Volume 29, Issue 4 • Fall 2019
eISSN: 2368-8076
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Canadian OnCOlOgy nursing JOurnal • VOlume 29, issue 4, Fall 2019 reVue Canadienne de sOins inFirmiers en OnCOlOgie
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Editor Note: This paper was based on the Helene Hudson Lectureship presented at the CANO/ACIO Annual Conference held in Charlottetown, Prince Edward Island, in October 2018.
Compassion in practice: Difficult conversations in oncology nursing
by Anne Katz
Cancer is more than biology: It is a social disease.
—Dr. Don Dizon
C
ommunication is central to our personal and professional rela- tionships and even more so with our patients. It is through communication that we inform, educate and support our patients and their families. It is also through communication, verbal and non-verbal, that we convey compassion and ease the patient’s path from diag- nosis, treatment, recovery and survivor- ship and, for some, to the end of life.The objective of the 2018 Helene Hudson lecture at the Annual CANO conference was to highlight how com- munication, especially in difficult con- versations, is the key to compassionate care in oncology nursing. Specifically, the three main objectives were:
• To identify key concepts in effec- tive communication in stressful conversations
• To suggest strategies to help the oncology nurse gain confidence in having these conversations
• To describe models that assist the nurse to have difficult conversations.
cONcePts iN cOMMuNicAtiON
Wittenberg-Lyles, Goldsmith and Ferrell (2013) identify key concepts in communication that are important for oncology nurses. These include accom- modation, whereby the nurse aligns his/
her communication with the needs of the patient and family, increasing trust
and breaking down barriers between healthcare providers and the patient and family. Good communication also requires adaptability to where the patient and family are situated in terms of their goals, plans and roles. The nurse also has to realize that the med- ical world is foreign to patients and so care needs to be taken to ensure that the patient and family understand this new world they have entered. Family/
caregiver communication has to be recog- nized as unique to that particular family and it is important to play to the patient and family strengths.
In addition to family patterns of com- munication, the health literacy of each member has to be taken into account, as this will influence their level of under- standing of the illness and treatment. It is also important to note that health lit- eracy differs from general literacy and even well-educated individuals are com- promised when trying to understand the complexities of a serious illness. When dealing with families, it is also import- ant to take into account the fact that each member of the family will have different goals whether these are expressed or not, and this can get in the way of open com- munication. Relational tensions will often exist within families and between the oncology team members and the family and may be enacted as withdrawal and/
or avoidance. Discussing why this is hap- pening with the patient and family can allow for misunderstandings to be cor- rected and/or changes in the disease pro- cess to be fully explained.
Communication is either affective/
relational or instrumental/ technical.
The former is important for nurses in oncology, as many of the sensitive top- ics that we need to address with our patients result in emotional responses for both the patient and their family, as well as, at times, the oncology nurse.
Talking about end-of-life issues, alter- ations in the disease process including recurrence, loss of fertility as a result of treatment and many other topics is not easy and requires sensitivity and an openness to an emotional response from the patient and/or their family caregiver(s). Many educational pro- grams do not offer training in this sort of communication and, instead, focus on instrumental and technical infor- mation such as history taking, explain- ing treatments or educating the patient about aspects of the disease, etc.
Oncology nurses need to be able to do both: relate in an empathetic manner when discussing sensitive or emotional topics and relay important information to the patient so that they understand the complex nature of the diagnosis and are prepared for treatment. Empathy in a clinical encounter is described as a professional interaction rather than an emotional response to a particular situ- ation (Mercer & Reynolds, 2002). Rather than subjectively feeling another’s suf- fering, it is a way of understanding the patient’s experience in an intellectual way rather than in an emotional way (Mercer & Reynolds, 2002).
BArriers tO cOMMuNicAtiON
It is recognized that, for many nurses, having difficult or sensitive conversations with patients is stress- ful. Many don’t feel prepared and/or are not sure whose responsibility it is. This may result in conflict, particularly with physicians who are primarily responsi- ble for certain actions, for example, dis- closing a cancer diagnosis. However, if the patient seems not to understand what they have been told by the phy- sician, how is the nurse supposed to respond? Nurses are often the interme- diaries between patient and physician
ABOut tHe AutHOr
Anne Katz, PhD, RN, FAAN, 3022 - 675 McDermot Avenue, Winnipeg, MB R3E 0V9
Phone: 204 787 4495 Email: [email protected]
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and if the communication from phy- sicians is not clear, nurses are often left not knowing what the patient has been told (Wittenberg-Lyles et al., 2013).
