional needs • Knowing who to contact 4. Were you linked in to any community services? 5. Did you feel physically ready to be discharged from hospital? 6. Did you feel emotionally ready to be discharged? 7. Were you informed of possible complications or things to be aware of after discharge, and how to manage them? 8. Would you have preferred to stay in hospital longer? If so, how much longer? 9. Did you experience any problems when you went home? If yes, what were they? 10. Was your recovery helped or impeded by early discharge from hospital? 11. Did you need to contact a health care professional for any reason relating to your surgery or hospital stay after you were discharged? If so, who did you contact and what was the reason?
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Patients’ Perspectives of Fast-Track Surgery and the Role of the Fast-Track Clinical Nurse Consultant in Gynecological Oncology ■ ■
Shannon Philp, MN(NP), RN, NP ■ J. Carter, MD (CGO) ■ C. Barnett, PhD ■ N. D’Abrew, BA S. Pather, MD (CGO) ■ K. White, PhD, RN This study examines the role of the fast-track nurse in gynecology from a patient perspective. The fast-track nurse is a specialist nursing role, which coordinates patient care, in addition to providing specialized clinical care. Semistructured interviews were conducted with women who had fast-track surgery for gynecological cancer. KEY WORDS: fast-track surgery, gynecological oncology, fast-track nurse, patient satisfaction, nurse-led follow-up Holist Nurs Pract 2015;29(3):158–166
Fast-track surgery (FTS) is a multimodal approach to the management of surgical patients and requires the successful organization of all members of the health care team. A key element of FTS is the nurse-led clinical coordination between acute and primary health sectors, in addition to the maintenance of quality clinical care. Nurses have increasingly become involved in the delivery of advanced technical care, triage, and coordination of care.1 This is in addition to patient education and psychosocial support from point of entry to the service, through surgery, initial recovery, and into the follow-up period where they provide ongoing support and appropriate referral. One area of nurses’ involvement is the development of nurse-led services in cancer care, including gynecological cancer. The establishment of a Author Affiliations: Lifehouse Gynaecologic Oncology Group, Chris O’Brien Lifehouse, Missenden Road, Camperdown, NSW, 2050, Australia (Ms Philp, Profs. Carter and Pather); Cancer Nursing Research Unit (MO2), Sydney Nursing School, University of Sydney, Sydney, NSW, Australia (Ms Philp, D’Abrew and Dr Barnett, Prof. White); Sydney Medical School, The University of Sydney (Profs. Carter and Pather); Sydney Cancer Network, Sydney Local Health Network, Sydney, NSW, Australia (Ms Philp and Prof. White); School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Joondalup WA Australia (Prof. White). The SGOG is now known as the Lifehouse Gynaecologic Oncology Group (LGOG) and is located at Chris O’Brien Lifehouse. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Cancer and Haematology Nursing, Sydney Nursing School, The University of Sydney, 88 Mallett St, Camperdown, NSW, 2050, Australia ([email protected]). DOI: 10.1097/HNP.0000000000000086
fast-track nurse (FTN), by the Sydney Gynaecological Oncology Group (SGOG) at Royal Prince Alfred Hospital (RPAH), Sydney, Australia, to coordinate patient care and communication before, during, and after FTS, is a new service, which was evaluated in this study from a patient perspective.
