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MODULE FIVE
Cancer Supportive
Care Principles
EdCaN Cancer Nursing Program (Entry to Specialty)
The National Cancer Nursing Education Project
131
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Overview
Learning objectives
The aim of this module is to develop knowledge of
concepts fundamental to the ability of the beginning
specialist cancer nurse to demonstrate competence in
providing supportive care.
On completion of this module, you should be able to:
Key concepts
The key concepts associated with cancer supportive care
principles are listed below:
•• Principles of supportive and palliative care.
•• Common supportive care needs.
•• Screening and assessment of supportive care needs.
•• Experience of transition to palliative care.
•• Evidence based approaches to education and
information provision.
•• Responding to family and carer needs.
Learning activities
At times, you will have learning activities to complete. The
questions will relate to the content you’ve just read or the
video you’ve just watched.
Videos
You will be prompted to access EdCaN videos throughout
this module.
Resource links
Resource links may be included throughout the module.
These links lead to interesting resources, articles or
websites, and are designed to encourage you to explore
other available information.
Estimated time to complete
40 hours
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MODULE FIVE
Cancer Supportive Care Principles
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1. Identify key supportive care needs for people during and
after treatment for cancer.
2. Demonstrate safe and effective assessment of
supportive care needs during and after treatment using
evidence based frameworks.
3. Implement supportive care interventions that are
tailored to an individual’s clinical, personal and social
circumstances.
4. Identify supportive care needs of people affected by
advanced and progressing cancer across all domains of
health.
5. Implement evidence based interventions to support
people affected by cancer to optimise their functional
abilities at the end of life, consistent with their
preferences and abilities.
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Supportive care needs
A diagnosis of cancer can effect a person’s physical,
psychological, spiritual, and social well being. Some of these
effects will resolve over time due to a person’s personal
coping resources and social and professional support.
However, unmet needs do not always spontaneously resolve
and can result in significant morbidity.1 Supportive care
interventions can prevent or minimise these effects, across
all phases of a person’s cancer experience.
Supportive care “embraces the full range of issues that
emerge for an individual as the impact of cancer and
treatment is felt and the person tries to deal with the
situation”.2 In the context of cancer, supportive care
includes services offered during the diagnostic, treatment
and follow-up phases of illness. It is aimed at meeting needs
in the following domains:3
•• Physical
•• Social
•• Emotional / psychological
Diagnostic phase:
•• Physical (includes symptoms such as fatigue, weight loss,
breathlessness, pain)
•• Social (includes needs such as financial, social support)
•• Psychological (includes needs such as anxiety, fear,
anger)
•• Information (includes needs for information regarding
disease, prognosis and planned treatments)
•• Spiritual (includes needs regarding feelings of guilt)
Learning Activities
Completed
Activities

1. Search the literature to identify a
recent research article on supportive
care needs of a person newly
diagnosed with cancer:
•• List the common supportive care
needs across each of the domains
identified above.
•• Information
•• Spiritual.
Nurses contribute to supportive care by:
•• Identify demographic, cancer
related and social factors that might
place a person at increased risk of
unmet need at this time.
•• Reducing the risk of developing unmet supportive care
needs
•• Detecting unmet supportive care needs early
•• Implementing interventions to address supportive care
needs, during and following treatment
•• Implementing interventions to address supportive care
needs at end of life.
For people affected by cancer, unmet supportive care
needs are often associated with significant morbidity
and distress. Distress has been defined as an unpleasant
emotional experience of a psychological (cognitive,
behavioural, emotional), social and/or spiritual nature
that may interfere with the ability to cope effectively with
cancer, its symptoms, and its treatment. Distress extends
along a continuum, ranging from common normal feelings
of vulnerability, sadness and fears to problems that can
become disabling, such as depression, anxiety, panic,
social isolation, and existential and spiritual crisis.4 Rates
of clinically significant distress have been reported to be
between 25% and 45% among people with cancer.5, 6
Treatment phase:
•• Physical (includes inability to attend to Activities of Daily
Living (ADL’s), fatigue, pain, mucositis, bowel changes,
weight changes, sexuality, poor sleep)
•• Social (includes financial issues, transport and
accommodation issues, work issues, family support,
relationship issues)
•• Psychological (includes fear of spread, worry about
carers, uncertainty of the future, sadness about loss of
health, cognitive impairment, pre-occupation with illness
and death, body image changes)
•• Information (includes information regarding self-care,
treatment benefits, management of side effects of
treatment)
•• Spiritual (includes needs such as making sense of the
experience)
A systematic review of unmet needs of people affected by
cancer summarised the most prevalent needs according to
time points across the cancer experience.7, 8 These unmet
needs are summarized below.
EdCaN Cancer Nursing Program (Entry to Specialty)
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Learning Activities
Completed
Activities

