Download AN EVALUATION OF ONCOLOGY PATIENT EDUCATION: A

CLINICAL FOCUS
AN EVALUATION OF ONCOLOGY PATIENT EDUCATION: A QUALITY
IMPROVEMENT EXERCISE
Gillian Blanchard NP, BNurs, MNurs(Nurse Prac), MClinicalNurs, GCert (Onc Nurs)
Oncology Nurse Practitioner
Calvary Mater Hospital, Newcastle, Australia.
Yolande Cox RN, DipHlthSc(Nursing), GCert(Onc Nurs), GCert(PallCare Nurs)
Lung Cancer Nurse Coordinator
Calvary Mater, Newcastle, Australia.
Abstract
Health Care Professionals (HCP) involved in the provision of
patient education must be aware that individual learning styles
of patients can vary. In times of stress the ability of patients to
remember important information can be hampered. In clinical
practice for example, patients may have difficulty remembering
what is told to them about their chemotherapy treatment plan
during their patient education session. This experience with
patient chemotherapy education formed the basis for the
quality activity reported in this paper.
At the Calvary Mater Newcastle, hospital standard practice
is to provide patients with a separate outpatient education
appointment on a day other than their first treatment. A
quality survey was sent to 80 patients who had commenced
intravenous chemotherapy in the preceding 6 months. The aim
was to assess if patients received and understood information
provided to them during the chemotherapy education session.
The survey contained 19 questions and patient opinion was
measured using a Likert scale. Additional information was
also asked to identify if patients were treated as inpatients
or outpatients, to identify wait times between education
and commencement of treatment, and also if they attended
education alone.
Of the surveys sent there was a 49% (n=39) response rate and
of these responders 70% (n=27) either agreed or strongly
agreed that the education appointment was beneficial. From
the information returned it was concluded that the majority
of patients received both written and verbal information on
chemotherapy treatments, and side effects, and had a high level
of understanding of the chemotherapy education received.
Keywords: Education, Patients, Chemotherapy, Needs
Introduction
Health Care Professionals (HCP) involved in the provision of
patient education must be aware that individual learning styles
vary. In times of stress for example, the ability to remember
important information is hampered and the provision of too
much, or too little information can increase anxiety (Ormandy,
2010). The process of chemotherapy education is a time of
particular importance in the oncology patient’s treatment
trajectory. Chemotherapy agents have the potential to cause
life threatening side effects and not adhering to recommended
therapy may have serious consequences for the patient. The
education process around treatment should be such that it
helps to promote patient safety, reduces anxiety and increases
knowledge about the treatment process. This is one of the most
important aspects of care for chemotherapy nurses (Jones et
al., 2008; Smith et al., 2004; Rigdon., 2010). In the context of
chemotherapy it is essential that the patient be as informed
as possible to assist in providing consent to their treatment.
Ziegler, Newell, Stafford & Lewin, (2004), reminds us that
information provision is an integral component of obtaining
informed consent. A review of the literature on adult learning
provided information that is useful when revamping current
teaching and learning styles associated with patient education.
Seminal work by Malcolm Knowles (1970) identified that one
key to adult learning is the person’s intrinsic motivation. Adult
learners must be self-directed and have set themselves clear
goals when entering into any learning process. This enables
them to focus on outcomes of value to them personally.
Additionally, Knowles (1970) identified six characteristics of all
adult learners:
1.
Autonomous and self-directed
2.
Accumulated a foundation of experience and knowledge
3.
Goal orientated
4.
Relevancy orientated
5.Practical
6.
Need to be shown respect
Knowing the characteristics of the adult learner can make a
difference between adequate and inadequate information
provision. Rose & Campbell (2001) from radiotherapy studies
showed that patients who receive structured education
report less interruption in usual activities of daily living. They
also suggest that there are several issues to be taken into
account when implementing patient education. These include
physical and emotional well-being, the ability to understand,
understanding the patient’s social situation and support,
whether there is enough time to ask questions and if there is
appropriate documentation and continual education across
the treatment continuum. They suggest that the provision of
both appropriate and creative teaching tools will assist in the
education process.
If information is applied practically it is more likely to
be remembered (Inott & Kennedy, 2011). Russell’s (2006)
comprehensive review of adult learning styles categorically
confirmed that active participation is the key to successful adult
learning. Timmins (2006) concurs that whilst most literature
suggests formalised processes meet the learning needs of
individuals and groups, open-style interviews and active
participation may be more appropriate in allowing patients to
express their unique learning styles, although this is more time
consuming for the educator.
In clinical practice it has become apparent that patients can
have difficulty remembering what is told to them about their
chemotherapy treatment plan during education. For this
reason this project evaluated if the way we provide patient
information could be improved. The need for improvement in
patient education is backed up by many authors in oncology
patient education.
Echlin & Rees (2002) and Smith et al (2004) found that
the type and amount of information required by patients
varies widely between individuals, with the greatest need
for information concerning the treatment itself. Because
cancer care requires a multifaceted approach, information
provided is often fragmented and lacking in relevance and
timeliness to the patient. (Van Mossel et al, 2012; Halkett et
al, 2010). Furthermore, HCP underestimate the complexity of
the information provided and level of patient understanding
and there can be a bias toward providing information they
deem appropriate. Additionally, patients may not recall the
information that is provided (Echlin & Rees, 2002). Echlin &Rees
(2002) and Milne (2001), identify that carers also have specific
information needs. Milne (2001) found caregivers preferred
being provided with information to deal with a situation rather
than learning skills through trial and error. If they knew what
could be expected at each stage of treatment it improved their
coping ability.