BACKGROUND Fast-track surgery aims to decrease the physical trauma of surgery and achieve a recovery outcome with no complications.2 Although reducing the patients’ stay in hospital forms part of these aims, the primary aim is to improve patients’ recovery after surgery, as well as reducing their morbidity.2,3 The elements of FTS occur at all stages of the surgical program. At the preoperative stage, the elements include commencing coordination of care, patient counseling, avoiding bowel preparation, minimizing fasting, and no premedications. Intraoperatively, they include patient warming, using short-acting anesthetics, analgesia, and transversus abdominis plane blocks while avoiding nasogastric tubes, fluid overloading, and drains. Finally, postoperatively, FTS elements include minimizing opioid analgesia and using nonsteroidal anti-inflammatory drugs, adhering to the postoperative nausea and vomiting protocol, and encouraging early mobilization, catheter removal, and oral feeding. More broadly, establishing care pathways and performing routine audits are also part of the FTS
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
process. For the purposes of this paper, a key feature of FTS is the introduction of the nurse-led follow-up clinic as part of patient care. The SGOG developed its fast-track protocol in 2008 and across several audits confirmed that FTS is safe and feasible in the gynecological oncology setting.3-5 In 2010, the SGOG established the role of the FTN, which was filled by an experienced clinical nurse consultant who provides expert coordination across the areas of gynecological cancer surgery. From a task perspective, the FTN provides day-to-day coordination, triage, clinical care (such as ensuring adequate analgesia, preventing postoperative nausea and vomiting, preventing constipation, and encouraging early mobilization), patient education, and psychosocial support including preoperative counseling, discharge planning, structured individualized advice, routine follow-up, and conduct of the nurse-led clinic, as well as appropriate referral. As part of the multidisciplinary health care team, the FTN is also able to consult with other clinical experts and refer to specialist services that the patient requires. More broadly, however, the role of the FTN, providing supportive and holistic care as it does across the entire process, benefits patients in additional ways. Patients receive consistent information and care, which can be tailored to their individual needs. This may also translate into emotional care, thereby supporting a more holistic view of the patient. These psychological outcomes of the higher-level, structured care provided by the FTN are some of the benefits of the realignment of the way patient care is provided during FTS and nurse-led follow-up. Preoperatively, the effectiveness of a fast-track program depends on adjusting the patients’ expectations of their hospital stay.6 Psychological preparation has been linked to shortened hospital stay and a decreased need for analgesics, thus balancing patient expectations with actual clinical outcome.7 Postoperatively, successful FTS includes nurse follow-up, such as an FTS nurse clinic. The few early studies specifically examining this highlight that nurse follow-up can be a cost-effective way of addressing the increasing pressure on follow-up services and is also acceptable to consumers.8,9 For the fast-track gynecological surgical route to be cost-effective, routine medical follow-up care needs to be sustained. However, the time constraint of a medical follow-up appointment may inhibit adequate assessment of issues or concerns women wish to explore. This has been addressed through
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the establishment of a nurse-led clinic conducted by the FTN that is managed separately to the routine medical follow-up. The nurse-led clinic appointment for follow-up, approximately 1 week after surgery, provides an opportunity for patients to discuss physical, emotional, and psychological concerns and for nurses to utilize their specialist skills.8 These skills include advanced clinical assessment skills and psychosocial screening and counseling skills and reflect not only higher education and training in such areas as oncology nursing and advanced assessment, but also the commitment to holistic patient care across the surgical/clinical process and upon a patient’s return to home. In light of this, this study aimed at exploring the experiences of fast-tracked gynecological oncology patients on the care provided to them by the FTN. It is anticipated that FTS, relying on nurse coordinated care, education, and follow-up, is a satisfying experience for gynecological oncology patients.
METHOD Participants All women who were part of the fast-track program between January 2010 and July 2011 were invited to participate in a program of research being conducted by the SGOG. This included women with a gynecological cancer or a complex benign gynecological condition. Eleven women agreed to participate in an interview exploring patients’ experiences around the role of the FTN.
Materials A semistructured interview schedule was developed and used. Patients were given the choice of a face to face interview or a telephone interview. Interview questions revolved around the impact of early discharge, preparedness (physically/emotionally) for surgery, managing complications, and general satisfaction (see Appendix 1).
Procedure Patients who had completed the FTS program were invited to participate via a letter sent to them after they were discharged. A total of 207 patients were sent invitations as part of a larger quantitative study, with 106 agreeing to participate. Of these 106, the first 11 patients (N = 11) who responded agreeing to an
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interview were contacted by telephone and an interview time was arranged. The interviews were mostly conducted over the phone and, in a few cases, were conducted in person. Written consent was obtained prior to interviews being conducted. All interviews were subsequently transcribed verbatim with identifying information removed. The qualitative data obtained from the interviews were analyzed collectively using content analysis. Interviews were transcribed and transcripts were read thoroughly, coded, and then collapsed under higher-order categories (see Table 1). These higher-order categories were verified by a second person with experience in qualitative research and reporting.
Ethical considerations This study was approved by the Human Research Ethics Committee at RPAH. All participants were informed of the study and assured that participation was voluntary. Participants were also assured that refusal to participate would not affect their care in any way. Written consent for interviews was obtained prior to being conducted in accordance with ethical and hospital guidelines.