This leads to frustration on the part of the nurse and the potential for missed opportunities where a meaningful dis- cussion with the patient/family may not happen because the nurse does not know what the patient has been told by the physician.
Personal factors may also play a role. Nurses may find it difficult to find the time to have longer conversations with patients due to increased patient loads or because they feel they lack the skills to have sensitive conversa- tions (Banerjee et al., 2016). Nurses also report that end of life conversations are difficult because they want to maintain hope for the patient while at the same time needing to be realistic (Leung et al., 2017). However, having challenging conversations while not feeling confi- dent may lead to compassion fatigue (Wentzel, 2017) and potentially burn- out (De La Fuente-Solana et al., 2017).
Nurses who experience compassion fatigue are more likely to be distressed in the presence of others’ suffering and have less empathy (Duarte & Pinto- Gouveia, 2017).
cOMMuNicAtiON sKills trAiNiNG
It has been suggested that com- munication skills training (CST) may increase both nurses’ confidence in their ability to have difficult conversa- tions, as well as improving outcomes for patients. The purpose of CST is to improve the quality of communica- tion between healthcare providers and patients, and increase empathy, as well as practising how to communicate in difficult situations (Barth & Lannen, 2011). However, a Cochrane review (Moore, 2013) of 15 randomized con- trolled trials suggests there is no evi- dence that this kind of training has an impact on mental or physical health of patients, patient satisfaction or health- care provider burnout.
So how can confidence and com- fort in talking about sensitive top- ics be improved among oncology nurses? If training is not effective,
could communication tools be helpful (McMullen, 2017)? A number of tools exist to aid in discussion or assessment of sensitive topics. For example, the PLISSIT Model (Annon, 1974) has been widely used in the area of sex therapy.
Similarly, the BETTER Model (Mick, Hughes, & Cohen, 2003), created by oncology nurses, has been suggested as a valuable tool to address sexuality specifically in individuals with cancer.
Two other tools, the 5As model (Bober, Carter, & Falk, 2013) and the SPIKES Model (Baer & Weinstein, 2013) may be useful in addressing other sensitive topics encountered in oncology nursing, namely overweight/obesity and treat- ment-related infertility.
MODELS FOR COMMUNICATION
There are a number of tools that are used with specific populations by cancer type or for specific purposes such as assessing for financial toxicity (McMullen, 2017). A more general tool that promotes communication may be more useful and can be used for sensitive conversations with patients with diverse issues. Key to having
sensitive conversations is that they are patient-centred and have an element of education that assists the patient in finding a resolution for whatever the issue is.
The 5As model has been used widely to address tobacco cessation. The five steps in the model are ask, assess, advise, assist and arrange. An example of how these can be used in talking about healthy weight with an over- weight or obese patient is presented in Figure 1.
The SPIKES Model is a slightly more complex one, but it takes into account heightened emotions that may be pres- ent for the patient. This six-step process begins with ensuring there is privacy and an example of a conversation about loss of fertility is shown in Figure 2.
cONclusiONs
Cancer care is relational at its core and oncology nursing is based on the relationships we have with our patients throughout the disease trajectory. We have to communicate so much to our patients to support all aspects of their care and to mitigate the side effects of the treatments they receive. Having
Figure 1: The 5As model
Ask: Start by asking the patient what they know and/or understand
Dr. X has asked me to talk to you about weight and how it affects people with can- cer. What do you know about the risks of being overweight and cancer?
Assess: It is important to understand the patient’s perspective on the issue Many overweight people say that they have tried to lose weight many times. What efforts have you made in the past?
Advise: Clear and concise advice is a starting point for a more extensive intervention
Making the necessary changes to your usual way of eating is difficult. Food has many different meanings for all of us. Being overweight can have negative out- comes for people with cancer and if you are willing, I can offer you some help in getting to a healthy weight.