1. Review Section 7 of one of the
Victorian Patient Management
Frameworks: “Specific supportive care
needs to consider for patients with...”.
•• List the common psychological,
social, informational and spiritual
needs of a person undergoing
treatment for the identified cancer.
Post treatment, follow up and survivorship phase:
•• Physical (includes fatigue, pain, bowel changes,
respiratory issues, sexuality, fertility, weight changes)
•• Social (includes financial needs, feelings of isolation)
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Advanced phase:
•• Physical (includes inability to attend to ADL’s, nausea,
fatigue, pain, bowel changes, respiratory issues, weight
changes)
•• Social (includes financial needs, expressing wishes
such as in wills)
•• Psychological (includes depression, anxiety, fear, isolation)
•• Information (includes care needs, advanced care planning)
•• Spiritual (includes feelings of hopelessness, helplessness,
fear of death)
Resource link
Lehto, R.H. (2012). The Challenge of Existential Issues
in Acute Care: Nursing Considerations for the Patient
With a New Diagnosis of Lung Cancer. Clinical Journal
of Oncology Nursing, 16(1): E4-E11.
•• Psychological (includes anxiety about the cancer
returning, cognitive impairments)
•• Information (need for information regarding follow up care)
•• Spiritual (includes concerns about meaning of life,
re-prioritising needs)
Learning Activities
Completed
Activities

1. Search the literature to identify a
recent research article on supportive
care needs of a person following
completion of cancer treatment:
•• List the common supportive care
needs across each of the above
domains
•• Identify demographic, cancer
related and social factors that might
place a person at increased risk of
unmet need at this time
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Cancer Supportive Care Principles
Learning Activities
Completed
Activities

1. Search the literature to identify a
recent research article on supportive
care needs of a person with advanced
disease:
•• List the common supportive care
needs across each of the above
domains
•• Identify demographic, cancer
related and social factors that might
place a person at increased risk of
unmet need at this time
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Supportive Care for the Carer
Failure to attend the supportive care needs of the person
can have a ripple effect throughout the family and can
create additional problems for the person,9 as they may rely
on family and friends to support them during their cancer
experience.
Major causes of distress for a carer include:10, 11
•• The physical care demands of the patient
Learning Activities
Completed
Activities

1. Identify, from your experience, the
common supportive care needs for
family carers at the following points
of a person’s cancer experience:
•• Dealing with troublesome symptoms, such as pain
•• At initial diagnosis
•• The uncertainty about the illness trajectory of the person
•• During the treatment phase
•• Fluctuations in the individual’s mental status, behavior
and personality
•• At diagnosis with recurrent
metastatic disease
•• Feelings of guilt, unhappiness, depression and
emotional upset
•• At the advanced phase
•• Difficulty remaining positive
•• Perceived lack of information and capacity to care for the
person
•• Changes in body image of the person
•• Changes in sexual intimacy
There are risk factors that identify carers at high risk of
adverse psychological events including:12
•• Providing over 20 hours of care per week
•• Existing caring responsibilities
•• Few supports
•• Poor health
•• A high level of dependency in a loved one
•• Low incomes
•• Distressed relationships
•• Increased intensity and duration of caring
•• A significant change in roles eg. From “cared for” to
“carer”.
EdCaN Cancer Nursing Program (Entry to Specialty)
The National Cancer Nursing Education Project
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Framework for Supportive Care
Fitch suggests there are five clinical standards of supportive
care for people affected by cancer.13
•• All individuals receive ongoing supportive care
assessment
•• All individuals have the opportunity to be referred to an
appropriate supportive care resource
•• All individuals have the opportunity for self-referral to
supportive care resources
•• All individuals have access to understandable, relevant
information regarding the medical, practical and
emotional aspects of their cancer and its treatment
A tiered model of supportive care can be useful when
undertaking an assessment and deciding on a plan of care
(Figure 1).3 Using this type of tiered model, it is estimated
that approximately 20% of people will require only an initial
assessment with provision of basic emotional support, good
communication and information provision and symptom
management. Approximately 30% will require further
assessment and help to link with other support services.
Another 35% to 40% of people will require the next level
of specialised information, education and encouragement
and only 10% to 15% will require intensive intervention.13
•• All individuals receive supportive care that is relevant to
their needs and sensitive to their age, gender, language
culture, sexual preferences, religion and economic status
Figure 1: Model of Supportive Care (adapted from Fitch)3
General
needs
Complex
needs
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MODULE FIVE
Cancer Supportive Care Principles
All patients
Screening for need
and information
provision
Many patients
Further referral
for assessment and
intervention
Some patients
Early intervention
tailored to need
Few
patients
Referral for specialised
services and programs (for
example, psycho-oncology)
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This model can assist nurses to identify where in the model
the supportive care services offered by the health service
and the primary care service may fit. For example, the nurse
may consider whether there are information resources
readily accessible in multimedia format for a person. Figure
2 shows an application of the model to the domain of
information needs with examples of some evidence based
interventions.
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Learning Activities
Completed
Activities

