Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention

Development and perception of surgery-specific goals of care discussions in the preoperative setting: A learning pilot

BACKGROUND

Goals of care discussions are infrequently documented in the preoperative period. Furthermore, documentation does not consistently address what matters most to patients, although patient values (PV) are central to person-centered care.

METHODS

A multidisciplinary working group was formed. An electronic note comprised of (1) topics of discussion, (2) PV, and (3) advance care planning (ACP), was created and embedded into existing note templates for Gynecologic Surgical Oncology. Surgeons and advanced practice providers (APPs) were educated to conduct and document these conversations in preoperative clinic for patients undergoing cancer surgery for a pilot period. Data were collected regarding usage of the template. Focus groups with surgeons, APPs, and patients were conducted. Qualitative analysis was performed on transcripts.

RESULTS

During the pilot, 7 surgeon/APP teams utilized the template on a total of 55 notes. Average number of notes completed per surgeon was 7.8 (SD 8.5). Forty-six notes (84%) included topics of discussion, 15 (27%) included PV, 4 (7%) included ACP. Qualitative analysis of focus group transcripts revealed that clinicians and patients perceived the initiative to be useful and important, although implementation barriers were identified.

CONCLUSION

Creating a surgery-specific GOC template is feasible. Iterative revisions are needed to increase utility in clinic workflows.

Beyond translation: Transcreation of a clinicians' guide to structure discussions about health-related values with Latinx patients throughout cancer

OBJECTIVE

This study aimed to ensure accurate translation and cultural appropriateness of a guide designed to help oncology clinicians provide person-centered care to Spanish-speaking Latinx patients with cancer.

METHODS

Initial translation of a clinician-patient values discussion guide in open-ended question format ("Guide") was pretested in interviews with 27 Spanish-speaking individuals, followed by national expert panel review. At three sites, semi-structured, in-depth, audio-recorded interviews in the participant's preferred language (Spanish/English) were then conducted with Latinx patients receiving systemic treatment for a solid tumor malignancy and family joining them at clinic.

RESULTS

Interviews of 43 patient/family participants representing diverse Latinx communities addressed the Guide's understandability, acceptability, relevance and responsiveness. Rapid analysis of interviews contributed to cultural adaptation/transcreation of the Guide for a pilot interventional trial.

CONCLUSION

Moving beyond translation to transcreation can help promote inclusion, equity, and cultural sensitivity in oncologic care/communication.

PRACTICE IMPLICATIONS

Clinicians now have a linguistically- and culturally-adapted guide including questions and prompts to help structure discussions in Spanish or English of health-related values with Latinx patients receiving oncologic care.

Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes

BACKGROUND

Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes.

AIM

To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes.

DESIGN

A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes.

DATA SOURCES

Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023.

RESULTS

The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined.

CONCLUSION

This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.

A Two-Phase Qualitative Enquiry Into Storytelling's Potential to Support Palliative Care Patient-Led Change, Using a Systematic Review Approach

A terminal diagnosis can diminish an individual's sense of agency and identity. Leading change appears to restore a sense of agential self. The first phase of this literature review explores factors influencing patient-led change across the palliative care ecosystem. The second phase illuminates how storytelling can support palliative care patients in leading ecosystem-wide change. 35 studies were identified in Phase 1 and 36 in Phase 2. This research highlights the need to situate patient leadership activity within a palliative care ecosystem to understand factors likely to support or hinder patient leadership activity within it. The evidence indicates the potential use of storytelling to support patients with a life-limiting illness to lead change across the palliative care ecosystem. This challenges current conceptualisations of such patients and offers them instead as an additional source of palliative care support.

What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients

BACKGROUND

Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care.

METHODS

At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified.

RESULTS

A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only."

CONCLUSIONS

Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.

Patient and Clinician Stakeholder Perspectives on a Patient Portal Questionnaire Eliciting Illness and Treatment Understanding and Core Health-Related Values

Introduction

Person-centered communication is foundational to cancer care. In pilot research, a questionnaire eliciting patients' illness and treatment understanding (ITU) and core health-related values (HRV) through the electronic patient portal demonstrated feasibility, acceptability, and efficacy. The aim of this study was to elicit stakeholder feedback to refine the design of the portal-based intervention, remain end-user centered, and optimize future system-wide integration.