TABLE 2. Demographic Results (N = 11) Variable
Mean (SD)
Range Frequency
Age, y 55.69 (10.48) 43-76 Marital status Never married/single Married/de facto Widowed Divorced/separated Qualifications Year 10 and below Year 12/HSC Tafe certificate/diploma University Bachelor’s degree University postgraduate degree Medical/allied health training (eg, nursing, midwifery, and physiotherapy) Place of birth Australia Other Regular sexual partner Children Major life event (eg, job change, death, financial stress, and house renovations) Length of stay 3.4
1 6 1 3 2 1 1 4 3 5
10 1 6 6 4
Abbreviations: HSC, Higher School Certificate; SD, standard deviation.
RESULTS Demographic results for the 11 (N = 11) participants are shown in Table 2.
Qualitative interviews Eleven participants were interviewed about their experience and satisfaction with care as a patient whose surgery was fast tracked. Three broad categories emerged in relation to participants’ experiences, with subcategories revealing specific issues relevant to the fast-track program. The broad categories were preadmission, postoperative care, and the role of the FTN. These are described below in
major headings, with subheadings articulating more specific issues. Table 1 illustrates the categories and subcategories. Preadmission All interviewees, except 1, attended preadmission. They reported mostly positive comments about the service in respect of the usefulness of the information given and the reassurance it gave to participants who were anxious about forthcoming surgery. Some participants found the process quite involved with a lot of information to absorb.
TABLE 1. Main Categories and Subcategories From Qualitative Interviews With Patients Preadmission
Practical needs Emotional needs
Postoperative Care
Role of the Fast Track Nurse
Readiness for discharge Discharge information Support at home Management of complications and issues
Management of medical issues Emotional support and reassurance Nurse led follow-up clinic and the coordination role
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
The information was great but in myself personally I was in - a bit of a horror. I was just in a bit of shock. [Line 68: #15] . . . ah you’re given written information but you’re not given that information verbally. I didn’t feel, I mean I sort of felt ah that I had that in the, in the paperwork that I got given, but I’d probably in terms of verbal instructions for that, I think that I could have done with more there. [Line 75: #19]
One patient did not expect the day to be so long but nevertheless found it to be very informative, straightforward, clear, and helpful. Another perceived it as more about providing the hospital with information and less about being prepared personally for surgery. Practical needs Being able to speak to the FTN at preadmission was relevant for participants’ practical needs, and these needs fell into the following 3 specific categories: (1) expectations regarding surgery and length of stay in hospital, (2) contact information, and (3) medical information needs. 1. Expectations Participants appreciated having advance knowledge about the surgery and what to expect in a procedural sense. . . . the most helpful was [the FTN] . . . but I just remember thinking at the time that she was extremely thorough in terms of what I should expect. She went through . . . you know just all the steps of what was going to happen. [Line 163: #186]
Participants generally commented that their understanding of being “fast-tracked” meant that they stayed for a shorter time in hospital, but for some even this was better than they had expected. 2. Contact information Participants commented positively on having contact details for the FTN provided up front for 2 reasons. First, simply having access to the FTN, as part of a team, gave participants a sense of support and reassurance. Second, it allowed for easy follow-up and communication between the participant and the FTN after preadmission. 3. Medical information needs Most participants commented on how useful it was to have tests and administrative matters dealt with at
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preadmission and then to be given information about surgery at that point as well. Preadmission concentrated on the forthcoming surgery and less on after care. For some it was a “fairly quick” process because of the recent discovery of their condition, which had been a “shock” [Line 71: #37]. Two patients raised concerns in relation to the medical aspects of preadmission. One patient felt underprepared in terms of the location of a “port” for the administration of peritoneal chemotherapy but acknowledged that she should have asked more questions about it and that she had appreciated being shown a “port” by the nurse prior to surgery. Emotional needs Although practical needs were covered well during preadmission, “emotional needs” was an area where many participants reported that they had a lack of preparation. Interestingly, while participants reported feeling underprepared and sometimes in a state of shock over the need for surgery, a number of them acknowledged that it was not actually possible to be fully prepared in an emotional sense, and when asked what would help, some said that they did not think anything further would have helped at that stage. This was largely due to the bigger issue of a cancer diagnosis outweighing other relatively smaller emotional aspects to do with surgery and after care. One patient spoke of her concerns about not having enough information at preadmission and having already consented to surgery. Her comments highlighted the fear that was elicited once patients were at preadmission and an insight into the greater emotional support they may require at that time. The patient also noted—“There really needs to be counselling . . . in order to help someone sign the consent and go ahead and have surgery” [Line 144, #19]. Most participants reported being focused at preadmission on the practical aspects of the surgery and dealt with emotional aspects in the aftermath of surgery and when they had returned home. Because of this focus on practical aspects, emotional issues were often unexpected by the patient—“afterwards it [emotions] sort of just hits you, you know” [Line 311: #181]. However, some patients felt that having good information about the practical aspects helped them deal better with the emotional upset of having cancer and requiring surgery.