1. Review the Supportive Care Standards
suggested by Fitch13, and briefly
describe examples in your health care
service how these standards are met.
Figure 2: Application of the Fitch model to information provision3
Information needs
Examples of interventions
All people affected by cancer need tailored
information regarding:
• Tailored discussion with the health care team regarding
the diagnosis, disease treatment and responses
• Diagnosis, treatment and plan for care
• Implementation of a process to screen for supportive
care needs
• Risk factors for supportive care issues
• Discussion about supportive care needs and possible
referral to relevant services
• Who is in their care team and the resources available
to them
• Structured discussion regarding the information obtained
from the screening tool, risk factors identified and
relevant referrals made
• Provision of information in multimedia format
• Basic emotional support, symptom management and
practical assistance.
Many people want more specific self management
interventions, opportunities to talk with others. Some
people may benefit from:
• specific interventions
• Nurse led structured interventions such as symptom
management clinics
• Referral to emotional support programs/groups, peer
support programs
• group or individual interventions.
Some people may benefit from
• Specialist interventions such as nurse led brief interventions
• specific interventions
• Referral to social worker or psychologist for:
• group or individual interventions.
cc
Behavioural Training
cc
Crisis Intervention (one-to-one)
cc
Short - Term Counselling (one-to-one) (family)
• Referral to pastoral care for spiritual conselling
Few people require intensive therapy.
• Referral to psychologist or psychiatrist for:
cc
Psychotherapy (Short-term/Long-term)
(one-to-one family)
• Complex symptom management
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Identifying supportive care needs
The tiered model of supportive care is based on the
assumption that the person’s supportive care needs have
been identified. Routine screening for supportive care needs
of people is therefore required to achieve the basic standards
in the provision of supportive care for people affected by
cancer.14 Nurses have a key role in screening people affected
by cancer to identify these supportive care needs.
The roles of the nurse in identifying supportive care needs are:
•• understanding and anticipating supportive care needs
•• considering the complexity of needs and their
interdependency when identifying possible responses
•• knowing the risk factors that may impact the person’s
response to the diagnosis
•• undertaking routine screening for supportive care needs
to enable early identification of needs and risk factors
Screening for supportive care needs should take place
following a recent diagnosis and on a regular basis using a
systematic, evidence-based approach. Screening involves
the routine and systematic identification of potential
supportive care needs or risk factors before the issue
becomes a symptom. Supportive care screening includes:
•• the prioritising of needs (relating to the five domains
of care)
•• providing an immediate response to high level risk
•• implementing appropriate follow up referral(s) and
support.
The nurse also has a role in identifying carers’ supportive
care needs, the level of care required and other carer issues
impacting on the person providing the care.
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Cancer Supportive Care Principles
Learning Activities
Completed
Activities

1. Consider the table “Factors
associated with an increased risk
of psychosocial problems” on page
98 of Clinical practice guidelines for
the psychosocial care of adults with
cancer.15
•• What process/es do you have in
place in your practice to identify
these risk factors?
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Screening tools
Other considerations when selecting a screening tool
include:
There are many supportive care needs screening tools
available for use in cancer care.
One example is the Distress Thermometer.6 The distress
thermometer is similar to ratings scales used to measure
pain, where the person is asked to rate their distress on a
scale from 0=none to 10=extreme distress. The distress
thermometer is used to identify distress from any source.
A second example is the Supportive Needs Screening Tool.16
This tool comprises a checklist covering aspects of the
individual’s health and wellbeing including:
•• Communication and understanding
•• Does the screening tool consider needs in all domains of
supportive care, not only psychosocial needs?
•• Does the tool offer opportunities to identify risk factors
for adverse psychosocial problems? (listed in Clinical
practice guidelines for the psychosocial care of adults
with cancer15 )
•• Is the tool appropriate for re-screening?
•• Can the data be easily documented / collected for both
the screening results and any referral or action plans?
•• Are versions of the tool available in languages other than
English?
•• Physical health
•• Emotional health
•• Are there any copyright issues over the use of the tool?
(e.g. do you need permission to use it / adapt it)
•• Activities of daily living
•• Support and coping
•• Use of support services
Learning Activities
•• Information requirements
It differs to the distress thermometer in that it assesses a
more comprehensive list of needs and may be more useful
for guiding focused assessment and intervention.
Completed
Activities

1. Watch the vignette Jane’s story 1:
Meet Jane.
In selecting the most appropriate screening tool, consider
whether it meets the following criteria:17
1. Does the content of the tool match your population?
2. What is the purpose of the tool? ie. Screening,
diagnosis, assessment
3. Is the tool clinically useful?
4. Can it be used in the ambulatory and inpatient settings?
•• Using a screening tool such as the
Supportive Needs Screening Tool16
or the Post Distress Thermometer
Discussion Guidelines as a
framework for your discussion,
outline the questions you would ask
and the possible referrals you would
suggest to Jane.
5. Is it reliable, valid and brief?
6. Is it at a reading level that can be understood by the
majority of people?
7. Does it link to a process to address the needs identified?