Methods

Between April and June 2023, we purposively sampled patients and clinicians from a previous pilot study to participate in a 20-30-minute semistructured interview about their opinions of and experiences with the portal questionnaire on ITU and HRV. An interdisciplinary coding team used a two-phase rapid analysis to identify themes, subthemes, and illustrative participant quotations.

Results

Fourteen patients (mean age = 68 years) and 12 clinicians participated (total n = 26). Colorectal cancer was the commonest malignancy (64%) among patients. Clinicians were mostly physicians (50%), nurse practitioners (33%), and registered nurses (17%), with two-thirds having >15 years of experience in their specialty. Analysis generated four themes: (1) clinical utility of questionnaire, (2) barriers to questionnaire implementation, (3) considerations and strategies for modifying the questionnaire, and (4) considerations and strategies for questionnaire implementation. Themes captured key information about incorporating this questionnaire into clinical practice.

Conclusion

Patients with cancer and their clinicians found a portal-based ITU and HRV questionnaire clinically useful to improve multiple aspects of person-centered communication. Participant recommendations about questionnaire timing and sharing of questionnaire responses with the clinical team will inform future questionnaire implementation and scaling in clinical settings.

A Worksheet to Facilitate Discussions of Values for Patients With Metastatic Cancer: A Pilot Study

CONTEXT

Individual goals and values should drive medical decision making for patients with serious illness. Unfortunately, clinicians' existing strategies to encourage reflection and communication regarding patients' personal values are generally time-consuming and limited in scope.

OBJECTIVES

Herein, we develop a novel intervention to facilitate at-home reflection and discussion about goals and values. We then conduct a pilot study of our intervention in a small population of patients with metastatic cancer.

METHODS

We first engaged former cancer patients and their families to adapt an existing serious illness communication guide to a worksheet format. We then distributed this adapted "Values Worksheet" to 28 patients with metastatic cancer. We surveyed participants about their perceptions of the Worksheet to assess its feasibility.

RESULTS

Of 30 patients approached, 28 agreed to participate. Seventeen participants completed the Values Worksheet, and of those 11 (65%) responded to the follow-up survey. Seven of eleven reported that the Values Worksheet was a good use of time, and nine of eleven would be likely to recommend it to other patients with cancer. Eight of ten reported mild distress, two of ten reported moderate to severe distress.

CONCLUSION

The Values Worksheet was a feasible way to facilitate at-home discussions of goals and values for select patients with metastatic cancer. Further research should focus on identifying which patients are most likely to benefit from the Values Worksheet, and should employ the Worksheet as one tool to facilitate reflection on the questions that arise around serious illness, as an adjunct to serious illness conversations with a physician.

A Prospective Study of Nurse-Led Oral Mucositis Management: Impact on Health Outcomes of Patients Receiving Radiotherapy for Head and Neck Cancer and Lung Cancer

OBJECTIVES

The study aimed to evaluate the impact of nurse-led mucositis management on the health outcomes of patients receiving radiotherapy for head and neck cancer and lung cancer. The study adopted a holistic approach that involved the patient in the care process by screening, providing education and counseling about mucositis management and integrating it into daily life by the radiotherapy nurse.

DATA SOURCES

In this prospective, longitudinal cohort study, 27 patients were assessed and monitored through use of the WHO Oral Toxicity Scale and Oral Mucositis Follow-up Form and educated on mucositis during their radiotherapy through use of the Mucositis Prevention and Care Guide. At the end of radiotherapy, an evaluation of the radiotherapy process was performed. In this study, each patient was followed for 6 weeks from the start of radiotherapy.

CONCLUSION

The worst clinical data for oral mucositis and its variables emerged at week 6 of treatment. While the Nutrition Risk Screening score increased over time, weight decreased was observed to decrease. The mean stress level was 4.74 ± 0.33 in the first week and 5.77 ± 0.35 in the last week. It was observed that 88.9% of the patients showed good compliance with the treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurse-led mucositis management contributes to better patient outcomes during the radiotherapy process. Such an approach improves oral care management in patients receiving radiotherapy for head and neck and lung cancer, demonstrating its positive impact on additional patient-focused outcomes.

The Acknowledge-Normalize-Partner (ANP) Framework: A novel empathic communication tool for oncology nurses

OBJECTIVE

To describe the development and implementation of a novel tool designed to enhance nurse-patient communication in a major academic cancer center, which nurses can learn quickly, incorporate into their primary palliative care practice, and broadly disseminate in order to improve the patient experience.