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. . . there’s always the, I suppose the . . . fear of the unknown but you know that was something that I was prepared I had as much information I think as I could have been given so I was relieved. [Line 76: #22]
Finally, timely support from family, friends, and the hospital team seemed to counter the negative effects of the emotional aspects. One patient commented that having follow-up at home, over the phone from the FTN, fortunately coincided with the time when she felt vulnerable and emotional. Patients consistently reported that where they had such support, this alleviated fears and anxieties helped them cope better with surgery and aided recovery at home. Well I have a great support network . . . by having all of my questions answered if I had concerns I think emotionally that, that made me feel a lot better. I wasn’t stressed, I wasn’t concerned . . . having the support of the hospital and then having people able to ask, answer questions helped and I also had the support of family and friends. [Line 88: #2]
health care professional who was able to give me advice and that basically is all you need when you’re at home. I think you just need to talk to someone who knows what they’re talking about . . . the fast track nurse was able to do that . . . . . . they are able to sort of look at files and know me as a person and know what I’ve gone through so I really don’t know how it [the service] could be improved because I just found that it suited . . . my needs. [Line 175: #2]
One patient who was not able to have someone at home on the original day they were due for discharge valued the hospital’s flexibility in keeping them in for an extra day until they had support at home. This indicates that while early discharge/fast-track is a worthwhile aim, some level of flexibility is required, and the support a patient has at home is important for the service to consider before early discharge occurs. Discharge information
Participants wanted to get home as soon as possible, and being discharged early was welcomed in most circumstances. Participants acknowledged 2 related reasons for wanting to be discharged early (or “fast-tracked”)—first, they did not enjoy being in hospital because of issues such as food, noise, lack of sleep, and risk of infection. Second, they reported the belief that getting home sooner would aid their physical, as well as emotional recovery. There was an important qualification to this, which was that participants believed that being discharged early required having appropriate and timely support, both at home and from the hospital. The participant below summarizes the all-encompassing nature of the fast-track service and why the role of the FTN was crucial in the success of the program for this patient.
The majority of participants reported that they were given sufficient information on discharge to feel confident about going home early. Information generally related to wound and pain management and how to avoid complications like constipation. However, some participants did suggest the issue of whether information could be tailored for individual patients. For example, 1 participant, commenting philosophically in relation to the placement of her “port,” suggested that it is possible to have too much information because this can mean dwelling on the “negatives” of surgery. On the contrary, while patients received an information sheet to take home with them, a couple of patients would have liked more information, or a chance to clarify the information before they left hospital. To assist with this, 1 patient suggested being provided with a “discharge pack” giving information such as what a normal wound should look like, an appropriate exercise regimen, and do’s and don’ts postsurgery. Another patient suggested the use of a “prompt sheet” of questions for patients to rely on when the medical team is visiting them prior to discharge. This participant referred to a whole range of issues (eg, being affected by chemotherapy, not having family around, new technologies, and feeling anxious) that confronted him or her and affected his or her ability to process information postsurgery:
I was actually quite impressed by the service itself . . . the short amount of time that you’re in hospital that you need some sort of support network. Now I found that that . . . was excellent for the fact that with a phone call . . . , I was able to contact a
. . . I guess in a sense because you’re just, you’re worrying or . . . you’re spending too much time thinking about it so maybe just a little, a prompt sheet you know would be helpful. [Line 603: #186]
Postoperative care A number of subcategories with respect to postoperative care emerged from the interviews. These were readiness for discharge and evaluation of the fast-track program, information given at time of discharge, support at home, and management of issues/complications (pain, wound, and emotional). Readiness for discharge
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