2. Outline the advantages and
disadvantages of using a
screening tool such as the Distress
Thermometer in your practice.
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Supportive Care Assessment
If supportive care needs are identified as part of the
screening process, a more focused assessment of these
needs or the sources of distress may be appropriate. A
range of tools can be used to guide this more focused
assessment. Some examples are provided below:
Learning Activities
Completed
Activities

1. Review the following examples of
assessment tools for assessing specific
supportive care needs.
•• Tools to assess specific symptoms or concerns, such as:
cc
Brief Pain Inventory
cc
Spirituality assessment process
cc
Bristol stool chart18
•• Brief pain inventory
•• Distress thermometer problem
checklist
•• Tools to assess specific sources of distress, such
the problem checklist associated with the Distress
Thermometer.
For each assessment tool, answer the
following:
•• What dimensions of need are being
assessed?
•• Tools to diagnose specific mental health concerns, such
as the Hospital and Anxiety Depression Scale.
•• Explain the strengths and limitations
of these tools in:
•• Grading scales identified in the Common Terminology
Criteria for Adverse Events (CTCAE)19 provide a
framework for consistent assessment of need.
These more comprehensive assessments are required to
enable an understanding of the aetiology or mechanisms
underpinning or factors contributing to the identified need,
the meaning of the need to the individual, and the impact
of need on the person’s day to day life. This understanding
is required so that interventions can be appropriately
targeted to the cause and tailored to individual needs.
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Cancer Supportive Care Principles
cc
cc

Identifying underlying
mechanisms or factors
contributing to the unmet need.
Guiding intervention.
2. Outline your nursing response if
you suspected a person affected by
cancer was experiencing anxiety or
depression.
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Responding to supportive care needs
The focus of this section is evidence based interventions
that are tailored specifically for the person affected by
cancer and within the scope of practice of the nurse.
The strategies and techniques that can be used to assist in
effective communication include:8, 25
•• use of active listening
Supportive care interventions need to be specifically
matched to the person’s needs.20-22 A combination of
activities, rather than any single intervention by itself, is also
likely to be the approach required.9
•• open body posture
Effective delivery of supportive care services includes five
components:9
•• using open ended questions
1. Identifying / screening for supportive care needs (as
discussed in previous section)
•• using silence appropriately
2. Linking patients to appropriate multidisciplinary services
(making referrals)
•• recognising and acknowledging the clinician’s own distress
3. Supporting people to manage their illness (education,
development of new skills, preparing for a threatening
procedure, brief counseling intervention)
•• identification and responding to verbal and non-verbal cues
•• ensuring appropriate timing and environment
•• sensitive handling of embarrassing situations
•• providing the person time to talk
•• using discussion prompt sheets
•• good eye contact
•• clarification of the person’s concerns
•• responding to cues suggestive of emotional distress
4. Coordination of care
•• asking questions about the person’s feelings
5. Evaluating effectiveness of care
•• inquiring about the situation at home
•• making supportive comments
Central to all these components is therapeutic
communication.
•• handling interruptions well
Therapeutic communication
Learning Activities
Intrinsic to communication between the health professional
and the person affected by cancer is the notion that
communication serves to address particular goals.23, 24
These goals may include:
Completed
Activities

1. Reflect on an interaction that you
have recently had with a person
affected by cancer who was
experiencing mild-moderate distress.
Using the communication skills list
noted above, describe:
•• developing a relationship
•• giving or receiving information regarding diagnosis,
treatment plan
•• how you applied these skills in your
interaction
•• improving emotional state
•• facilitating development of new skills.
For people whose needs sit within the first level of the
tiered model for supportive care, it is likely that minimal
intervention, such as the provision of information, education
and knowing how to access resources, may be all that is
required. The main goal of this type of communication
includes developing a relationship and provision of summary
information.
•• what you could have done to
improve your communication skills
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Developing communication skills
Communication skills training, identifying personal
issues, altering the environment and professional clinical
supervision are all interventions that may improve
communication skills.26
Good communication skills do not necessarily improve over
time or with clinical experience but they are easily learned.
There is value in further developing communication skills in
clinicians as it has been associated with decreased levels of
stress in the workplace. All nurses should have a minimum
level of training in communication.
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Resource link
•• Cancer Australia Frontline Psychosocial Support
Tutorial – free of charge, registration required,
video tutorial that focuses on anger, distress and
depression management
•• IPOS Online Curriculum Communication and
Interpersonal Skills in Cancer Care - US based online International Psycho-oncology Society (IPOS)
presentation
•• IPOS Online Curriculum Psychosocial Assessment
in Cancer Patients - US based on-line International
Psycho-oncology Society (IPOS) presentation
Learning Activities
Completed
Activities

