Abstract

Objective: To explore the nursing management of psychological distress in patients with advanced cancers based on the best evidence and evaluate the effect of its application. Methods: 153 patients with advanced cancers admitted to the oncology department of a tertiary-level hospital in Hubei Province from January to December 2024 were selected as the study subjects, and 79 patients with advanced cancers admitted from April to June 2024 were selected as the baseline group and 74 patients with advanced cancers as the evidence-based practice group. Using the “evidence-based continuous quality improvement model” as a guide, the evidence-based practice of psychological distress management was applied to patients with advanced cancers according to the four stages of evidence acquisition, current status review, evidence introduction and effect evaluation, and the changes in the incidence rate of psychological distress were compared before and after the application of the evidence-based practice. Results: Nineteen pieces of evidence on hospice management of psychological distress in patients with advanced oncology were summarised, and the evidence was translated into 13 review indicators for evidence-based practice. The implementation rate of the review indicators for the management of psychological distress in patients with advanced oncology and the level of nurses’ knowledge, attitudes, and behaviours related to psychological distress in patients with advanced oncology were significantly improved, with statistically significant differences in the knowledge and behavioural dimensions (P < 0.05). The incidence of moderate to severe psychological distress in patients with clinically advanced cancers was reduced from 76% to 43.5% (P = 0.04). Conclusion: Evidence-based nursing practice of hospice management of psychological distress in patients with advanced cancers can effectively improve the clinical practice environment, improve nurses’ knowledge of prevention of psychological distress in patients with advanced cancers, attitudes and adherence to clinical measures, reduce the incidence of moderate-to-severe psychological distress in patients with advanced cancers in the clinic, and improve the quality of their lives.

Keywords

Advanced Cancers, Psychological Distress, Evidence-Based Care, Evidence Application

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1. Introduction

According to data from the International Agency for Research on Cancer (IARC) [1], in 2020, China will have the highest number of cancer deaths and incidence cases in the world. Cancer is now one of the leading causes of death in China. With the deterioration of the disease, advanced cancer patients have to suffer from severe symptoms and adverse effects of treatment, and will face the threat of death at any time, which is very easy to produce great psychological distress [2]. With the transformation of medical care model, national policies and oncology care-related guidelines encourage healthcare professionals to pay attention to the psychological needs of patients. Studies have shown that the psychological distress of advanced cancer patients is more difficult to be recognised by healthcare professionals than their physical symptoms, and there is a lack of evidence-based hospice management for the assessment of psychological distress in advanced cancer patients [3]. In order to promote evidence-based clinical translation and enhance the quality of clinical care, the evidence-based continuous quality improvement model diagram, which provides an effective way and method for the localised application of evidence by promoting the translation of evidence to the clinic, can effectively promote the continuous improvement of the quality of clinical care. Based on the prevalence of psychological problems in patients with advanced lung cancer, the transformation of medical care models, and the effectiveness of evidence-based care in addressing psychological problems, this study summarised the current best evidence, carried out the application of evidence translation, and adopted the evidence-based continuous quality improvement model developed by the Centre for Evidence-Based Nursing at Fudan University [4], which was carried out in accordance with the four phases of evidence acquisition, review of the current status quo, introduction of evidence, and evaluation of the effect of evidence translation, which provides reference for nursing staff to adopt effective management strategies. The project was approved by the Hospital Ethics Committee.

2. Material and Methods

2.1. Access to Evidence

2.1.1. Subject

According to PIPOST, the initial question of evidence-based nursing was formed [4], i.e. P (Population, target population for evidence application): advanced oncology patients assessed for psychological distress. I (Intervention): screening, assessment, response, referral, follow-up. P (Professional, professionals applying evidence): clinical nurses. O (Outcome, indicators of the project): (structural indicators) at the system level (relevant system processes in the department, educational materials), (process indicators) at the practitioner level (nurses’ knowledge, attitude, and knowledge about psychological distress), (outcome, indicators of the project): (structural indicators) at the system level (relevant system processes and educational materials in the department), (process indicators) at the practitioner level (nurses’ knowledge, attitude and behavioural level related to psychological distress, and the rate of implementation of each review indicator), and at the patient level (the incidence and degree of psychological distress, improvement of the patients’ psychological status, and the patients’ quality of life). S (Setting, evidence application site): screening, assessment, response, referral, follow-up. E (Evidence Application Place): oncology wards and other related institutions. T (Type of Evidence): clinical decision-making, clinical practice guidelines, best practices, evidence summaries, systematic evaluations, expert consensus, randomised controlled trials, etc.