METHOD

An evidence-based empathic communication tool and educational program were designed to provide essential skills to oncology nurses in having discussions with patients about their personal values. Evaluation included nurse focus groups, pre- and post-course evaluations and interviews, and patient questionnaires.

RESULTS

Nurses were satisfied with the educational program and found the communication tool effective in a variety of clinical situations including discussions about personal values. Patients reported increased occurrences of these discussions when nurses utilized the framework (97% vs. 58%, p < 0.0001) and a higher quality of clinician communication (mean [SD] from 0 = very worst to 10 = very best: 7.18 [2.3] vs. 5.04 [2.9], p = 0.001).

SIGNIFICANCE OF RESULTS

Skilled, empathic communication is an essential component of high-quality primary palliative care. Oncology nurses are well suited to lead communication and provide this care as part of an interprofessional team. The training and tool described here are targeted and efficient, and prepare nurses to respond skillfully to emotion while facilitating important discussions about patient values.

Effects of a Web-Based Pediatric Oncology Legacy Intervention on the Coping of Children With Cancer

BACKGROUND

Recurrent or refractory cancer often results in substantial and extensive physical, emotional, psychosocial, and spiritual burdens for children and their families. However, the therapeutic benefits of legacy interventions in children with recurrent or refractory cancer have been examined only recently, with limited attention to specific effects on children's coping abilities.

OBJECTIVE

The purpose of this study was to determine the effects of a digital storytelling-legacy intervention on the adaptive coping of children with recurrent or refractory cancer.

METHODS

This study used a 2-arm randomized, waitlist-controlled trial design. A total of 150 children with recurrent or refractory cancer and their parents were recruited via Facebook advertisements.

RESULTS

The analysis sample included 92 dyads (35-intervention group, 57-control group). The legacy intervention showed small and statistically nonsignificant effects on primary-control and disengagement coping strategies among children with recurrent or refractory cancer.

CONCLUSIONS

Legacy interventions using readily accessible digital storytelling have the potential to enhance the adaptive coping skills among children with recurrent or refractory cancer. Further research should determine how to enhance interventions tailored to this population to optimize the benefits.

Advance Care Planning in Serious Illness: A Narrative Review

CONTEXT

Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility.

OBJECTIVE

To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness.

METHODS

We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care.

RESULTS

Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations.

CONCLUSIONS

We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.

Managing Critical Patient-Reported Outcome Measures in Oncology Settings: System Development and Retrospective Study

BACKGROUND

Remote monitoring programs based on the collection of patient-reported outcome (PRO) data are being increasingly adopted in oncology practices. Although PROs are a great source of patient data, the management of critical PRO data is not discussed in detail in the literature.

OBJECTIVE

This first-of-its-kind study aimed to design, describe, and evaluate a closed-loop alerting and communication system focused on managing PRO-related alerts in cancer care.

METHODS

We designed and developed a novel solution using an agile software development methodology by incrementally building new capabilities. We evaluated these new features using participatory design and the Fit between Individuals, Task, and Technology framework.

RESULTS

A total of 8 questionnaires were implemented using alerting features, resulting in an alert rate of 7.82% (36,838/470,841) with 13.28% (10,965/82,544) of the patients triggering at least one alert. Alerts were reviewed by 501 staff members spanning across 191 care teams. All the alerts were reviewed with a median response time of 1 hour (SD 185 hours) during standard business hours. The most severe (red) alerts were documented 56.83% (2592/4561) of the time, whereas unlabeled alerts were documented 27.68% (1298/4689) of the time, signaling clinician concordance with the alert thresholds.

CONCLUSIONS

A PRO-based alert and communication system has some initial benefits in reviewing clinically meaningful PRO data in a reasonable amount of time. We have discussed key system design considerations, workflow integration, and the mitigation of potential impact on the burden of care teams. The introduction of a PRO-based alert and communication system provides a reliable mechanism for care teams to review and respond to patient symptoms quickly. The system was standardized across many different oncology settings, demonstrating system flexibility. Future studies should focus on formally evaluating system usability through qualitative methods.

Accuracy of curability expectations in patients with gastrointestinal cancers

BACKGROUND

Assessment of illness and treatment understanding among cancer patients has largely focused on those with advanced disease. Less is known about patient expectations at earlier stages of cancer and potential modifiers of accurate understanding.