1. Review the EdCaN Competency
Assessment Tool for Therapeutic
Communication 2009.
•• Reflect on an interaction you have
had recently with a person you have
cared for. Use the tool to rate your
performance against each of the
criteria.
•• Review the criterion and
performance indicators and develop
a learning and development plan
with your mentor with the aim to
develop beginning competence in
therapeutic communication (middle
band descriptor) by the end of you
transition to practice program.
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Communication with specific groups
Communicating with carers
•• Check with the carer that they believe they have
adequate information to provide care
The nurse requires good communication skills to assess
the carer’s needs, provide information, and understand
preferences for type and level of information provided.
•• Facilitate a discussion with the carer as to the positive
aspects or potential benefits they may see from
providing care
Strategies to enable the eliciting of concerns include:
•• Reflect with the carer the degree to which the caregiver
finds gratification and meaning in the relationship
•• Spending time with the carer to obtain information
regarding the care required by the person
•• Encourage the carer to maintain existing social
interactions.
•• Maintaining appropriate hope whilst allowing for
expression of concerns regarding the diagnosis
and prognosis
Family meetings can be useful to assist in clarifying goals
of care and site of care options. Family meetings should be
offered as part of routine care in palliative care and other
situations which require discussion and negotiation of care
plans with the family.28
•• Providing recognition of the importance of the
carer’s needs
•• Providing information in multiple modalities – verbal,
written, family meetings, video, audio tapes, DVDs.
The conceptual model described by Hudson27 suggests
the following strategies may be useful when designing
interventions for carers:
Learning Activities
Completed
Activities
•• Provide information to improve the carer’s perception of
preparedness to undertake the tasks and demands of the
carer’s role

1. Review the Clinical Practice Guidelines
for Conducting Family Meetings in
Palliative Care. 28
•• Encourage the carer’s sense of mastery or sense of
control the carer believes they have over their situation,
with clear discussions regarding aims of treatment and
goals of care, and respect of their perspective
•• Provided positive reinforcement of the skills of the
carer to encourage feelings of competence in overall
performance of the role of care giver
•• When providing information to the carer, encourage the
carer’s sense of self-efficacy in the tasks associated with
care giving by modelling and positive reinforcement
of actions
•• Assess the carer’s level of anxiety and depression and
address strategies appropriately
•• Remind the carer of the usual support systems the carer
has available to encourage a positive perception of
available social support
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Special considerations when
communicating with parents and
children with cancer in the family
The family of a child with cancer has significant supportive
care needs throughout the cancer journey, as they cope
with a serious physical illness and the fear that their child
will not be cured.29 At diagnosis, parents must adjust to
the emotional realisation that their child is living with a
life-threatening disease, while simultaneously receiving a
large amount of information on how to manage and care
for their child during treatment. Parents are very vulnerable
during this time, and have an intense need for support from
partners, families, friends, employers, hospital staff, and
other parents.30
How parents respond to their child’s diagnosis and
subsequent management can also have a profound effect
on how the child develops and responds to his/her illness.
Factors which may influence how parents react include:29
•• reactions to previous crises
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Primary caregivers, who are important to the well-being of
the child during treatment, need to understand the nature
of the disease, treatment options and prognosis in order to
participate in treatment decisions and to take on the care
roles expected of them.31, 32
More than one half of all children with cancer can
experience moderate to severe cancer related pain.33 One
of the most distressing events for children is pain resulting
from diagnostic procedures and treatments.34 Young
children will often view non-invasive procedures such as
imaging, radiological tests and radiation treatment as
painful and may become distressed prior to and during
these procedures. Issues such as lying still for prolonged
periods, confined spaces and being separated from parents
can also exacerbate this distress.29 Interventions can include
pharmacological and non-pharmacological strategies for
the child and their family to reduce procedural distress.29
These strategies should take account of the child’s age,
developmental stage, understanding of their situation and
previous responses to stressful situations.
•• reactions of the child
•• child rearing practices and attitudes
•• available support systems
•• perception of the illness
•• previous knowledge or experience with cancer
•• cultural and religious beliefs
•• beliefs about the cause of the disease
•• effects of the disease on the family
•• concurrent stresses in the family.
Characteristics which affect children’s responses to cancer
include:29
•• age (most vulnerable - six months to four years)
•• development level
•• temperament
•• social skills and self concept
•• pre-existing conditions and previous experiences
•• intelligence level
•• type of disease
•• reactions of significant others.
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Resource link
Uman LS, Chambers CT, McGrath PJ, Kisely SR.
Psychological interventions for needle-related
procedural pain and distress in children and
adolescents. Cochrane Database of Systematic
Reviews. 2006(4).35
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Learning Activities
Completed
Activities