Assist: Help the patient to access the resources they need as this may be out of your scope of practice or expertise
We have two nutritionists who are part of the staff here. They meet with patients and their family to help with changing your usual patterns to assist you in getting to a healthy weight. I can see if one of them can see you while you are here at your clinic visit.
Arrange: It is important to see the patient in follow up to show support and also to learn what the patient found helpful.
I would like to see you again in about a month to see how you are doing and what you found helpful from your visit to the nutritionist.
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difficult conversations is part of that. It is important to remember that interac- tion with patients is not a checklist. We have to be truly present when we assess for side effects or the impact that can- cer has on quality of life because it is in the pause that a patient takes before answering a question that we can detect a problem. Their uncertainty may be a reflection of lack of knowledge that needs to be corrected. Their body lan- guage may show us their actual pain rather than the words that they speak.
Silence on our part can prompt the patient to disclose what is really both- ering them, but we have to learn to be comfortable in being silent and allow ourselves to resist the impulse to move on with another question.
Every patient has a story and leaving room for the story teaches us more than any checklist ever will.
reFereNces
Annon, J. (1974). The behavioral treatment of sexual problems. Honolulu: Enabling Systems.
Baer, L., & Weinstein, E. (2013). Improving oncology nurses’ communication skills for difficult conversations. Clin J Oncol Nurs, 17(3), E45–51. doi:10.1188/13.cjon.
e45-e51
Banerjee, S. C., Manna, R., Coyle, N., Shen, M. J., Pehrson, C., Zaider, T., … Bylund, C. L. (2016). Oncology nurses’
communication challenges with patients and families: A qualitative study. Nurse Educ Pract, 16(1), 193–201. doi:https://doi.
org/10.1016/j.nepr.2015.07.007
Barth, J., & Lannen, P. (2011). Efficacy of communication skills training courses in oncology: A systematic review and meta- analysis. Ann Oncol, 22(5), 1030–1040.
doi:10.1093/annonc/mdq441
Bober, S., Carter, J., & Falk, S. (2013).
Addressing female sexual function after cancer by internists and primary care
providers. Journal of Sexual Medicine, 10(Suppl. 1), 112–119. doi:10.1111/
jsm.12027
De La Fuente-Solana, E. I., Gómez-Urquiza, J. L., Cañadas, G. R., Albendín-García, L., Ortega-Campos, E., & Cañadas-De La Fuente, G. A. (2017). Burnout and its relationship with personality factors in oncology nurses. European Journal of Oncology Nursing, 30, 91–96. doi:10.1016/j.
ejon.2017.08.004
Duarte, J., & Pinto-Gouveia, J. (2017). The role of psychological factors in oncology nurses’ burnout and compassion fatigue symptoms. European Journal of Oncology Nursing, 28. doi:10.1016/j.ejon.2017.04.002 Leung, D., Blastorah, M., Nusdorfer, L., Jeffs,
A., Jung, J., Howell, D., … Rose, L. (2017).
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Figure 2: The SPIKES Model Getting the SETTING right
Let’s go to a room where we can close the door and not be disturbed while we talk.
Patient PERCEPTION
What do you understand from what you were just told by Dr. Y?
INVITATION
I can try to answer any questions you may have as well as give you some additional information about next steps if you are interested.
Giving KNOWLEDGE
As Dr. Y indicated, there is a high risk that the treatment we are offering will cause you to become infertile. But you may be able to freeze your eggs now for use in the future when the time is right for you to have a baby. We can arrange for you to visit the fertility specialist in the next day or two where you can discuss this further.
Addressing EMOTIONS
I understand how upsetting this is and it is overwhelming to have to think about things like egg freezing when your head is whirling with all the information we have given you today. It’s fine if you want to think about this overnight and perhaps talk to family.
SUMMARY / STRATEGY
So I will wait for your call tomorrow to tell me if you want to see the fertility specialist. In the meantime, you do need to have some blood tests as ordered by Dr. Y and if it’s okay with you, we can add the tests that the fertility specialist will want you to have if you go ahead with egg freezing. That will save you from having another visit to the clinic – and another needle poke!
