Addressing the Need to Set a Framework for the Education of Nurses in Psychooncology in Developing Countries: A Systematic Review

Author for correspondence:

Tihana Gašpert

Krešimirova 42, Rijeka, Croatia

E-mail: tihana.batrnek@gmail.com

https://doi.org/10.24141/2/7/2/6

Keywords: framework, nursing, oncology nursing, psycho- oncology education, psycho–oncology

Abstract

There is a need to study the impact of nursing care in psychosocial treatment in developing countries. The aim is to emphasize the importance of psychoon- cological education for oncology nurses in order to identify and create a framework for implementation. A systematic review was conducted. The literature was searched for in the Medline database. The inclu- sion criteria were articles in English published in the last five years within the Web of Science Category: Nursing. After filtering articles by the inclusion crite- ria, 107 results were found, and this review includes

14 articles. Psychosocial interventions positively affect the progression of illness, psychosocial con- dition, symptoms, treatment and side effects. How- ever, nurses have little opportunity to receive educa- tion on the psychological care. Therefore, in the field of psychooncological nursing care, it is necessary to improve the education and training systems for psy- chological assessment and stress management.

Introduction

Nursing is a profession that is constantly evolving and changing, focusing on providing care to individu- als, especially in the field of oncology. While nurses primarily provide nursing care that addresses the physical needs of patients, they meet their spiritual, emotional, and psychosocial demands as well. The nurse needs to precisely define the health condition, assess coping mechanisms and their effects, and plan and implement nursing interventions according to the data collected (1). Oncology nurses have an important role to play in providing quality oncologi- cal psychosocial care and in recognizing psychosocial problems because they are in constant contact with patients and their families (2). It is important to em- phasize that all oncology patients are necessarily in contact with nurses, as opposed to psychologists or social workers (3).

Psychosocial care is defined as the provision of psychological, social, spiritual, counseling, and in- formational support (4). It includes communication between nurses and patients and their family mem- bers, as well as teamwork among health profes- sionals to ensure a multidisciplinary treatment (5). Understanding and experience in delivering psycho- logical treatment are essential for its efficacy (6). The goal of psychosocial oncology (or psychooncol- ogy) is to manage depression, feelings of hopeless- ness, and stress associated with cancer diagnosis (7), whereby the integration of the psychological part of treatment is emphasized (8).

Today, the field of psychooncology is growing into a foundation in many regions of the world, helping to reduce the burden of the disease itself, improv- ing the quality of life from the moment of diagnosis throughout the treatment and survival or palliative care. Nevertheless, the inclusion of psychosocial on- cology in conventional cancer care remains diversely implemented and limited in many countries, with continued adherence to a predominantly biomedi- cal approach (9). In addition, the COVID-19 pandemic has also contributed to widening the gap in health system inequality and in the availability of psychoso- cial interventions (10). Despite the fact that the ma- jority of psychosocial oncology research originates from developed countries, there is a need to study

the impact of psychosocial treatment in developing countries, as it not only improves quality of life but also lowers overall health-care costs. In both devel- oped and developing countries, this is a critical goal in health care management (11).

However, in nursing documentation, most psycho- social problems are not addressed adequately or at all, so nurses may have difficulty formulating or im- plementing interventions focused on psychosocial problems. Nurses` attitudes toward patients can be therapeutic, with appropriate communication skills (12), yet even nurses with experience are insecure and therefore do not fully document the presence of psychosocial problems (13). Due to the existing hi- erarchy, a lack of interest in providing psychological care, challenges in sharing tasks, and communication issues, psychosocial care is usually not an obvious aspect of nursing care (14). Challenges faced by on- cology nurses in recognizing psychosocial problems in patients include lack of time and resources (15), lack of knowledge (16), and lack of privacy for talk- ing to patients about their problems (15). Nurses feel uneasy when it comes to psychosocial problems and psychooncological care because they do not know how to approach the issue (12). There is a lack of guidelines and frameworks on how to provide psy- chosocial care that meets the needs of patients (17). However, if psychosocial problems are not integrated into the nursing care, they will not be continuously and adequately addressed, and interventions con- ducted by nurses will not be visible (18).

