Holistic Needs Assessment: an acute hospital’s story…. Nicky Laking, Nurse Consultant & Lead Cancer Nurse Dr Clare Davies, Consultant Clinical Psychologist

Background Cancer Action Team 2007: ‘All NHS patients with a diagnosis of cancer and/or receiving care in any setting should be offered this assessment.’ North East Cancer Network – Holistic Assessment Developed with permission from Northern Comprehensive Cancer Network, USA.

Methodology Working group to explore delivery and effectiveness of the Holistic Needs Assessment (HNA). Minimal modification to HNA. Identification of training needs. Establishment of the ability to audit Formation of a pilot group

Score: __________________ This screening tool is aimed to encourage professionals and patients to explore current problems and issues that may be affecting patients’ physical, psychological, social and spiritual well-being. The outcome (including patient score) of this assessment is to be documented in the patients ongoing record with an agreed plan of care and referral on for symptom control, rehabilitation, social, spiritual or psychological care where necessary. My appearance / Body image Skin Dry / Itchy / wound healing Swollen (limbs/abdomen) Weight Changes – loss or gain Sexual Problems Hair Loss Other Reduced Independence Bathing / Dressing Getting Around Toileting Difficulties Constipation Diarrhoea Stoma Changes in passing urine Physical Symptoms Difficulties in Communicating Breathing Pain Temperature Change in sensation: hands/feet Seizures Eating Difficulties Indigestion Sores /painful mouth Nausea/vomiting Taste changes Swallowing difficulties Change in appetite Food preparation Any other factors Social Concerns Coping with dependents Work/School Hobbies/Leisure activities Housing Finances Travel Carer Relationships Emotional Wellbeing  Sadness Fears Worries / Anxieties Anger Alcohol/smoking/other drugs Unable to express feelings Feeling isolated Loss of dignity Forgetful/confused Stress Loss of control Spiritual / Religious Concerns Questioning values and beliefs Sense of meaning Issues relating to dying and death Rest / Activity Sleep Fatigue Tiredness Alteration in sleep pattern Identify the number (1-10) that best describes how much distress has been experienced over recent weeks, if ‘0’ is no distress and ‘10’ is high levels of distress or anxiety. Score: __________________

2 3 1 4  Finances Sadness  Stoma  Sleep  Change in appetite This screening tool is aimed to encourage professionals and patients to explore current problems and issues that may be affecting patients’ physical, psychological, social and spiritual well-being. The outcome (including patient score) of this assessment is to be documented in the patients ongoing record with an agreed plan of care and referral on for symptom control, rehabilitation, social, spiritual or psychological care where necessary. My appearance / Body image Skin Dry / Itchy / wound healing Swollen (limbs/abdomen) Weight Changes – loss or gain Sexual Problems Hair Loss Other Reduced Independence Bathing / Dressing Getting Around Toileting Difficulties Constipation Diarrhoea  Stoma Changes in passing urine Physical Symptoms Difficulties in Communicating Breathing Pain Temperature Change in sensation: hands/feet Seizures Eating Difficulties Indigestion Sores /painful mouth Nausea/vomiting Taste changes Swallowing difficulties  Change in appetite Food preparation Any other factors Social Concerns Coping with dependents Work/School Hobbies/Leisure activities Housing  Finances Travel Carer Relationships Emotional Wellbeing Sadness Fears Worries / Anxieties Anger Alcohol/smoking/other drugs Unable to express feelings Feeling isolated Loss of dignity Forgetful/confused Stress Loss of control Spiritual / Religious Concerns Questioning values and beliefs Sense of meaning Issues relating to dying and death Rest / Activity  Sleep Fatigue Tiredness Alteration in sleep pattern 2 3 1 Identify the number (1-10) that best describes how much distress has been experienced over recent weeks, if ‘0’ is no distress and ‘10’ is high levels of distress or anxiety. Score: ______7___________ 4

NECN HOLISTIC ASSESSMENT OF CONCERNS Developed with kind permission of the Northern Comprehensive Cancer Network (2005) from the Distress Thermometer Group NECN HOLISTIC ASSESSMENT OF CONCERNS Patient Details Today’s date: Previous assessment date: Staff member to print and sign name: Assessment number: 1 2 3 4 5 Comment Diagnosis Location Duration of interview (in minutes): Copy given to patient Yes  No  Highest Ranked Concerns Rating 0-10 Description and history of concern Plan of action 1 2 3 4

Pilot Group 5 site cancer specialist teams (11 specialist nurses) 10 assessments per tumour group SPCT, Urology, UGI, Breast, Haematology (All on JCUH site) 3 month pilot, or 10 assessments completed Training session.

Training 3 hour session – Nicky and Clare Presentation: Background to Holistic Assessment, What do we mean by distress?, What deters patients from expressing concern, exploratory / open-ended questions *, Therapeutic Conversation. Role-play: modelling use of administering HNA. Introduction, Eliciting information, action points. Group practice: scenarios, specific cases. Documentation and Quick Guide. * Those staff that have not undertaken adavanced comms

Training Information Folder: “The assessor should have access to up to date information about local service providers, referral criteria and support services”. (Cancer Action Team) Macmillan Information Centre – updating information.

Pilot Group Results 9 out of 11 individual questionnaires were returned (89%) 4 of the 5 specialist services (80%) Years spent as a specialist nurse ranged from 1 to 15 years ( mean average 7 years).

Improved Communication / focused time Patient feedback   Improved Communication / focused time “Having someone to talk too” “I felt someone cared” “Spending time with clinical nurse specialist herself was really beneficial for me” “The time felt focused on me” “The opportunity was never there before to actually ask questions without a rush

Chance to discuss issues that would not normally come up in conversation To be asked about sexual and financial problems was a chance for me to think about these things – I hadn’t really” “I found it helpful to talk about when I could resume a sex life” “I didn’t think I could offload about all my problems in clinic – I was asked bout things I was worrying about but usually I am just in and out of clinic”

Conclusion Time Not all patients appropriate Environment Patients verbalised a positive process Peer review measure Community environment a positive experience for both patient and staff

Challenges Engagement of staff Developing the therapeutic conversation Ensuring transfer of information to others Recording the use of HNA

Positive experiences Engagement of staff Involvement of Macmillan Information Centre Development of the information folder HNA training sessions Feedback from patients

Recommendations and Outcomes Full role out of HNA across all tumour sites March 2012 6 month evaluation of the tool June 2012 3 month audit of its use July 2012 Full compliance with the peer review measure May 2012 6 month review – opportunity to feedback in a larger group, discuss supervision needs

Who did we train? Nurse Consultants Clinical Sisters Specialist Nurses Therapy Radiographers Ward & Clinic Staff 90% staff undertaken Advanced Comms, Some Level 2 Psychology trained, All band 6 or above Plan to train key AHPs?

Raising Awareness Clinicians – oncology/ haematology meetings MDT meetings Ultimately benefit patient care

Acknowledgments Dr James Brennan, Consultant Clinical Psychologist. Bristol Haematology & Oncology Centre. University Hospitals Bristol NHS Foundation Trust. Specialist Nurses for embracing the tool Macmillan Information Centre Andrea Harris Macmillan Specialist Nurse – SPCT