1. Watch the vignette Ellies story 5:
Support during procedures and
complete the following activities.
Outline evidence based strategies to:
•• prepare and support Ellie during the
accessing of her CVAD
•• support Ellie’s parents during
invasive procedures.
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Discussion of issues around prognosis or
end of life
Nurses caring for people affected by cancer are often
challenged to assist individuals with managing difficult
thoughts, feelings and concerns. Existential concerns are
normal and common and can be a significant source of
distress among individuals facing a life-threatening illness.
Individuals who are successfully supported to overcome
existential challenges may experience end of life as a time of
enhanced relationships with loved ones, a deepened sense
of self and heightened psychological growth.36
Guidelines have been developed to support health care
professionals to effectively communicate with people with
life-limiting illnesses regarding prognostic and end-of-life.
Key recommendations include:37
Clayton, J.M., Hancock, K.M., Butow, P.N., Tattersall,
M.H.N., & Currow, D.C. (2007). Clinical practice
guidelines for communicating prognosis and endof-life issues with adults in the advanced stages of a
life-limiting illness and their caregivers. MJA, 186(12):
S77-S108.
Learning Activities
Completed
Activities

1. Observe an experienced health
professional discuss end-of-life or
poor prognostic information with
people affected by cancer. Outline
how the guideline recommendations
outlined above were implemented in
the interaction.

2. Reflect upon your own life and
clinical experiences and describe
your thoughts, feelings and attitudes
regarding death and dying.
•• Relate to the person
•• Elicit patient and caregiver preferences
•• Provide information
•• Foster realistic hope
•• Encourage questions
•• Document
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•• Prepare for the discussion
•• Acknowledge emotions and concerns
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Making Appropriate Referrals
Referrals to other health professionals or services are
sometimes required to provide specialised support or
address more complex issues beyond the capabilities of the
team. Recommendations for referrals include:38
•• The referral should be made by the health care provider
as this is more likely to result in service use.
•• Structured referral sheets are useful checklists that can
be completed at the time of screening or assessment.
The referral checklist can include prompts for the nurse
as to the criteria for referral and include suggestions
for referral linked to these criteria. Examples of referral
tools are available on the Supportive Cancer Care
Victoria website.
•• The development and dissemination of referral guidelines
is a useful strategy for the nurse to clearly identify the
internal and external supportive care resources available.
The referral guidelines would be more effective if
the supportive care services were involved in their
development and dissemination.
•• The referral guidelines need to be applicable to the local
circumstances and address local issues.
Fewer than 10% of people are actually referred for
psychosocial help despite having needs identified.6 Reasons
for the lack of follow up include:39, 40
•• Inappropriate timing of referrals
•• Clinicians not knowing the supportive care resources
available
•• Clinicians not asking about supportive care needs
•• Clinicians not able to skillfully introduce the supportive
care service.
Inappropriate timing of referrals
Inappropriate timing of the referral can result from issues
such as not being ready to acknowledge current difficulties
or their current difficulty in coping, not wanting to share
their issue with other team members, or focusing attention
on the physical treatment first. Strategies relating to this
barrier include:15
•• Find an acceptable opening by exploring other more
acceptable issues first – “I see that you say that you are
not sleeping well perhaps we could explore that a bit
more.”
•• Normalise feelings and the need for help – “Many
people I see experience an overwhelming sadness when
they have been told they have cancer, this is a normal
feeling.“
•• Try introducing the referral at another time.
Clinicians not knowing the supportive
care resources available
Some strategies that could be attempted include:15
•• Mapping available supportive care resources in the area
and speaking to the health professionals to identify
criteria for referral and your own referral network for
supportive and psychological care of their patients.
This will generally involve a mix of internal and external
resources.
•• Initiating local supportive care multidisciplinary team
meetings and including supportive care issues in each
case discussion.
•• Developing a flow chart / care pathway for decision
making that reflects the resources available in the area and
is agreed to by the multidisciplinary team (see Figure 3).
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Effective introduction of supportive
care services
The method of introducing referrals to supportive care
services can influence their uptake. For example, if a service
is introduced as extra to and not as part of the team or care
provided, people may see the referral as a burden, or the
referral to supportive care services may be seen as a failure
as the person is unable to cope.
Strategies to assist include:
•• Introduce the other service as part of the team providing
care, and advise the person that they will not need to
repeat their story over again
•• Advise that speaking to someone else and listening to
another perspective may assist with developing strategies
that may help in their maintaining / improving their
overall feeling of health and well-being
•• Give illustrations of where such referral has been helpful
to another person you have cared for
If a referral is refused, you might ask the person’s
permission for you to discuss their problem with relevant
colleague/s and bring suggested strategies into your work
with them. This may also lower the barriers to accepting the
referral as the individual begins to see the suggestions as
helpful.
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Learning Activities
Completed
Activities