Research shows that nurses need to invest more ef- fort because screening and assessment of psychoso- cial problems is not carried out routinely or systemat- ically, and many interventions are patient-centered, without the involvement of family members (19). Healthcare providers often do not recognize mental health disorders in cancer patients (20). The major- ity of published research suggest that health pro- fessionals` ability to recognize the cancer patients` emotional stress is insufficient (21). Nakaguchi (22) reported that nurses are unable to identify the needs and symptoms of patients on chemotherapy and feel incapable of recognizing psychological symptoms as well as the need for support. Several studies have found that nurses tend to focus more on physical problems rather than on psychosocial needs (23) and look at assessing, managing, and reporting on psychosocial needs as part of a practice that is not considered routine (24). Another study based on Gor-

don’s health patterns indicated that nurses disregard the psychological requirements of patients while identifying their physical demands (25). Unmet psy- chological requirements are reported to be present in 22 to 58% of cancer patients (26)..

Oncology patients may benefit from psychooncologi- cal interventions in order to reduce discomfort. Zhang

(27) found that guided safe and brief self-discovery interventions can facilitate positive psychologi- cal outcomes. Therefore, nurses should encourage patients to verbalize their emotions, problems, and challenges they face, as well as to reflect on positive changes (28). Psychoeducation increases knowledge and satisfaction with nursing care (29) and reduces anxiety and stress (30–33). Interventions can help patients and families in prioritizing needs and can promote joint decision-making (34). It is therefore im- perative that the psychosocial problems of patients are recognized and addressed through appropriate nursing interventions (35). The current article aims to fill this education gap by exploring the interven- tions associated with psychooncology education for nurses. The objective of this systematic review is to emphasize the importance of psychooncological edu- cation for oncology nurses in order to identify and create a framework for implementation in developing countries.

Methods

The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (36) (Figure 1).

The literature was for in the Medline database (Web of Science) in English ending with 22 October, 2021. Searched key words included: psychooncology (TOP- IC) or psychosocial oncology (TOPIC). These terms were selected following an investigatory search of available literature and based on their occurrence as well as their relevance to the research question. The inclusion criteria were articles in English published in the last five years within the Web of Science Catego- ry: Nursing and studies of any design type.

Exclusion criteria were published articles older than five years, articles that were not in English, articles outside the Web of Science Category: Nursing, and non-full text-articles or abstracts.

A detailed extraction was done for all articles in- cluded in the review paper. A standardized table was used to extract the data, which included: general in- formation (first author, year of publication, country), type of study, study objective, sample (in case of a research), and key result of the review / research.

Results

While searching the Medline (Web of Science) data- base, a total of 4,806 results were found using the keywords psychooncology (TOPIC) or psychosocial oncology (TOPIC). After filtering articles by using the inclusion criteria, 107 results were found. All 107 articles were read and reviewed in detail, and this review paper includes 14 articles that focused on education in the field of psychooncology in nurs- ing. Most of the articles examined nurses (1, 4, 5, 16,

34, 36, 37), two were patient-oriented (39, 40), and two were oriented on nurses and patients (41, 42). Same number of studies are conducted in Europe (13, 42), predominately in Turkey (1, 16, 41), and in North

America (9, 34, 38, 39, 43) (Table 1).

When speaking of formal education, most authors do not mention such education for nurses in the field of psycho-oncology (1, 4, 5, 9, 12, 16, 34, 38, 41,

43). Authors such as Cantrell (39) and Jabaley (34) discuss psychosocial standards of nursing care that have been developed as well as guidelines from dif- ferent societies. Only three authors describe formal education for nurses; Kubota (37) who talks about the effectiveness of a short training for general nurses that touches upon normal psychological re- sponses to cancer and supporting communication; Daem (42) who states that nurse consultants are supported in participating in the oncological care programs of hospitals; and Kim (40) who developed a seven-week program about a nurse-led psychological intervention program.