Support at home As reported above, patients were pleased to be discharged early as long as they had sufficient support at home or from the hospital. A couple of patients commented that if they had not had family support at home they would have preferred to stay in hospital for an extra day or so, and in the case of 1 patient referred to above, flexibility existed so that that patient could stay in an extra day. Patients felt additionally supported because they had access to the FTN as 1 patient reported: . . . when I came home . . . there were several questions that I needed to ask and I was able to contact [Name] who is the fast track nurse and as I say I was, that alleviated a lot of my concern. [Line 80: #2]
Patients were also asked about whether they were offered or accessed home community services, and while it was offered to all patients, none of the interviewees required support from community care. Management of complications Participants were able to return to hospital to see their doctor and attend the nurse-led clinic. However, sometimes participants referred to complications arising from the surgery that they had to deal with at home. These complications commonly related to wound care, management of pain, side effects, and emotional issues. As mentioned earlier, most participants had sufficient information to be able to deal with the practical issues, such as wound care, at home. But when complications arose, participants reported needing specific support from the hospital or the health care team, which included the FTN, their general practitioner, or the surgical team. . . . I experienced a couple [side effects] that I wasn’t, that hadn’t been spoken about. I rang [FTN]. [The FTN] kept in contact with me, gave me the procedure to go through and what I should be doing so I you know I was pretty well taken care of. [Line 135: #2]
The role of the fast-track nurse The interviews highlighted that the FTN assisted and supported patients in 3 ways. First, the FTN was able to assist patients in the management of any medical complications, such as wound and pain management. Second, they offered emotional support to patients in the preadmission process, as the provider of information about aspects of surgery, and in the postoperative stage, by giving reassurance and
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information to patients about their recovery. Finally, the FTN had overall coordination of patients in the fast-track program, which gave additional support to patients, by specifically offering the nurse-led follow-up clinic postsurgery and, more generally, by managing patient care across the entire fast-track program. Management of medical issues Patients were able to contact the FTN about any problems that arose after surgery. These problems mostly related to wound and pain management as outlined above. In addition, regardless of any issues, patients received follow-up calls from the FTN to check on their progress. . . . [the FTN] called me so she answered any questions I had about anything ‘cause I was, . . . I was getting a lot of diarrhoea . . . . [Line 245: #181]
Emotional support and reassurance The FTN provided emotional support to patients related to the practical aspects around care. In the preadmission stage, this was about providing additional information to patients about the surgery. . . . The bit [of preadmission] that was good was that I waited and I spoke to the nurse clinician . . . and that was really good. That was the best part because she explained more about what was going to happen and, and that was very valuable. [Line 34: #40]
In the postoperative stage, the FTN was able to provide patients with reassurance about their recovery. One participant even surmised that having this positive emotional support and reassurance was linked to improvements in their health. . . . the fast track service was excellent . . . being able to contact someone virtually immediately and have whatever concern I had eased rapidly rather than sit and you know worry about it, stew about it. I felt that that actually . . . I suppose let me . . . I suppose improve and my health improved, I think a lot quicker by knowing that support was there. [Line 192: #2]
The nurse-led follow-up clinic and coordination role The FTN offered a clinic to patients a week or so postsurgery so they could visit the nurse and have problems addressed prior to visiting with the doctor. Most patients reported visiting the clinic, with 1 patient reporting that it was “good to have an, have an interim sort of appointment” [Line 413: #181] before
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seeing the doctor “cause sometimes it seems a long time til you get to see the specialist after” [Line 415: #181]. Finally, the FTN was able to provide coordination across the fast-track program and provide patients with information when other members of the health care team were unavailable. . . . [FTN] was very very good at saying to ring anytime and if you know if I had any questions . . . yeah she in particular seemed to be the, link person . . . you know so it was nice, it was nice to have her there as the, the go between and she was, she has been terrific in, in that respect . . . to ring anytime with questions and concerns. [Line 369: #186]
DISCUSSION The aim of this study was to describe women’s experience and satisfaction with a fast-track surgical program for gynecological cancer, coordinated by the FTN. The qualitative data provide important details about the FTS program and the FTN who coordinates it, with the results showing strong patient satisfaction with their positive experiences of FTS and the beneficial support provided to them by the FTN.