METHODS

We assessed accuracy of cure expectations in patients across all stages with gastrointestinal (GI) cancers. Accuracy was determined by independent reviews of patient health records by oncologists on the investigative team. Impact on cure accuracy of selected clinical variables and health-information preferences was analyzed.

RESULTS

Hundred and thirty five patients were included for analysis, with 100% interrater agreement for accuracy between oncologist reviewers. Sixety five patients (48%) had accurate cure expectations from their cancer treatment. Accuracy was lower in Stage IV versus Stage I-III disease (35% vs. 63%, p < 0.01), lower in unresectable versus resectable disease (35% vs. 67%, p < 0.01), and higher in patients with early-stage disease who received adjuvant chemotherapy versus those who did not (78% vs. 53%, p = 0.04). Accuracy did not differ by health-information preferences and remained stable over time. Of 63 patients who died, baseline accuracy differed by location of death (p = 0.03), with greater accuracy in those who died with home hospice (56%). Accuracy was lower in those who were hospitalized in the last 30 days of life versus those who were not (25% vs. 59%, p = 0.01).

CONCLUSIONS

Inaccurate cure expectations are prevalent across all stages of GI cancers, but particularly among those with metastatic or unresectable disease. High-quality, iterative communication strategies may facilitate patient illness and treatment understanding throughout the disease course.

Advance care planning imperative: High-quality patient-centred goals of care

Advance care planning (ACP) discussions aim to ensure goal-concordant care for patients with serious illness, throughout treatment and especially at the end of life. But recent literature has forced the field of palliative care to wrestle with the definition and impact of ACP. Are ACP discussions worthwhile? Is there a difference between ACP discussions early in a patient's illness versus discussions occurring later when a concrete medical care decision must be made? Here, we identify elements needed to answer these questions and describe how a multisite initiative will elucidate the value of discussing and documenting what matters most to patients.

A scoping review of nurse-led advance care planning

BACKGROUND

Advance care planning (ACP) supports persons at any age or health status to determine their values, goals, and preferences regarding future medical care. The American Nurses Association endorses nurses to facilitate ACP to promote patient- and family-centered care.

PURPOSE

This project reviewed and synthesized literature on nurse-led ACP training models.

METHODS

A scoping review used the Arksey and O'Malley Framework to identify: (a) ACP training model type, (b) nurse-led ACP recipients, (c) ACP in special populations, (d) ACP outcomes.

FINDINGS

Of 33 articles reviewed, 19 included 11 established models; however, the primary finding was lack of a clearly identified evidence-based nurse-led ACP training model.

DISCUSSION

Nurses are integral team members, well positioned to be a bridge of communication between patients and care providers. This is a call to action for nurse leaders, researchers, educators to collaborate to identify and implement an evidence-based, effective nurse-led ACP training model.

Needs and Perspectives of Cancer Center Stakeholders for Access to Patient Values in the Electronic Health Record

PURPOSE

High-quality cancer care must incorporate patients' personal values in decision making throughout illness. Unfortunately, patient values are neither consistently elicited nor easily accessible in the electronic health record (EHR). Memorial Sloan Kettering Cancer Center is deploying a major EHR innovation, called the Patient Values Tab, which provides ready access to patients' values and personhood. To inform the Tab's design, we interviewed a large, diverse group of institutional stakeholders to understand their user needs for this Tab.

METHODS

Qualitative data were collected through semistructured, audio-recorded, in-person, individual interviews. An interdisciplinary team of four coders conducted a process of thematic content analysis. Thematic saturation was achieved, and member checking was performed.

RESULTS

A total of 110 stakeholders were approached and interviewed. Participants comprised a wide range of disciplines or professions and others involved in hospital and/or clinic administration. Analysis revealed the following themes related to important Tab content: personhood, support system or resources, social history, communication preferences, future planning, end of life, and illness and treatment understanding. Participants also discussed implementation considerations, the Tab's potential to improve communication, and privacy implications.

CONCLUSION

This study focused on a major EHR innovation to centralize information about values and personhood of patients with cancer. We elicited views of over 100 institutional stakeholders through in-depth interviews that were rigorously analyzed, yielding themes related to content and format that helped guide the Tab's design. The interviews generated a sense of ownership and enthusiasm for the Tab among future users. The Tab's introduction advances the use of the EHR as a driver of the delivery of patient-centered care.

