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Holistic Needs Assessment
Holistic needs assessment should be part of every cancer patient’s care. It can make a huge difference to a patient’s overall experience and has the potential to improve outcomes by identifying and resolving issues quickly.
Benefits of undertaking holistic needs assessment
The process of undertaking an holistic needs assessment:
- Identifies people who need help
- Provides an opportunity for the person to think through their needs and, together with their healthcare professional, to make a plan about how to best meet these
- Helps people to self manage their condition
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Helps teams to target support and care efforts and work more efficiently by making appropriate and informed decisions
Practical guide
In March 2011, NCAT published a practical guide intended for healthcare professionals responsible for undertaking holistic needs assessment. The guide provides practical advice including examples of assessment tools and case studies to assist local teams with implementing HNA in day-to-day practice.
All printed copies of the guide have now been distributed, please see the documents box above to download an electronic version of the guide and example tools.
Embedding holistic needs assessment
Nearly all services are considering how best to ensure HNA is effectively carried out and recorded but few have yet achieved widespread implementation. One of the main reasons teams struggle is a perceived lack of time due to competing demands and priorities. A study was carried out in 2011 at Southampton University Hospitals Trust to see whether this barrier could be overcome using ‘lean’ techniques.
The approach taken was to gain an in-depth understanding of the workload of Clinical Nurse Specialists (CNSs) in 3 different site specific teams. Further work was undertaken to clarify the respective contributions of both the CNSs and multidisciplinary team (MDT) coordinators.
One of the main findings was that there was an unecessary administrative workload placed on the CNSs. There was also a degree of duplication observed between the work of CNSs and MDT coordinators. The study concluded that if CNSs and MDT coordinators worked in a more collaborative manner and undertook tasks that best fitted with their expertise, this would lead to the release of time for CNSs to invest in HNA and other high value, high impact activities. A poster summarising this project is available.
This section gives some examples of where holistic needs assessment is being implemented. It is intended to enable emerging practice and practical solutions to be shared. If you would like to suggest further case studies to add to this section please contact claire.morris@ncat.nhs.uk
Nottingham University Hospitals NHS Trust
Key points:
- Patients with thoracic cancer have their needs assessed by the cancer nurse specialist or a member of the rehabilitation team using the SPARC tool
- Further assessment or support needs based on the patients’ responses to the SPARC tool are discussed and agreed at the weekly multi-disciplinary team meetings
A Macmillan Cancer Support 3-year project grant is providing a pro-active rehabilitation service for people with thoracic cancer, consisting of a dietitian, occupational therapist, physiotherapist and data manager. The service works closely with, and is supported by, existing thoracic cancer and specialist palliative care services.
The Sheffield Profile for Assessment and Referral to Care (SPARC) questionnaire is routinely used to screen for supportive and palliative care needs at the time of diagnosis. An initial survey of 100 patients had established that the SPARC was acceptable in this setting, with questionnaires completed by the patient alone, or with the aid of a member of staff or carer in 65, 22 and eight instances respectively.
Either a member of the rehabilitation service or a lung cancer nurse specialist invites the patient to complete the SPARC. This is generally 1–4 weeks after being informed of their diagnosis at their next visit to hospital, e.g. for an investigation or outpatient review. For those patients with no planned visits within this time frame, following telephone contact, a SPARC is posted out with a stamped addressed envelope.
The SPARC questionnaire begins with an explanatory paragraph and contains 45 questions with 56 possible responses covering seven areas of potential need. For most questions, patients rate the degree to which they have been distressed or bothered by a symptom or issue in the past month using the responses; 0 ‘Not at all’, 1 ‘A little bit’, 2 ‘Quite a bit’ and 3 ‘Very much’. Generally, the SPARC takes about 15 minutes to complete and, according to patient preference, it can be completed during the visit, or at home (SAE provided). Experience in non-English speaking patients is limited; however, it has been successfully completed with the use of translators.
The results of the SPARC are then discussed at a weekly multidisciplinary meeting attended by the members of the rehabilitation service, lung cancer nurse specialists and a consultant in palliative medicine. All patients are assessed by the dietitian. Generally, patients scoring ‘Quite a bit’ or ‘Very much’ in particular issues will also be contacted for further assessment by the appropriate team member.