Experience and satisfaction with fast-track surgery and the fast-track nurse The results of the qualitative interviews with patients who participated in the fast-track program highlighted important issues around emotional and practical needs at the time of preadmission, but more particularly during the postoperative care phase and after discharge. The FTN has an important role to play across the continuum but, more crucially, seems to have had a significant role once the patient has left hospital after an early discharge. The role that the FTN has in the later stages of the fast-track program coincides with the greater needs expressed by these patients. There were obvious individual differences among the patients in terms of the level of support that they needed, but all interviewed patients valued their interaction with the FTN and the range of support she offered. The data from the qualitative interviews highlighted the importance around the patients’ emotional needs as part of the fast-track program. The mixture of responses around emotional needs suggests that this is 1 area where patient care and satisfaction can be enhanced. A small group of patients highlighted that their emotional needs were more complex and would
like to have had additional support and understanding to help them move through the process. For example, a mother of a young child found herself getting quite depressed out of frustration at not being able to do things at home for the family or her daughter. She had higher expectations of her recovery and would have liked more support at home with practical aspects of running a home and being a mum. Another patient had never had any surgery before and was daunted by that particular aspect of what she needed to go through. She would have liked more information around this. However, most patients felt that the support received from the hospital, friends, and family was sufficient. Fast-track surgery might impact on a patient’s emotional needs in a number of ways. Within the fast-track program, patients spend less time in hospital. The focus at preadmission is on preparing patients for surgery and then they are discharged in a relatively short space of time (usually on day 3). Combined with the delay in emotional reaction reported by some patients, emotional needs are then understandably an area of less immediate concern while the patient is being preadmitted and in hospital. Nevertheless, research shows that healthy emotional responses to surgery aid with recovery and healing.10 Given that patients did report a delay in their emotional response to having surgery, the FTN was seen to be an important support person to the patient after discharge. The ability to contact the FTN, as well as to attend a nurse-led clinic a week after discharge, provided an opportunity for emotional responses to be addressed and reassurance given. Having nursing follow-up is 1 way to help allay fears or to pick up on any delayed emotional reactions/responses. A recent initiative of the SGOG is for “distress screening” of all patients so as to better understand likely emotional reactions at different time points. Patients are assessed prior to surgery in relation to their distress/anxiety levels and how they are likely to respond in different situations. Their answers to questions help identify potential problem areas and allow the medical team to put appropriate resources in place if and when issues arise. The other related issue is the possible link between information and emotional needs. Information needs was viewed in this research as a practical need of the patient. However, the comments by some patients suggest that the provision of adequate information also satisfied an emotional need on some level. The provision of good information at preadmission, along with the ability to contact the FTN throughout the
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Patients’ Perspectives of FTS and the Role of the FTN Consultant in Gynecological Oncology
process, supported a number of patients emotionally and gave them reassurance. This suggests that emotional reactions can be anticipated to some extent and supported by the provision of quality information from the outset. Although patients were generally happy with the amount of information given to them on discharge, it was apparent that some patients would have liked more information around practical issues after surgery. It is clear that individual patients have different information needs, and the use of the Web and other avenues for providing patients with ready access to an appropriately tailored level of information is being explored. Interestingly, some patients commented that there could be too much information provided, so the decision on level of information will also depend to some extent on an understanding of the patient and how information is likely to affect them emotionally. The FTN is ideally placed to give patients timely and tailored information, and their role in doing this is integral to the success of the FTS program. The introduction of distress screening referred to above may further assist in this understanding and would be a useful evaluative tool for future research in this area. At preadmission, patients generally reported wanting their practical needs met, and the findings suggest that this was done well. Medical preparation, such as tests and administration, took place at this stage and was a fairly streamlined process. Other patient needs included information about what to expect in terms of the surgery as well as their length of stay. Patients were pleased to have direct contact information for the FTN, which remained relevant to the patients right the way through the fast-track program. Managing patient expectations throughout the fast-track program is a key role of the FTN and requires someone with the requisite experience to coordinate this. An advanced practice nursing role, the FTN, is not only a specialist gynecological oncology nurse with advanced skills, expertise and knowledge in gynecological cancer, surgical care and adjuvant cancer treatments, but also has the ability to provide patient education and counseling, and thus practice in a truly holistic manner. However, there is such a focus on practical, medical, and information needs at this early stage that emotional preparation may not have been a priority. Given that emotional preparation was not a focus of the medical staff, it appears that patients also “took their lead” from this and generally reported a lack of preparation in this area. As mentioned above, this is an