Ormandy (2010) states that in order for HCP to be successful
information providers they need to have an understanding of
the theories that underpin patient information needs. Nurses
need to be aware that there may be significant differences
between the patient’s and the nurse’s perception of learning
needs. In an elderly population, consideration needs to be made
as older persons are less able to filter out irrelevant information.
The body of evidence on the cognitive and physical changes
of aging can help the oncology nurse tailor the provision of
information (Rigdon, 2010).
Li et al (2011), in their assessment of patient satisfaction with
the information provided about illness and treatment, showed
that the information provided by health care professionals
ranked low on level of satisfaction compared to information
obtained by patients from other sources (eg media, friends
and the internet). This has implications for clinical practice and
confirms Rigdon’s (2010) findings related to the importance of
identifying the actual needs of patients. At relevant times along
the continuum the information needs of the patient will change
and nurses must be mindful to adapt to their ever changing
information requirements.
Procedures
At the Calvary Mater Newcastle (CMN) standard practice is
to provide patients with a separate outpatient education
appointment on a day prior to their first treatment. During this
appointment patients watch a DVD then have one on one time
with a specialist chemotherapy nurse, and are provided with
tailored written and verbal information.
The aim is to determine if patients received and understood
information provided to them during education and identify
any process or content gaps in the education activity that could
be improved. In order to achieve this, a survey was sent to 80
patients who had commenced intravenous chemotherapy in
the preceding 6 months.
This survey contained 19 questions. Understanding and
satisfaction of chemotherapy education was measured using
a five point Likert scale, with patients rating their preferences
from strongly agree to strongly disagree. The Cancer Institute
NSW (2012) antineoplastic drug patient education checklist was
used to generate questions to elicit patient understanding of
the information provided.
Additional information was also asked to identify if patients
were treated as inpatients or outpatients, to identify wait
times between commencement of treatment and also if they
attended education with a support person.
Results
Of the 80 surveys sent out, 39 were returned. This represented
a response rate of 49%. Of those returned, 10 were partially
completed and 1 was returned incomplete due to patient
death. For the purpose of data analysis all surveys whether
complete or partially complete were included.
Responses to the question about who provided patients with
information about chemotherapy and side effects, indicated
this role was evenly shared between health professionals, with
86% (n=34) of the respondents indicating they had received
this information from all 3 health professionals (Table 1).
Table1: Provider of Chemotherapy Information
Those respondents who provided an unsure response may
have been confused about the title of the different nursing
roles. Of the patient surveys returned, 92% (n=36) of patients
indicated that they had received written information, 87%
(n=34) indicated that they had received verbal information
and 85% (n=33) of total respondents received both written
and verbal information.
The effectiveness of the style of information provision was
assessed by asking the following questions and using a Likert
scale response. Responses are indicated in Table 2.
A After my education I understood what medications to take
B I understood how many chemotherapy treatments the doctor had planned for me
C After my education I understood when I needed to have a blood test
D After my education I understood when I needed to have a scan E After my education I knew who to contact for further information
F After my education I understood what side effects needed urgent attention
G After my education I knew who to contact in an emergency
Table 2: Patient Understanding of Information Provided
Eight patients indicated that they were unaware of scan
requirements. This may be a reflection of patients receiving
adjuvant treatment for which routine scanning is not standard
of care; lack of information provided to patients or alternatively,
it may reflect poor recall. Of the patient surveys returned, 43%
(n=16) indicated a preference for receiving written information
prior to the education appointment and 38% (n=15) indicated
they would have preferred to have received the DVD prior.
Overall 70% (n=27) of respondents returning their survey
agreed that the education appointment was beneficial and
95% (n=37) attended the education session with a support
person.
Many of the survey respondents provided comments about the
education process, care and staff at the hospital. Some of these
included:
“DVD at the hospital is better you can ask the nurse there!”
“Chemo DVD reinforced what we already knew”
“Personally sourced information from cancer council and
internet websites”
“On the first day of chemo I was advised by a nurse that I
would not need medication at home for nausea and that
everything I needed was in the drip. It only took me that first
time to realise that information was not correct”
“Education day was rushed and constantly interrupted; it
seemed very impersonal due to other emergencies for staff
on that day. I felt it would have been an imposition to ask
questions and use staff time”
“Both myself and my wife found all the information helpful
and all the staff very helpful, and friendly nothing was too
much trouble”
“Slow down when giving education session and allow time
for understanding procedures”
“Found the education process very helpful and informative”
Conclusion
Although the sample was small, 70% (n=27) of this number
agreed that the education appointment was beneficial.
The majority of patients received both written and verbal
information on chemotherapy treatments and side effects
and perceived they had a high level of understanding of the
chemotherapy education received. Information drawn from
the survey supports our current method of education; written,
verbal and audio-visual. Further improvement of this process
may be enhanced by consideration of individual learning
preferences. The comments made by the patients outside of
specific questions may reflect both the teaching styles and
experience of the individual nurse and the learning style and
needs of the participant. These variables were not measured
and may be considered for further areas of evaluation.
Information obtained about the education sessions will assist
us to continuously improve the patient education process and
oncology experience.
Acknowledgements
Nursing Staff and patients of Calvary Mater Newcastle Day
Treatment Centre.
This paper has been approved by the Hunter New England
Human Research Ethics Committee (HNELHD HREC) as a quality
project not requiring ethics approval.
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