1. Identify an individual who has a
supportive care need requiring
referral:
•• Determine what screening is
required to identify individuals who
have/are at risk of unmet need.
•• Describe the outcomes of any
focussed assessment relating to this
unmet need.
•• Describe the process of referral.
•• Outline any barriers and enablers
experienced throughout the
process.
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Figure 3: Summary of care and referral to psychological care.
Identify and document high risk factors and assess level of distress
Patient not considered ‘high risk’
and not distressed
Patient distressed
Clarify nature and
extent of distress
(eg. is it financial,
emotional distress,
depression)
Continue to
provide care
Assess
Self-harm
Monitor psychological
distress and provide
non-specialised
interventions as
required
2 weeks history of
Refer to Social
Worker or Psychology
services for early
intervention
Distress
• Symptoms of low mood
Thoughts of
self-harm
• Emotional support
• Somatic signs of significant distress
Emotional and
financial
• Cognitive symptoms of distress
• Group support
• Access to information
Patient considered ‘high risk’
Enquire
Enquire about
general psychological
and emotional
well-being as well as
other specific issues
(body image, anxiety,
concerns about
family etc)
Requires urgent
psychological
consultation
Refer to psychologist
Refer to social worker
Assess degree of
psychological distress
Patient not distressed
Patient distressed
Adapted from Clinical practice guidelines for the psychosocial care of adults with cancer by Cathie Pigott.
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Information provision / education
The provision of information to people affected by cancer is
essential to making informed choice, reducing anxiety and
participating in decision making. Nurses play an integral
role as information providers for people affected cancer,
especially relating to treatment. A recent review of the
literature indicated that specialist nurses are very effective in
providing information.41
Some general steps to include in an education / information
session are:15, 42
1. Introduce yourself to the person and their family,
and ensure a comfortable environment, minimise
interruptions.
2. Assess the anxiety levels of the person and their family,
normalise feelings of anxiety. If the person has a history
of anxiety disorders such as needle phobia, refer the
person to psychologist for extra support.
3. Provide an overview of the session, the structure,
timeframe and ensure you allow time for questions.
4. Assess understanding and correct any misconceptions.
5. Assess level of information required.
6. Teach relevant concepts eg. introduce and discuss the
treatment.
7. Introduce concept of self care.
8. Review who to contact and role play when to make
contact.
9. Provide information in multimedia format, use diagrams
or pictures where possible.
10.Encourage the presence of another person.
11.Ask the person to repeat back to you their
understanding of the information you have provided.
12.Repeat the important information in a follow up session/
phone call. Send a summary letter as a follow up to the
information.
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Some of the principles of information and education
provision include: 15,43
•• Give the most important information first eg antibiotics
full course must be taken
•• Stress the important messages for eg. “This is
important...”
•• Provide simple concrete advice and be specific with
advice. For example: “You can have one full strength
beer with dinner but no more” (as opposed to drink
moderately)
•• Divide the instructions into categories and announce the
categories before giving the person the information in
each category. For example “I’m now going to tell you
when and how to take the tablets, and the reasons for
taking them this way”
•• Providing encouraging responses to emotional cues
improves recall of the information provided
If the aim of the information or education session is
to prepare the person for a threatening procedure or
treatment, the nurse needs to consider the ways in the
information is presented. Information should describe
both sensory and procedural elements of the proposed
procedure, and psychological concerns should be
addressed, especially for highly anxious people.44 Sensory
information is information that describes the sensations
that the person is likely to experience as a result of the
procedure. Procedural information emphasises the order /
sequence in which the procedure will be undertaken.45
When considering coaching or the development of new
skills a standardised structured approach to the discussion
will maximise the effectiveness of the session. Utilising
an evidence based model for tailored education and
coaching is a useful approach. One model is the TEC
model (tailored education and coaching). The TEC model
is a brief, person centered model that is underpinned by
social cognitive theory.46
Print
The components of the TEC model include:47
•• Assessment of current knowledge, attitudes and
preferences (values). The first step in skilled information/
education provision involves assessing the person’s
preference for information. People’s needs vary about
the depth of the information about their disease,
treatment and prognosis they want to hear. A structured
coaching session is more effective if information is
tailored to the person’s needs.
•• Correction of misconceptions about the disease,
treatment and / or side effects. Identification of
misconceptions may be achieved by the person
completing a questionnaire prior to the interview
•• Teaching of relevant concepts, this could include selfmanagement skills, as well as increasing confidence
when communicating with the health team
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Learning Activities
Completed
Activities

1. Plan an education session for
someone preparing for a cancer
treatment. Consider what preeducation questions you would ask,
content of the session, access to
other resources and the process for
follow up would you use.