Records identified from databases searching (n=4806)

Records screened (n=4806)

Reports sought for retrieval (n=146)

Reports assessed for eligibility (n=107)

Studies included in review (n=14)

Reports excluded (n=93): Does not include psychooncology (n=59) Does not include psychosocial interventions (n=3)

Only focused on patients (n=1)

etc.

Reports not retrieved (n=39)

Records excluded (n=4660)

Additional records identified through other sources

(n=0)

Identification of studies via databases

Included

Screening

Identification

Figure 1. PRISMA flow diagram showing phases of the systematic review

Except for Kubota (37) who talks about onsite edu- cation and e-learning lectures on assessment and management of normal psychological stress with role-play; Daem (42) who relies on a multidisciplinary approach; and Kim (40) who provides data on seven weekly sessions, authors Bultz (9), Ercolano (43) and Jabaley (34) state that there is no formal form of edu- cation, but they point out the availability of multi- disciplinary clinical practice guidelines. The adoption of guidelines largely depends on the motivation of

nurses and is not conditional. Since there is no men- tion of formal education in other articles, delivery of education could not be done, but everyone recom- mends training for nurses, with the expectation of more professional interventions that would make no- ticeable changes.

Overall, authors agree that it is important for nurs- es to acquire knowledge and skills before providing psychosocial care (41) and that standards for nurs- ing psychosocial care needs to be established (5, 34,

Güner, P., et al. (2018).

Turkey.

Qualitative descriptive study.

Identify the attitudes, barriers, and needs of oncology nurses in relation to psychosocial care.

30

nurses

The study findings will aid in the development of the scope and structure needed to handle psychosocial care challenges.

Chen, C.S., et

al. (2017).

Singapore.

Research qualitative study with individual face-to-face interviews.

Examine the nurses` perspectives and experiences in delivering psychosocial care, as well as impediments to providing psychosocial care.

18

nurses

The findings help fill a gap in the nurses’ understanding of psychosocial care, which will aid in the development of a strategy

Ercolano, E.

(2017). USA. Systematic review

Describe the psychosocial issues faced by a postoperative oncology patient, as well as current evidence-based psychosocial interventions.

-

Nurses should play a central role in assessing the effectiveness of physical or psychosocial interventions.

Kim, Y.H., et Randomly

al. (2018). controlled study South Korea.

Developing a program of psychosocial interventions under the guidance of nurses and assessing their effects on stress and quality of life in breast

cancer patients.

Psychosocial interventions could help patients feel more secure and

60 encourage their proactivity and self- patients control, which should be conducted to alleviate psychological stress and

increase the quality of life.

to promote psychosocial care and improve nursing care quality.

Jabaley, T., et al. (2020).

USA.

Prospective research based on the SPAWN model.

Develop and evaluate psychoeducational interventions by using multimedia tools.

45

nurses

The study describes an approach to the development and evaluation of psychoeducational interventions. They serve as a model for effective psychoeducational interventions.

39, 40, 43). Also, they agree that psychooncology nursing practice should concentrate on training, edu- cation and counseling elements (1, 4, 9, 13, 16, 38) in order for patient to be the center of nursing care

(42). Education program would have multiple ben- efits: enhancing confidence, knowledge and attitude associated with cancer patients (37).

The articles included in the systematic review clearly show that nurses do not have an adequate psychooncological education, nor enough self-confi- dence to carry out the interventions. Also, educated nurses had a better assessment and initiative to put psychosocial oncology as a part of the comprehen- sive nursing care. Integration of psychosocial nurs- ing care at all levels could help oncology nurses with coping, assessing, managing, and understanding the complexities of cancer.

Discussion

Cancer patients have different psychological difficul- ties at each stage of treatment (44). As a result, eve- ry member of the health-care team should be able to diagnose the psychosocial difficulties of patients and provide ongoing and consistent health treatment. Since psychosocial therapies and support are ubiq- uitous across all disciplines, they can also produce collaborative problems. Psychooncological scope of action is not restricted to that of a single team mem- ber; the diverse methods of each discipline allow for a complementary care (42).