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area where more is being done to assist patients and future research will assess whether patient satisfaction, with improved emotional support, is increased as a result. In contrast, some patients stated that they were not sure that much could ever be done that early on to assist them emotionally, and that their emotional response to surgery and being “fast-tracked” was part of a “larger” response to being diagnosed with cancer. Nevertheless, the FTS program operates in the context of this “larger” emotional response and for an FTS program to be successful; it must acknowledge and understand all the emotional needs of the patient at this time. This highlights the importance of tailored information on a practical and an emotional level. As patients moved through the FTS program, practical needs were more than adequately met by the FTN whose role assumed a greater importance as they managed the ongoing needs of their patients. Patients reported being keen to go home, and therefore responded favorably to the option of an early discharge from hospital. They also appreciated the flexibility of the hospital when it was not possible to go home on their designated day. Knowledge about the patient’s support situation at home was coordinated by the FTN and was essential to ensuring the success of the surgery and the fast-track program. For all 11 patients interviewed, no extra support was required from community services, indicating that they were comfortable with the forms of support that they had from the hospital and the fast-track program. Information on wound management and possible complications was provided to patients by the FTN on discharge. The main issues that arose here were those referred to above, that is, some patients would have liked more information or information presented in a different way. For example, a discharge pack or prompt sheet of questions; at the time of writing, additional information is now being provided to patients. It is possible that due to pain medication or delayed emotional responses, some patients could not adequately process discharge information which is why being able to contact the FTN, being followed up by her, and attending the nurse-led clinic (to discuss wound and pain management, alleviate any concerns, and assess all aspects of recovery) a week or so after discharge are essential components of the fast-track surgical program run by SGOG at RPAH. Having the FTN available to assist with information provision, management of medical issues, emotional support, and reassurance clearly becomes important in these later stages of an FTS program. The coordinated
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support that is provided throughout the FTS program, as well as the provision of extra services such as the nurse-led clinic and follow-up phone calls to patients, is indicative of the high levels of patient satisfaction highlighted in the qualitative data. An area for future research would be to examine patients’ quality of life as a result of early discharge in conjunction with the coordinated support provided by the FTN. The qualitative results form part of a larger program of research examining patient satisfaction with FTS, and future directions include the development of a patient satisfaction measure of FTS, with specific examination of the role of the coordinated care provided by the FTN.
CONCLUSIONS This study supports a high level of satisfaction for the unique service provided by the FTN. Patients were generally satisfied with their overall experience in hospital for the duration of their stay and reported clear additional benefits offered through the nurse-led clinic and follow-up by the FTN. The FTN has a unique role in being able to provide timely and tailored support to patients, in addition to coordination of their care. Possible future steps to improving the service would be ways to better support patients’ emotional needs, which might be accommodated through more detailed understanding of their individual information requirements. This study
suggests that the advantages of a fast-track program far outweigh any potential negatives and supports the idea of nurse coordination of treatment throughout FTS program and in the postdischarge phase for gynecological oncology patients.
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APPENDIX 1. Fast-Track Surgery in Gynecological Oncology—Patient Experience and Satisfaction Interview Schedule 1. Did you attend the preadmission clinic prior to your surgery? 2. How long was your hospital stay? 3. How well prepared for surgery did you feel in relation to: • Preadmission information • What to expect • How long you would be in hospital for • The support you would require at home after your surgery • Emotional needs • Knowing who to contact 4. Were you linked in to any community services? 5. Did you feel physically ready to be discharged from hospital? 6. Did you feel emotionally ready to be discharged? 7. Were you informed of possible complications or things to be aware of after discharge, and how to manage them? 8. Would you have preferred to stay in hospital longer? If so, how much longer? 9. Did you experience any problems when you went home? If yes, what were they? 10. Was your recovery helped or impeded by early discharge from hospital? 11. Did you need to contact a health care professional for any reason relating to your surgery or hospital stay after you were discharged? If so, who did you contact and what was the reason?
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