Cultural and Ethical Barriers to Cancer Treatment in Nursing Homes and Educational Strategies: A Scoping Review

(1) Background: The aging of the population, the increase in the incidence of cancer with age, and effective chronic oncological treatments all lead to an increased prevalence of cancer in nursing homes. The aim of the present study was to map the cultural and ethical barriers associated with the treatment of cancer and educational strategies in this setting. (2) Methods: A systematic scoping review was conducted until April 2021 in MEDLINE, Embase, and CINAHL. All articles assessing continuum of care, paramedical education, and continuing education in the context of older cancer patients in nursing homes were reviewed. (3) Results: A total of 666 articles were analyzed, of which 65 studies were included. Many factors interfering with the decision to investigate and treat, leading to late- or unstaged disease, palliative-oriented care instead of curative, and a higher risk of unjustified transfers to acute care settings, were identified. The educational strategies explored in this context were generally based on training programs. (4) Conclusions: These results will allow the co-construction of educational tools intended to develop knowledge and skills to improve diagnostic and therapeutic decision-making, the consistency of care, and, ultimately, the quality of life of older cancer patients in nursing homes.

Development of the Oncolo-GIST ("Giving Information Strategically & Transparently") Intervention Manual for Oncologist Skills Training in Advanced Cancer Prognostic Information Communication

CONTEXT

Patient prognostic understanding is improved by oncologists' discussions of life expectancy. Most patients deem it important to discuss prognosis with their oncologists, but a minority of cancer patients within months of death report that they had such a discussion with their oncologist.

OBJECTIVES

To query stakeholders about their perspectives on the clinical approach and utility of an Oncolo-GIST manualized communication intervention, designed to enhance oncologists' ability to convey the gist of prognostic information simply, clearly, and effectively in the setting of progressing solid tumors and limited life expectancy.

METHODS

We obtained and analyzed feedback on the intervention from solid tumor oncology clinicians and bereaved family caregivers, soliciting opinions on the clinical approach taken in the videos, acceptability and likely impact of the instructions, and specific phrases recommended in the manual.

RESULTS

Twenty stakeholders (9 clinicians, 11 caregivers) participated. All agreed that oncologists should broach prognosis with patients, balancing honesty and sensitivity. Participants also advocated for oncologists to involve interprofessional team members (e.g., nurses, social workers) when serious mental health concerns arose. After the research team's discussion of the stakeholder feedback, the manual was modified to include or exclude preferred language and approaches.

CONCLUSION

The Oncolo-GIST intervention was characterized as simple and potentially effective at conveying prognoses to advanced cancer patients. Future research should determine if this approach to medical communication, which distills the essence of prognostic messages clearly and simply, is associated with improvements in patients' prognostic understanding.

Development of the competency assessment scale for clinical nursing teachers: Results of a Delphi study and validation

BACKGROUND

Highly competent clinical faculty is a prerequisite for graduating competent nurses, and it is very important to explore the comprehensive ability and post competence of clinical nursing teachers (CNT).

OBJECTIVE

To construct the competency evaluation elements of clinical nursing teachers and test the reliability and validity of the scale.

DESIGN

A Delphi study.

SETTINGS

34 Grade A tertiary hospitals and eight colleges and universities in China, covering 14 provinces, autonomous regions, and municipalities directly under the Central Government.

METHODS

Modified Delphi method was used in this study. Between August 2018 and May 2019, 40 experts participated in three rounds of consultation to build the CNT competency assessment scale. The expert coordination coefficient (W) and the coefficient of variation (CV) were used to examine the level of coordination and concentration of expert advice. Then, the reliability and validity of the scale were tested. Using the convenient sampling method, a total of 190 questionnaires were distributed to nursing teachers, and 187 were recovered. Cronbach's α coefficient was used to evaluate the reliability of the scale. Validity was evaluated using the content validity index.

RESULTS

After the three rounds of expert consultation, the questionnaire contained five dimensions and 44 elements. After expert inquiry, the total coefficient of variation index (CVI) value of the scale was 0.992, and the CVI of each item was 0.95-1.00. The Spearman-Brown correlation coefficient was 0.984. By comparing the results of the two surveys 2 months apart, the Pearson correlation coefficient was tested, and the retest reliability was 0.852. The Cronbach's α of the scale was 0.962, indicating excellent internal consistency.