The aim of this systematic review is to emphasize the importance of psychooncological education of

oncology nurses in order to identify and create a framework for its implementation in developing countries, especially in the Republic of Croatia. Over- all, the number of articles found in the systematic review was low, but it suggests that research of psychooncology in nursing is a vital aspect in help- ing to support nurses. So far, no article was found to have been published in Croatia that would refer to the implementation or education of psychooncol- ogy in the field of nursing. Generally speaking, five articles have been published by psychologists (45), physicians (46–48) and rehabilitators (49), only one of which was published in the past five years. That is why it is necessary to introduce the education of nurses in the field of psychooncology in order to im- prove nursing care that focuses not only on physical but also on psychological needs of patients.

All oncology nurses have a key role in detecting psychological distress (34, 37). Compared to other health professionals, nurses are most exposed to in- tense emotions given the time spent with patients and their families (50). That is why they must ade- quately assess the psychosocial problems of patients and try to avoid causing psychological harm (37). In this way, they can reduce potential barriers to psy- chosocial interventions by emphasizing the normal- ity of the need for them. Patients are also more likely to receive psychological care from nurses than from other health workers, according to Daem study (42).

Despite their critical role in potentially detecting ill- nesses, a study demonstrates that oncology nurses do not recognize the specific psychosocial problems of patients (20). For example, McDonald et al. (51) in- cluded 40 nurses in 25 oncology clinics and discovered that out of 1,109 patients, nurses could reliably iden- tify clinical depression in only 29% of cases of mild depression, and only 14% of cases of major depres- sion. McDonald et al. (51) concluded that nurses tend to underestimate the levels of depression in patients, especially in cases of major depression (22). Oncology nurses expressed concern about their abilities to rec- ognize psychosocial disorders in a research by Pehli- van et al. (1). In a study by Kaneko et al. (52), out of 88 oncology nurses, more than half expressed concern about their ability to assess anxiety and depression. The symptoms they managed to notice were indica- tors of a major depressive disorder: apathy, withdraw- al, sadness, hopelessness, helplessness, indifference, and discouragement. Also, irritability, anger, fear, and anxiety were considered potential signs of psychoso-

cial problems (38). Nakaguchi et al. (22) examined the psychosocial needs of patients and the level of aware- ness among oncology nurses. The results showed that during the implementation of the nursing care, the nurses` awareness about psychosocial require- ments and symptoms was low. It was concluded that nurses cannot adequately detect psychosocial symp- toms or respond to psychosocial demands of patients

(1). A study conducted in Turkey identified that most nurses (98.7%) believe that patients need psychoso- cial evaluation. More than half of nurses (51.6%) are able to make a psychosocial assessment of patients, while 48.4% are not able to make such an assessment. Most nurses believe that all patients need psychoso- cial treatment and support (66.2%) (1).

Lack of specialized education and training for nurses in the field of psychooncology can have a negative impact on nursing care because nurses feel inad- equate when it comes to specific needs of patients and their families, especially during active treatment and at the end of life (5). Disease stage and prog- nosis, treatment uncertainty, inability to keep symp- toms under control, and long and arduous treatment procedures are all reasons why nurses experience difficulty in delivering psychosocial care (4). They be- lieve that physicians are more focused on the illness itself, that psychological treatment is not considered a priority, and that nurses should not spend time on it since they are under pressure to address the physical needs of patients (16).

Skills needed to provide adequate psychosocial care include empathy, holistic care, and communication with patients as authentic human beings and active participants in the nursing care (41). Hinds et al. (5) identified seven specific nurses` behaviors that af- fect patient well-being and psyche: clear explana- tions, sympathy, patient involvement, conversations about topics that do not focus only on the patients` disease, clinical competence, focusing on the future and sharing the experiences of cancer survivors. There are six dimensions for improving the quality of cancer care (50): a holistic approach to caring for patient needs; alleviating physical discomfort; provid- ing emotional support and recognizing psychosocial problems; family involvement; providing information and education; integration and coordination (5).