2. Describe how you would evaluate
the effectiveness of the education
session?
•• Planning which includes identifying goals, matching
strategies to goals.
•• Rehearsal using role play exercises.
•• Portrayal of learned skills.
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Providing a single brief
counseling intervention
At the next level of the framework, people affected by
cancer can require an intervention such as a once off
therapeutic counseling session. Specialist Cancer Nurses
with advanced skills in communication and available
support processes, such as clinical supervision, may be able
to provide this level of intervention.
Learning Activities
Completed
Activities

1. Watch the vignette Harold’s Story.
There are a number of models that can guide these types
of therapeutic sessions. One example is the Chronic Illness
Self Management 5 A’s model.48
The Five A’s Model of Self-Management Support is used to
help people develop action plans particularly focused on
their chronic illness. The model has been used by the QUIT
program for smoking cessation and is helpful in a range of
contexts. The Five A’s are: 48
•• Assess – the beliefs and knowledge of the person
•• Summarise the evidence regarding
smoking cessation for someone
with lung cancer.
•• Advise – provide specific information that will enhance
the knowledge of the person and correct any myths,
tailored information provision
•• Outline the advice would you
provide for Harold in relation to his
smoking.
•• Agree – work with the person to identify goals and
priorities to achieve, develop an action plan for specific
behaviour changes
•• Assist – work with the person to identify barriers and
establish some strategies to overcome these, suggest
strategies to help achieve the goals
•• Arrange – arrange a follow up phone call or visit to
review achievements against goals set.
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Barriers to providing evidence based
supportive care
Barriers to providing evidence based supportive care can be
categorised into three categories:49
Learning Activities
•• Predisposing factors
Completed
Activities

1. Review Barriers to the provision of
evidence-based psychosocial care in
oncology.
cc
Knowledge of what is evidence based practice
cc
Attitudes and beliefs about supportive care
cc
The value attributed to supportive care
cc
•• Appraise current services and
practices in your practice setting
in light of the barriers to care
identified in Table 1.
The extent to which the person believes they can
manage on their own
•• Enabling factors include having:
cc
cc
cc
cc
cc
cc
cc
Time to discuss supportive care issues
Skills in detecting supportive care issues and systems
to support the assessment
Skills to intervene
•• Outline strategies which may be
useful to consider implementing
in your own practice setting to
improve supportive care services.
Reminders come up to remind the clinician to address
supportive care issues
Resources including environmental and clinicians
A clear understanding of roles of each of the
multidisciplinary team members
Support available to relieve stress of clinicians
•• Reinforcing factors include
cc
cc
Receiving feedback regarding performance of clinician
and outcomes
Rewards and negative consequences
Some strategies to help overcome these barriers include:49
•• Undertaking communication skills training and education
in the use of supportive care tools
•• Identifying a person’s current supportive care resources,
such as family, friends, local doctor or local minister who
may reduce the need for other services. Remembering
the inverted triangle model and that many people do not
require high levels of intervention
•• Mapping the resources and developing a service
directory of what services are available to provide
supportive care in the community
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Self care for nurses
Healthcare workers participating in cancer control efforts
face an increased risk of stress or compassion fatigue.50-52
Protective practices for health care professionals are
recommended to:53
Causes of stress may include:50, 52
•• help compartmentalise work from the rest of life identify ways to leave the job behind
•• complex healthcare states and comorbidities
•• the high level and intensity of interpersonal relationships
•• clarify and support staff in establishing professional
boundaries
•• increasing acuity
•• promote emotional and physical health
•• individuals’ expectations of care
•• include regular self-care techniques for managing stress.
•• technological advances requiring increasingly
sophisticated nursing skills
•• decreased length of hospital admission
Resource link
•• the necessity of dealing with the dying process.
Aycock, N., & Boyle, D. (2009). Interventions to
manage compassion fatigue in oncology nursing,
Clinical Journal of Oncology Nursing. 13(2):183-19161
In palliative care, unique factors may magnify the risk of
compassion fatigue. These include:53
•• accumulated losses
•• emotionally charged care
•• sustained and exclusive focus on terminal illnesses and
terminal care
•• mortality issues of the clinician (existential, spiritual, or
personal).
Cancer nurses must examine their own thoughts, feelings
and attitudes regarding death and dying so as to better
recognise and understand how to cope with their own
aversive thoughts and emotions. Peer support from
experienced cancer nurses may facilitate this process in
novice nurses.54 Research has shown that nurses who
receive death communication education become more
comfortable with discussion of life and death concerns with
individuals and their families.55
The clinical importance of compassion fatigue has been
highlighted through its impact on outcomes such as:
•• increased medical errors56
•• increased turnover and absenteeism57
•• decreased quality of care58
•• decreased satisfaction expressed by recipients of care59
•• significant impact which burnout has on the professional
and personal lives of affected personnel.52, 60
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Learning activities
Completed
Activities

1. Reflect on a situation where a person
has asked if medication administered
to their loved one will hasten death.
•• How did / would you respond?
•• Discuss evidence-based
communication strategies you
might use in this situation.

2. Access self care resources at the
following links:
•• CareSearch53
•• Cancer Learning
cc
Discuss strategies nurses could
implement to protect themselves
from workplace stress and
compassion fatigue.
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