2.1.2. Evidence Search

A top-down data search was conducted according to the “6S” evidence resource pyramid model. The search included BMJ Best Practice, UpToDate, Cochrane Library, JBI Centre for Evidence-Based Health Care, Guidelines International Network (GIN), Scottish Intercollegiate Guidelines Network (SIGN), National Comprehensive Cancer Network (NCCN), Registered Nurses Association of Ontario (RNAO), European Society of Medical Oncology (ES-MO), American Society of Clinical Oncology (ASCO), European Society of Oncology (ES-MO) and American Society of Clinical Oncology (ASCO), Italian Association of Medical Oncology (AIOM), Medline, Embase, SinoMed, CINAHL, PubMed, Web of Science, the official website of the National Health Commission of the People’s Republic of China, China Knowledge Network (CKN), Wanfang Database (WFD), Wipo Database (WDB), and China Biomedical Literature Database for all evidence on the management of psychological distress in advanced cancer patients. Search terms in Chinese: advanced, terminal, end-stage; cancer; psychological distress, psychological crisis; management, care.

Search terms: advanced, end-of-life, terminal, near-death period, end stage; cancer, tumor, oncology, neoplasms; psychological distress, psychological crisis, psychological pain, mental pain; hospices, hospice care, palliative care, terminal care, disease management, management, nursing. The search period is from January 2010 to March 2024.

2.1.3. Inclusion Criteria

Inclusion criteria: 1) the study object is to assess the psychological distress of patients with advanced cancers; 2) the content addresses the screening, assessment, response, referral and follow-up of psychological distress in patients with cancers; 3) the types are: guidelines, systematic evaluations, evidence summaries, high-quality randomized controlled trials, and expert consensus; and 4) the languages of the included literature are set to be Chinese and English. Exclusion criteria: 1) guideline interpretation type of literature; 2) duplicate publication or already have an updated version; 3) literature with incomplete information and full text unavailable; 4) graded C by literature quality assessment.

2.1.4. Literature Quality Evaluation

Because the clinical decision-making source BMJ Best Practice, UpToDate, belongs to the top level of evidence in the “6S” pyramid, and the quality of the evidence is high, the evidence that is consistent with the present study and the clinical application scenario in China was directly adopted. The guidelines were evaluated by the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Expert consensus, best practice, and randomised controlled trials were evaluated using the Australian JBI Centre for Evidence-Based Health Care’s Authenticity Evaluation Tool for Opinion and Consensus Articles and the Authenticity Evaluation Tool for Randomised Controlled Trials, respectively. Summaries of evidence were evaluated using the Critical Appraisal for Summaries of Evidence (CASE). Systematic evaluations were evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR). In the end, we obtained 13 papers that met the inclusion criteria, including 3 guidelines, 1 best practice, 1 evidence summary, 4 systematic reviews, and 4 randomised controlled trials (see Table 1 for the quality assessment of the included guidelines).

Table 1. General information and quality assessment of the included literature (n = 13).

2.1.5. Evidence Extraction Evaluation and Review Indicator Generation

17 pieces of evidence were initially extracted for training and assurance, screening, assessment, timing of intervention, non-pharmacological interventions, and health education through the JBI evidence-based framework [18] [19], structured search of the literature, and quality evaluation and integration; 4 pieces of evidence were deleted after the FAME evaluation, and 13 review indicators were constructed using structured observation, questionnaire, and interview methods, as see in Table 2.

Table 2. Table of indicators for the evaluation and review of the integration of evidence.

2.2. Subjects of Practice

Convenience sampling was used to select the 12 nursing staff included and the 79 patients included in this ward from April-June 2024 with the same inclusion and exclusion criteria as the baseline review group. The 10 nursing staff included at the time of the baseline survey and the 74 patients included in this ward from July-September 2024 with the same inclusion and exclusion criteria of the baseline survey were the evidence application group evidence application group. Patient inclusion criteria: 1) Age 18 - 75 years old. 2) Advanced tumour patients. Exclusion criteria: 1) People with impairment of perception, understanding and expression. 2) Those who are delirious or have serious mental illness. 3) Those who are depressed or take other mental disorders. 4) Those who are on psychotropic drugs. 5) Those who have recently participated in psychological interventions related to psychological distress. Nurses’ inclusion criteria: engaged in oncology nursing ≥ 1 year, and voluntarily participated in this study. Exclusion criteria: Further training, rotation nurses.

2.3. Evaluation Indicators

The implementation rate of the review indicators for the management of psychological distress in patients with advanced oncology, the level of nurses’ knowledge, attitudes and behaviours related to psychological distress in patients with advanced oncology, and the incidence of moderate to severe psychological distress in patients with clinically advanced oncology.

2.4. Analysis of Influencing Factors

The project team analysed barriers and reasons in the clinical translation of evidence based on the evidence-based continuous quality improvement model according to the results of the status quo review by team members. Through focus group discussions, a fish bone diagram is drawn based on the 4M1E theory, and barrier factors are analysed facilitators and change strategies are constructed for each review indicator, see Table 3.

2.5. Statistical Processing

SPSS 21.0 statistical software was used to analyse the data. Measured data were statistically described by a kind of x ± s, count data were statistically described by percentages, t-test and chi-square test were used for comparison between groups, and P < 0.05 was considered as statistically significant difference.