The psycho-oncology training program began at the Memorial Sloan-Kettering Cancer Center in New York City in 1977, where the formal training lasted a year, adding information to the primary discipline and tailor-

ing the program to acquire appropriate skills. Kubota et al. developed a psychooncological education for nurses. A normal psychological response to illness, clinically significant stress, suicidal thoughts, and delirium were among the four frequent psychosocial disorders in can- cer patients addressed by the program. A short program of psychooncology education helped to improve the nurses` self-confidence, their knowledge, and attitudes regarding psychological care (37). The goal of psycho- social education is to include education, coping strate- gies, and emotional support that will enable the provi- sion of effective and sustainable interventions (40).

The approach to psychosocial nursing care includes building trust, understanding, presence, setting com- mon goals, and providing social support (13, 39). In- terventions to detect psychosocial problems include assessing stress levels and identifying problem are- as: physical, emotional, practical, social, and spiritual

(6). Nonpharmacological therapies, such as stress reduction techniques, support groups, or individual therapy, should be discussed with patients and their families by the nurses (7, 8).

In order to provide integrative care, nurses must be trained to recognize psychosocial problems. Such an education is the basis for addressing psychosocial problems, as well as a tool for solving them (13,38). Education can effectively improve communication skills, empathy, and support during the nursing care of oncology patients (9). Psychooncological education should include the providing of patient-specific infor- mation about the disease, diet, chemotherapy side ef- fects, and symptom management (40). Also included in psychological interventions should be the strate- gies for dealing with negative emotions during treat- ment, as well as emotional support, which includes coping with stress, expressing fear of cancer recur- rence, techniques for overcoming personal difficulties, utilizing social resources, sharing sex life experiences, and self-acceptance (40, 6). Psychoeducational inter- ventions include a therapeutic approach of giving and receiving information, discussion problems, problem solving, coping, expressing emotions, and social sup- port (6). Interventions can be implemented through a variety of modalities, including health education, cog- nitive behavioral therapy, or social support (2).

The first major psychooncological intervention is the early diagnosis of unmet psychological needs (43). The key psychosocial element is communicating the diag- nosis to patients and family. Most often this is done by physician in a presence of a nurse. Since this period

causes high levels of stress and uncertainty that might lead to few days even weeks of struggling to cope with diagnosis, nurses might best support the patient by providing a focused therapeutic dialogue that encour- ages patients to express their feelings and worries in a secure atmosphere (43). As part of psychosocial treat- ment, cognitive behavioral therapy, awareness-based stress reduction, psychoeducation, and psychophar- macology are recommended (8). Cognitive behavioral therapy is particularly effective in redirecting negative thoughts and behaviors and improving the patients’ self-confidence and sense of control (43).

The importance of communication in psychosocial care cannot be overstated (4). According to literature, strong communication between nurses and patients leads to improved nursing care and a higher degree of trust, which is the foundation of the therapeutic relationship

(4). Furthermore, multidisciplinarity is an important component of psychosocial care (5, 9). Encouraging pa- tients to express thoughts and feelings, and educating them on symptom management, help alleviate the level of insecurity during chemotherapy (5), which reduces the level of anxiety and depression, encourages pro- activity and self-control (6). The most important strat- egy is to ask direct questions which include questions about their work, potential mood swings, and general physical and emotional state. It is also necessary to find out what they were like before the disease and how they currently feel so that the nurse can assess potential problems (38). Psychosocial interventions should be conducted from the outset of treatment to minimize the level of stress, improve mental health, and ultimately increase survival rates (39).