CONCLUSIONS

The scale of clinical nursing teachers' competence has high reliability and validity. This tool could be widely used to evaluate and improve nursing teaching.

A Novel Patient Values Tab for the Electronic Health Record: A User-Centered Design Approach

BACKGROUND

The COVID-19 pandemic has shined a harsh light on a critical deficiency in our health care system: our inability to access important information about patients' values, goals, and preferences in the electronic health record (EHR). At Memorial Sloan Kettering Cancer Center (MSK), we have integrated and systematized health-related values discussions led by oncology nurses for newly diagnosed cancer patients as part of routine comprehensive cancer care. Such conversations include not only the patient's wishes for care at the end of life but also more holistic personal values, including sources of strength, concerns, hopes, and their definition of an acceptable quality of life. In addition, health care providers use a structured template to document their discussions of patient goals of care.

OBJECTIVE

To provide ready access to key information about the patient as a person with individual values, goals, and preferences, we undertook the creation of the Patient Values Tab in our center's EHR to display this information in a single, central location. Here, we describe the interprofessional, interdisciplinary, iterative process and user-centered design methodology that we applied to build this novel functionality as well as our initial implementation experience and plans for evaluation.

METHODS

We first convened a working group of experts from multiple departments, including medical oncology, health informatics, information systems, nursing informatics, nursing education, and supportive care, and a user experience designer. We conducted in-depth, semistructured, audiorecorded interviews of over 100 key stakeholders. The working group sought consensus on the tab's main content, homing in on high-priority areas identified by the stakeholders. The core content was mapped to various EHR data sources. We established a set of high-level design principles to guide our process. Our user experience designer then created wireframes of the tab design. The designer conducted usability testing with physicians, nurses, and other health professionals. Data validation testing was conducted.

RESULTS

We have already deployed the Patient Values Tab to a pilot sample of users in the MSK Gastrointestinal Medical Oncology Service, including physicians, advanced practice providers, nurses, and administrative staff. We have early evidence of the positive impact of this EHR innovation. Audit logs show increasing use. Many of the initial user comments have been enthusiastically positive, while others have provided constructive suggestions for additional tab refinements with respect to format and content.

CONCLUSIONS

It is our challenge and obligation to enrich the EHR with information about the patient as a person. Realization of this capability is a pressing public health need requiring the collaboration of technological experts with a broad range of clinical leaders, users, patients, and families to achieve solutions that are both principled and practical. Our new Patient Values Tab represents a step forward in this important direction.

Applying User-Centered Design in the Electronic Health Record (EHR) to Facilitate Patient-Centered Care in Oncology

Patient-centered care is an essential component of quality health care. To support patient-centered care initiatives at our institution, we created a feature in our EHR to centrally view information about the patient's values, goals and preferences. We applied user-centered design methods to ensure that the aggregate view was easy to use and would meet user needs. We created a six-week plan to iterate through increasingly detailed design mock-ups. We defined 7 user stories that later served as a basis for user testing scripts. We conducted user testing on our third design iteration; we reached theme saturation with 8 testing sessions. We incorporated findings into the fourth design (week 6) but continued to refine the design in parallel to development (through week 20+). The advance directives section required the most attention. We will use a pilot and additional user testing to validate the design and to inform future versions.

Patients' Experience of Communication During Their Course of Treatment in an Oncology Outpatient Clinic: Qualitative Study

BACKGROUND

Communication between patients and healthcare professionals becomes increasingly important as patients with cancer are primarily treated in outpatient settings, where the time to communicate is brief. There is a need to understand patients' experiences of communication to ensure person-centered communication during treatment.

OBJECTIVE

The aim of this study was to explore how patients experience communication with healthcare professionals during their course of treatment in an oncology outpatient clinic to elucidate how their needs for support are met.

METHODS

Data were generated through semistructured qualitative interviews in patients with cancer who received treatment in an oncology outpatient clinic (n = 18). Interpretive description methodology and symbolic interactionism inspired the analytical approach.

RESULTS

Three overarching communication categories were generated, namely, verbal practices, relational practices, and nonverbal practices, which reflect distinct characteristics and the quality of the communication. Communication was characterized as being informative, cheerful, and routinized, which the patients found supportive and, contrarily, superficial, task focused, lacking continuity in care, and missing existential dimensions.