3. Results

3.1. General Information of the Study Population

153 patients were included in this study, including 79 cases in the baseline review group and 74 cases in the evidence application group, and the 2 groups of patients’ gender, age, education level, and basic diagnosis, and the difference was not statistically significant (P > 0.05), see Table 4.

Table 3. Barriers analysing facilitators and constructing change strategies.

3.2. Implementation of Review Indicators before and after the Clinical Translation of Evidence

The investigator ticked off whether the clinical practice was standardised in accordance with each review indicator through on-site review, on-site observation,

Table 4. Comparison of baseline data between the two groups of patients (x ± s, n).

handover questions, and access to nursing records (the on-site review was blinded to the person being observed to avoid Hawthorne benefits). There were a total of 13 review indicators in this project, before the application of evidence, there was a gap between clinical practice and evidence, the baseline review had an implementation rate of 0% for 4 indicators, and the remaining 8 indicators had an implementation rate of 6.50% to 52.80%, none of which exceeded 60%, and after the application of evidence, 4 indicators had an implementation rate of 100.00%, and no indicator had an implementation rate of 0, and the implementation rate of the remaining indicators had an implementation rate of 65.20% to 88.60 percent.

3.3. Incidence of Psychological Distress

The results of this study showed that the MSAS scores of all dimensions, DT scores, and PL scores of patients in both groups decreased after the application of evidence compared with the pre-intervention period, and the group with the application of evidence was lower than the group with the baseline review, and the incidence of moderate-to-severe psychological distress in patients with clinically advanced cancers was reduced from 76% to 43.5% (P = 0.04).

Nurses’ knowledge, attitudes and behavioural levels related to psychological distress in patients with advanced cancers (nurses’ knowledge, attitudes and behavioural levels related to psychological distress in patients with advanced cancers): a total of 14 nurses were included in this study, and due to the adjustment of the staff in the department, the application of the evidence was included in 12 of them, and 2 reviews were carried out before and after the application of the evidence, and the average age of the nurses was (26.48 ± 7.47) years old, with 1 male and 11 female, 7 with tertiary education and 12 with bachelor’s degree. Through the introduction of evidence, nurses’ knowledge, attitudes and behaviours in the management of psychological distress in patients with advanced oncology were improved, in which in the dimensions of knowledge and behaviour, the difference was statistically significant (P < 0.05), see Table 5.

Table 5. Nurses’ scores on the level of knowledge, attitudes and behaviours related to psychological distress in patients with advanced oncology before and after the application of evidence.

4. Discussion

4.1. Impact of Evidence-Based Practice on Nursing Behaviour

This study shows that nurses’ knowledge of psychological distress prevention and adherence to measures increased significantly, which is consistent with previous studies. This may be attributed to the multidisciplinary collaboration of standardised processes (e.g. the application of the psychological distress screening tool DT, the symptomatic management pathway) and hierarchical training mechanisms (e.g. communication skills training combined with scenario simulation). It is worth noting that nurses’ perceptions of psychological distress shifted from “emotional problems” to “multidimensional symptom clusters”, which led to a shift in the focus of nursing care from passive intervention to early prevention, a shift that is in line with the national hospice guidelines. This shift is in line with the concept of “whole-person care” advocated by the domestic hospice guidelines.

4.2. Potential Mechanisms for Improved Patient Outcomes

The reduced incidence of moderate-to-severe psychological distress may be associated with the following mechanisms: 1) Prevalence of structured assessments: by incorporating the DT scale into routine nursing assessments, the identification of patients’ psychological distress increased, ensuring that high-risk individuals received timely psychological interventions or referrals; 2) Integration of personalised interventions: evidence-based interventions (e.g. positive thought stress reduction, family meetings, pre-established healthcare plans) targeted to alleviate patients’ concerns about the death anxiety, and family burden as core sources of distress [15]; 3) Enhanced nurse-patient trust: improved communication skills of nurses facilitated patients’ willingness to express their emotions and avoided the insidious accumulation of distressing emotions.

This study constructed an evidence-based practice pathway for the management of psychological distress in patients with advanced cancers in line with China’s cultural background [20], covering the closed-loop process of “screening-assessment-intervention-evaluation”, which is highly operable in clinical practice. However, the study sample was limited to a single medical institution, and multi-centre validation is needed in the future.

5. Summary

This study integrated evidence-based recommendations for the management of psychological distress in patients with advanced oncology into clinical practice through an evidence translation strategy [21], confirming that the model is effective in enhancing nurses’ professional competence, reducing the incidence of moderate-to-severe psychological distress in patients, and improving their quality of life. Further validation of the long-term effects of the intervention is needed in the future, exploring the use of digital tools (e.g. AI psychological screening) in dynamic assessment and focusing on the adaptation of the intervention model in the context of healthcare resource inequality. We advocate the inclusion of psychological distress management into the core indicators of quality of care for advanced oncology patients [22], and promote the standardisation and humanisation of hospice services.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References