Providing emotional care to our patients: Not enough time? Or, too little skill?
All patients will be affected by their cancer diagnoses and treatment. Psychosocial support has been shown to be beneficial in reducing psychosocial distress as well as physical symptoms, such as pain.
Nurses are in an ideal position to assess and address emotional needs of patients. I often say that, nurses have a unique opportunity to make a profound difference in how a patient and their loved ones manage the cancer journey. Just take, for example, that nurses are within closest proximity to a patient, usually getting to know visitors and family members, and are providing the most intimate level of care. Nurses are there continually during the day time as other professionals are, but also at night- when patients are most often “alone” with their thoughts, concerns and fears-an ideal time to check on how someone is doing and on occasion a useful period when a nurse has a few extra minutes to have some quiet time alone with the patient.
Nurses also place high value on their relationships with their patients and they speak often of treasuring the “caring” nature of their work. How many times have we heard “Nurses care. Doctors cure”.
So, how are we doing in relation to providing emotional care? Generally, nurses want to provide emotional support and in fact, often believe that they are providing adequate or even a high level of support during their care. However, patient surveys continue to demonstrate less than optimal results in relation to this aspect of cancer care, regardless of where they are in the cancer journey. National agencies and care centers continue to try to address these gaps in care.
As nurses we have barriers still, in providing excellence in psychosocial care. And, I have to say I frequently hear about them when I co-lead our de Souza workshop on psychosocial care. Mostly, I hear about the lack of time; the lack of privacy; and that other needs, for example the more medically-oriented tasks, take precedence over emotional care, or are even valued more so. Yet, it causes me to wonder…
On the one hand, more than ever before, cancer centres and many community or general care settings have access to evidence-based guidelines and tools to do psychosocial assessments, even assessing for symptoms of depression and anxiety. I see that they are now routinely being used and I understand electronic forms such as the kioks with ESAS are now widely distributed. But, what is troubling to learn is how little we sometimes truly know about a score of 4 versus a 7? Do we ask as we should? How are we doing in our communications with patients and families? How are our assessment skills?
Psychosocial social support is key to me- as it supports all the other cancer care interventions- including medical decision-making, adherence to difficult treatment regimes, and is necessary to facilitate quality of life and decrease the burden of cancer. Psychosocial care involves a complexity of skills. It is so much more than “nurses exhibiting a caring attitude and stance”. Yes, nurses care. When I hear the words “nurses are empathic”, it makes me ask what do folks mean by that statement? Are they really able to articulate the role of empathy and all that it encompasses as a scientifically- informed, intentional, purposeful set of responses and an approach? Responding to a patient’s expressions of fears or concerns, or to a needs for further information and comprehension or clarification concerning their treatments or diagnosis, involves a sophisticated set of evidence-based skills in assessment and delivery of care. Communication skills and psychosocial care involves culturally- attuned approaches to assess psychological, social and spiritual functioning and needs. Emotional care involves complexity in active listening, observations of body language, paying attention to the voicing of nuances, and of “silence”, making eye contact, asking a set of carefully crafted questions to assess the specific and concrete issues that are driving the psychosocial need, monitoring the patient, and our own reactions as they are occurring. In other words, this means paying attention to the minute-by-minute reactions, as well as self-monitoring our own reactions, feelings, perspectives etc. This is important as patients and their families are continually scrutinizing nurses’ responses and even our nonverbal behavior, in the looking for clues and the need to manage their sense of uncertainty that comes along with a life-threatening illness, such as cancer.
The “care” part involves carefully timed responses, followed by an assessment of those responses in order to follow up with the appropriate level next nurse response. All this is scientifically based, (although I do recognize the role of natural talent and the “art” of communication); but empathy and psychosocial care are highly informed.
Assessment skills are actually necessary in order for nurses to build relationships- something we value- and also for one to feel a sense of competency, professional confidence and satisfaction in our work.
But are nurses feeling prepared? I frequently see room for growth in this area of skill development. Nurses can benefit from further understanding on how a “4” on an ESAS scale for one patient is different than a “4” reported by another patient. A common criticism on the use of screening instruments- which are an ideal “first step” to providing care, is that the scores are recorded but nurses are not responding or documenting about their specific care. I think it can be fairly straight forward to determine the need based on a high score and its “red flag” to refer or find out more about the distress, but there is that large group of patients who have needs who score above a 2 or more , but who continue to have unmet needs. Scoring in and of itself or charting a score, are not enough. A score doesn’t tell us anything about the concern. For example, what is driving the depression or anxiety score up? How is the patient feeling about that level of distress or managing with it? What methods are they using to manage the distress? What works for them? Or has worked in the past?
Mishra et al. (2010) found that beyond the barriers of time and workload, nurses are at times unwilling to delve deeper into concerns when it comes to the psychosocial realm , for example , in relation to a cancer diagnosis or prognosis. Mishra et al. (2010) found that nurses feared they could not appropriately respond or had the capacity to deal with such concerns. Similarly, I have had nurses open up about such difficulties in our workshops, admitting that they have indeed felt badly to purposely not open up subject matters that they feel “are a can of worms” or where they do not feel they can adequately lead the discussion. This is a courageous disclosure and important to recognize in addressing the need for further skill. My experience is that nurses, in fact, wish to delve deeper and can really build on their skills and really have a significant impact on a patient’s experience. The emotional care of our patients is a part of the nurses’ work life that contributes job satisfaction and when not addressed in practice, can be associated with increased compassion fatigue
We can learn, we can do better…and we must do better. Oncology is an existential illness-everything about it, whether viewed as a chronic or terminal illness. It evokes issues around the finiteness of life. Authenticity in our work is important for us; Feeling supported and effective is an important component of being a health professional and it is an integral part of nursing care- Indeed, CANO recognizes it as a standard of care- and emotional care and addressing emotional, spiritual and social needs of our patients is part of overall cancer care excellence.
In our workshops we have a tool that allows nurses to delve deeper.We utilize the BATHE model which helps nurses practice with a set of specific questions which help guide them in learning about a patients specific concern or issue (Lieberman & Stuart, 1999). This helps the nurse to understand much more fully what the “4” means for one person exactly -versus someone else’s “4”. And, so the nurse can more effectively employ a well-tailored intervention to address the patient’s personal need and concern. As a result, patient experience is automatically enhanced: the patient is listened to and understood and has a far better chance of having their need or concern met. But also importantly, the nurses’ work life satisfaction and value in their work increases.
If managing your patients’ emotional wellbeing is a clinical area where you need assistance, please consider attending one of our courses or IPODE series courses. This is definitely an area where we can all keep continuously building on our skills. There are levels of skill in assessment and intervention delivery that we as nurses can make a big difference in our patient’s management of their illness.
Lieberman, J. A., 3rd, & Stuart, M. R. (1999). The BATHE Method: Incorporating Counseling and Psychotherapy Into the Everyday Management of Patients. Prim Care Companion J Clin Psychiatry, 1(2), 35-38.
Mishra, S., Bhatnagar, S., Philip, F. A., Singhal, V., Singh Rana, S. P., Upadhyay, S. P., & Chauhan, G. (2010). Psychosocial concerns in patients with advanced cancer: an observational study at regional cancer centre, India. Am J Hosp Palliat Care, 27(5), 316-319. doi: 10.1177/1049909109358309