It is hoped that greater understanding of the needs of people with thoracic cancer and the provision of better support from the time of diagnosis will have the potential to improve the overall experience of care, optimize independence, quality of life and to help them to remain in their preferred place of care.
Contact details for more information:
Dr Andrew Wilcock DM FRCP
Macmillan Reader in Palliative Medicine and Medical Oncology
University of Nottingham
Hayward House Macmillan Specialist Palliative Care Cancer Unit
Nottingham University Hospitals NHS Trust
Nottingham
NG5 1PB
Tel: 0115 9627 778
andrew.wilcock@nottingham.ac.uk
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
Key points:
- The SPARC tool is being used for self-assessment prior having the assessment ‘conversation’ and is posted out to patients prior to a clinic or home visit, or given during clinic
- Healthcare assistants are able to help patients to complete the questionnaire
- Different teams are tailoring the process according to how best they feel it fits with their patient group
At Doncaster and Bassetlaw NHS Trust, the Sheffield Profile for Assessment and Referral for Care (SPARC) tool is being rolled out to support the holistic needs assessment process.
Self assessment using the SPARC tool is the first part of a three step process, and is followed by the assessment ‘conversation’ held between the cancer specialist nurse and patient and the action plan which is agreed together.
The project has been going since September 2009 and to get started, teams have agreed to carry out the holistic needs assessment at least once for all patients with cancer. The trust has not been prescriptive about exactly when the assessment should take place and different teams are tailoring the process according to how best they feel it fits with their patient group though in all cases the assessment is never carried out at the same time that the patient receives their diagnosis.
- It was found that the main concerns recorded by patients were centred on their surgery when the SPARC questionnaire was used for colorectal patients during a hospital stay. When used during outpatient consultations a wider range of concerns were elicited covering psychological, social and spiritual issues. All teams now only use the questionnaire for outpatients.
- Teams looking after patients with cancer of the breast, lung or head and neck and those with a stoma carry out home visits and the assessment is done during one of these visits. The SPARC questionnaire is posted out to the patient a few days before the visit, along with an accompanying letter.
- Other patients are invited to complete the SPARC questionnaire during a clinic visit (in some cases the questionnaire and letter are posted to the patients a few days before their clinic visit). Healthcare Assistants are being involved to assist patients complete the questionnaire, for example with reading questions and helping them to write on the form, but it is always a clinical nurse specialist who carries out the assessment conversation
- The Lung CNS have set up a nurse led clinic to allow more time to explain and support patients after their diagnosis and treatment plan, or if a patient has additional concerns, symptoms that need to be addressed. This is an ideal opportunity to use the HNA process
The assessment is something which is considered a core part of the specialist nursing role. The SPARC tool and process gives the assessment process a structure and use of the same tool across the trust means it is easy to identify that the assessment has been undertaken. Despite the questionnaire enabling the assessment conversation to focus on issues of greatest concern, the process does take time, the amount of time being variable depending on the patient and the complexity of the issues raised. The accompanying guidance gives permission for nurses to say “I’ve only got 20 minutes…” or “I can talk about x issue but will ask y person to follow up with the other things”.
The trust has developed a sticker which is inserted into the patient’s notes following the assessment. The action plan form is very simple, identifying the main issues and actions which have been agreed. As well as a copy being given to the patient and included in their notes, copies of the action plan are also sent to the patient’s own GP and to any services to which the patient is referred.
The trust recognises that the process of ensuring that all patients with cancer are assessed holistically is only just beginning – for example only the more complex breast and urology cancer patients currently receive an assessment – but the intention is to develop the use and spread of the SPARC tool and assessment process over time encompassing staff in primary care, particularly the district nurses. The local hospice is beginning to use the tool for their day-care patients and the trust is keen to develop the process to support follow-up care as part of the wider survivorship agenda.