CONCLUSION

The communication practice in the oncology outpatient clinic especially supported patients in managing their treatment and side effects. However, psychological, social, and existential concerns were rarely addressed, requiring the patient to self-manage these issues in everyday life while living with cancer.

IMPLICATIONS FOR PRACTICE

Patients are socialized by verbal and nonverbal communication practices in the outpatient clinic, which influences their expectations of what to talk about during their treatment. Methods are needed to support person-centered communication in outpatient settings, so patient care needs are met more broadly.

Verification of expected death in the community: role of the community specialist practitioner

In 2019, the Royal College of Nursing (RCN) and Queen's Nursing Institute (QNI) recognised a significant reduction in the number of qualified district nurses (those who hold the Community Specialist Practitioner (CSP) qualification). Community nursing is an evolving role, and, with the role of community nurse expanding, the role of the CSP in supporting teams to adapt to the development of the role is more important than ever. As a leader, the CSP possesses skills in leadership and co-ordination of the team, alongside specialist knowledge of the provision of nursing care in community settings. This article seeks to explore the hidden practice of verification of expected adult deaths by registered nurses and how the CSP role is integral in developing and embedding this skill within a team.

Pancreatic cancer-A disease in need: Optimizing and integrating supportive care

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that continues to be challenging to treat. PDAC has the lowest 5-year relative survival rate compared with all other solid tumor malignancies and is expected to become the second-leading cause of cancer-related death in the United States by 2030. Given the high mortality, there is an increasing role for concurrent anticancer and supportive care in the management of patients with PDAC with the aims of maximizing length of life, quality of life, and symptom control. Emerging trends in supportive care that can be integrated into the clinical management of patients with PDAC include standardized supportive care screening, early integration of supportive care into routine cancer care, early implementation of outpatient-based advance care planning, and utilization of electronic patient-reported outcomes for improved symptom management and quality of life. The most common symptoms experienced are nausea, constipation, weight loss, diarrhea, anorexia, and abdominal and back pain. This review article includes current supportive management strategies for these and others. Common disease-related complications include biliary and duodenal obstruction requiring endoscopic procedures and venous thromboembolic events. Patients with PDAC continue to have a poor prognosis. Systemic therapy options are able to palliate the high symptom burden but have a modest impact on overall survival. Early integration of supportive care can lead to improved outcomes.

Emotions in the room: common emotional reactions to discussions of poor prognosis and tools to address them

Introduction: Advanced cancer patients often want prognostic information, and discussions of prognosis have been shown to enhance patient understanding of their illness. Such discussions can lead to high-quality, value-consistent care at the end of life, yet they are also often emotionally challenging. Despite how common and normal it is for patients to experience transient emotional distress when receiving 'bad news' about prognosis, emotional responses have been under-addressed in existing literature on prognostic discussions. Areas covered: Drawing upon psychology research, principles of skilled clinical communication, and published approaches to discussions of serious illness, we summarize patients' common emotional reactions and coping strategies. We then provide suggestions for how to respond to them in clinic. Expert opinion: Ultimately, effective management of emotional reactions to bad news may lead to earlier, more frequent, and more transparent discussions of prognosis, thus promoting cancer patients' understanding of, and adjustment to, their illness and improving the quality of their end-of-life care.

Culturally Adapting an Advance Care Planning Communication Intervention With American Indian and Alaska Native People in Primary Care

Introduction: Advance care planning (ACP) is a process in which patients, families, and providers discuss and plan for desired treatment goals. American Indian and Alaska Native people (AI/AN) have higher prevalence of many serious, life-limiting illnesses compared with the general population; yet AI/ANs use ACP considerably less than the overall population. Method: We conducted a qualitative study to culturally adapt an existing ACP intervention for AI/ANs in two primary care settings. Results: We found that it is important to incorporate patients' cultural values and priorities into ACP, determine who the patient wants involved in ACP conversations, and consider the culturally and locally relevant barriers and facilitators when developing an ACP intervention with AI/AN communities. Discussion: At the core, ACP interventions should be clear and understandable across populations and tailored to facilitate culturally appropriate and meaningful patient-provider communication. Our results and methodology of culturally adapting an intervention may be applicable to other underrepresented populations.