Crying during treatment or while discussing their situ- ation is an apparent symptom of psychological prob- lems. The patient`s appearance may also indicate psychosocial distress: disheveled look, neglect of daily activities such as personal hygiene and nutrition. Also, patients who isolate themselves or who appear lonely may have psychosocial problems (38). However, pa- tients often explicitly verbalize their psychosocial problems by saying, “I'm sick and tired,” “I want to die,” “I don't want to live in pain,” “My life has no meaning,” “I don't want to suffer,” or “It's too hard to deal with illness.” (38). Therefore, a good way to satisfy the psy- chosocial needs of patients is to increase their self- confidence, which includes the belief that they are able to undergo treatment with emotional support, increasing disease awareness, and sharing the burden together with the family (13, 34).

Limitations

The advantage of this systematic review is the focus on unifying psychosocial interventions that could be implemented in oncology nursing care regardless of the location of the tumor. Also, this systematic review has a potential of becoming a foundation in the psy- chooncological education of nurses, which can be sup- plemented and expanded depending on educational needs. However, one should bear in mind that this educational framework is not suitable for all countries and systems, especially in developed countries, since their curricula include psychooncology training for nurses, and there are numerous trainings available to nurses, but it can serve as an example for developing countries that are only starting to implement psycho- social oncology nursing care. Unfortunately, the lack of scientific articles in Croatian language shows that this area is not covered in any way, especially when it comes to the field of nursing. In general, there is a lack of literature that specifically targets the psychoonco- logical education of nurses in developing countries. Another limitation may be that we only used one data- base, which may have excluded a number of relevant studies. Nevertheless, this systematic review contrib- utes to highlighting the need for the development of psychooncological education for nurses and research in this field in developing countries.

Conclusion

Psychooncology requires the readiness of nurses to provide support in dealing with oncology patients with psychosocial problems, pointing out the normal- ity of such feelings, and helping to endure physical treatment. This systematic review has shown that psychosocial interventions positively affect the progression of illness, psychosocial condition, symp- toms, treatment and side effects, as well as lowering stress levels and improving the quality of life.

Nurses should be able to determine the psychological needs of patients as well as their physical demands by utilizing a holistic approach. However, nurses have

little opportunity to learn about the psychological care that needs to be provided. The burden of can- cer continues to grow disproportionately in develop- ing and underdeveloped countries and is affected by changes in life choices, current health policies, health system infrastructure, and resource availability (10, 9). Therefore, in the field of psychooncological nurs- ing care, it is necessary to improve the education and training systems for psychological assessment and stress management. Further research is needed in this area, especially in developing and underdevel- oped countries, to highlight the need for education. Consequently, the psychosocial problems of patients will become a priority, in addition to providing care and focusing on their physical needs.

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RJEŠAVANJE POTREBE ZA POSTAVLJANJEM OKVIRA ZA OBRAZOVANJE MEDICINSKIH SESTARA U PSIHOONKOLOGIJI U ZEMLJAMA U RAZVOJU: SUSTAVNI PREGLED

Sažetak

Postoji potreba za proučavanjem utjecaja zdrav- stvene njege na psihosocijalni tretman u zemljama u razvoju. Cilj je naglasiti važnost psihoonkološke edukacije onkoloških medicinskih sestara kako bi se identificirao i stvorio okvir za provedbu. Proveden je pregledni rad. Literatura je pretražena primjenom ba- ze podataka Medline. Kriteriji za uključivanje bili su članci na engleskom jeziku objavljeni u posljednjih pet godina unutar kategorije Web of Science: Sestrin- stvo. Nakon filtriranja članaka prema kriterijima uklju- čivanja, pronađeno je 107 rezultata, a ovaj pregledni rad uključuje 14 članaka. Psihosocijalne intervencije pozitivno utječu na progresiju bolesti, psihosocijalno stanje, simptome, liječenje i nuspojave. Međutim, me- dicinske sestre imaju malo prilika naučiti o psihološkoj skrbi. Stoga je u području psihoonkološke zdravstve- ne njege potrebno unaprijediti sustave obrazovanja i osposobljavanja za psihološku procjenu i upravljanje stresom.

Ključne riječi: okvir, sestrinstvo, onkološko sestrinstvo, psihoonkološka edukacija, psihoonkologija