Contact details for more information:
Lesley Barnett
Macmillan Lead Cancer Nurse
C block
Doncaster Royal Infirmary
Armthorpe Road
Doncaster
DN2 5LT
Tel: 01302 553194
City Hospitals Sunderland NHS Foundation Trust
Key points:
- Led by their patients’ needs, rather than those of the consultants, the CNSs have re-structured their contact time with their patients in order to introduce a pre-operative counselling session
- The distress thermometer is used to structure the holistic needs assessment at several times during the patient pathway
- As well as being used during and at the end of treatment the distress thermometer is also being used at post treatment and ‘moving on’ workshops, the points at which patients often seem more vulnerable as the safety net of regular hospital visits are dramatically reduced
The breast care clinical nurse specialists at Sunderland felt that their practice of having a post-operative session with patients on the ward was not as effective as they wanted and for more than a year now have moved the session ‘upstream’ and now carry out a pre-operative counselling session instead with all their patients.
The appointment is scheduled in the hour before the pre-operative assessment clinic and happens very soon after the patient has first received their diagnosis. It is at this stage that the distress thermometer is used to structure the counselling session. The tool is introduced and the nurses talk through how it is used.
The nurses have observed that the concerns which are identified soon after diagnosis are usually those ones listed on the right hand column on the page – concerns around physical effects, independence and appearance. By the end of treatment the concerns tend to move across to those listed in the left hand column and focus more on social and emotional wellbeing as well as spiritual issues.
Partners are encouraged to attend at the pre-operative counselling session and often prompt the patient to be more assertive about some of the worries they have expressed privately. Although the nurses always offer the patient a copy of the completed distress thermometer tool to take home, many do not wish to have a copy.
A copy of the results from each time is kept in the nursing notes and a summary documented on the Trust’s hospital information system.
The distress thermometer is then used a number of times during the course of the patient’s treatment both by the breast care nurses at the monthly chemotherapy/ Herceptin drop-in sessions and by the chemo nurses during treatment sessions.
When patients come to the end of their treatment, by now they are very familiar with using the distress thermometer tool and it is posted out to them two weeks before their end of treatment workshop, again two to four weeks after this workshop and then again six months later when they are invited to attend a ‘moving on’ group.
The aim of these workshops is to help patients to take greater control of their lives, promoting good health and self-management. Patients seem to experience a peak in anxiety around the end of their treatment and are often more vunerable as the safety net of regular hospital visits are dramatically reduced. The nurses feel it is vitally important patients are assessed with the distress thermometer at the end of treatment so any distress can be highlighted and interventions agreed.
In addition to all this a reconstruction workshop is also offered and a ‘walk and talk’ session has been introduced inviting cancer survivors on a 2 hour Sunday morning jaunt!
The nurses were apprehensive about using the distress thermometer at first but gave it a go and soon realised that it can give a useful structure to what is, after all, good nursing practice. Some patients do require much more time spent during the assessment conversation, but the nurses feel that they would have required that whether or not the tool was being used. In fact, for these people the DT can help structure the conversation and enables the nurses to focus their patients on their more pressing concerns.
One training session was felt sufficient before starting to use the distress thermometer in practice. Learning to adapt to the changes needed to embed this process into day-to-day practice was however not always easy – it took a while to introduce the pre-operative assessment and to find the best point at which to introduce the distress thermometer. But the benefits which this gave to the patients were quick to become apparent and provided enough encouragement and incentive to carry on using the tool.
In summary, points on the pathway when the distress thermometer (DT) is used at Sunderland are:
- At pre-operative counselling the DT is first introduced to the patient
- The DT is used regularly at the breast care nurses monthly Chemotherapy and Herceptin drop in sessions.
- Two weeks before the End of Treatment Workshop the DT is posted to patients and they are asked to bring their completed DT with them to the workshop session; between two and four weeks after the session another DT is posted to patients which they are asked to post back.
- It is posted again to the patient two weeks before they attend a ‘moving on’ group which is held 6 months following the end of their treatment
- Any concerns highlighted at any stage are signposted to complementary services as appropriate.
Contact details for more information:
Michelle Derbyshire and Caroline Misell
City Hospitals Sunderland NHS Foundation Trust
Kayll Road
Sunderland
Tyne and Wear SR4 7TP
Tel: 0191 565 6256
The practical guide for Holistic Needs Assessment, published in March 2011, sees the completion of the facilitation activities in this area by the National Cancer Action Team. Ongoing links will be maintained with other related work, for example the National Cancer Survivorship Initiative, in order to ensure a ‘joined up’ approach.