Doctor of Nursing Practice (DNP) Final Projects

Cancer survivorship has been identified as separate stage in cancer treatment posing unique issues that arise from the diagnosis of cancer, as well as late effects associated with treatments. Evidence shows that cancer survivors demonstrate suboptimal follow-up care, and report high levels of unmet needs related to their cancer experience. To improve care for the increasing number of cancer survivors in the United States, survivorship care plans (SCPs) have been proposed as way to strengthen care coordination and improve patient outcomes.

Research suggests that SCPs have favorable impact on patient satisfaction and quality of life, however little research to date investigates the utility of SCPs in improving patient outcomes, adherence to follow-up recommendations, or patients’ confidence in self-care management. To further understand the role of SCPs in survivorship care, a pilot implementation of SCPs in colon cancer patients was implemented to gather data on the identified gaps.

Approximately 15,270 children were diagnosed with cancer last year and a common treatment includes daily radiation therapy. Children must remain immobilized for the planning and treatment to ensure the radiation beam precisely delivers radiation to the tumor and reduces exposure to the normal surrounding tissue. Radiation therapy may last several weeks, which requires children to be put under daily anesthesia for an extended length of time to ensure immobilization. The risks for anesthesia include airway obstruction, broncho/laryngospasm, oxygen desaturation, apnea, nausea/vomiting, hypothermia, hypotension, hypoxia, cardiac arrest, sepsis due to central line access, and death. The relationship between daily anesthesia administration and neurotoxicity is currently unclear.

The purpose of audiovisual distraction (AVD) during radiation therapy was to decrease anesthesia exposure, improve quality of life, and decrease anxiety of patients and families. A plan to implement an AVD device at the time of radiation planning and during daily treatments was conducted in a large pediatric radiation oncology practice in Arizona. Inclusion criteria were children needing radiation, between the ages of 5 and 15, who do not have history or complaint of visual impairment, who have the ability to follow directions for AVD, and were deemed candidates by the Radiation Oncologist and Child Life Specialist through physical and mental assessment. Data collection included anesthesia requirements, heart rate, PedsQL Tool, and time in treatment room gathered at the planning session and at the end of treatment. Microsoft SPSS was used for data analysis. Descriptive statistics were used to describe the sample and outcome variables.

The aggregated data was analyzed to ascertain if the number of children in the inclusion age range had a decreased need for anesthesia, decreased anxiety, and increased quality of life. The primary outcome for the AVD was: all four children who participated were able to undergo radiation therapy without the need for anesthesia . The children were able to remain awake for treatment could attend school, as permissible, eat before treatment, and spend significantly less time at the treatment facility. The concern of repetitive anesthesia and neurotoxicity will not be a factor in the child’s long term late effects of treatment. The reduction of need on anesthesia staff and nursing staff was estimated to save over 500,000 dollars for the 89 treatments the four children underwent with the AVD. The benefits of the intervention not only provided a better treatment experience for all children, but it allowed the facility to utilize the treatment machine more efficiently, providing radiation therapy as an option to even more patients.

There is an increasing number of cancer patients outliving their diagnosis and treatment and requiring more support as they transition to cancer survivors. To bridge this gap, survivorship care plans should be provided to all cancer survivors to provide post treatment plans of care, recommendations, and resources (Commission on Cancer, 2016). A quality improvement project was implemented in the urology practice of a National Cancer Institute-designated, academic hospital in Phoenix, Arizona to provide survivorship care plans to prostate cancer patients with surgical intervention as their cancer treatment.

Through interprofessional collaboration, the process change was designed and implemented with the residents and Physician Assistants of the urology practice. There was a 93% adherence rate in delivering the survivorship care plans during the project. The “Confidence in Survivorship Information” questionnaire was used to measure the patients’ confidence in survivorship information prior to and after receiving a survivorship care plan. A paired t-test showed statistical significance in improvement in confidence in the knowledge of long-term physical effects of cancer treatment, strategies for preventing and treating long-term physical effects, and resources available for family members who may be at risk. The project will continue in order to meet requirements for cancer programs established by the Commission on Cancer (Commission on Cancer, 2016).

Cancer survivors meet survivorship with uncertainty due to a lack of uniform information provided post cancer treatment. The implementation of survivorship care plans (SCP) has been recognized by key stakeholders as the solution to transitional uncertainties. In fact, to achieve accreditation by the Commission on Cancer (CoC) cancer centers are required to deliver SCPs to cancer survivors within a year of their treatment completion. Research demonstrates SCP delivery results in significant improvement in patient satisfaction, coordination of care, and survivorship care knowledge.

In order to meet CoC standard 3.3 and bring understanding to SCPs function in cancer survivorship care a quality improvement project was initiated within an Arizona cancer center. SCPs were delivered at a survivorship visit to adult breast cancer patients. SCPs affect on survivors’ confidence in cancer self-care knowledge and care satisfaction was evaluated as well as the organization’s adherence to CoC standard 3.3 requirements. Identified survivors were scheduled for a survivorship visit where a SCP was delivered by a oncology provider.

Survivors perceived confidence in knowledge and satisfaction was measured using the modified 16-item Confidence in Survivorship Information Questionnaire (CSI). Questionnaires were completed pre and post survivorship visit. A paired t-test analysis was used to evaluate SCP effectiveness. There was an increase in the delivery of SCPs from zero to 57 with an 84 percent SCP delivery from August 2017 to January 2018. Survivors and providers verbalize value in SCPs.

No statistical significance was found in the comparison of SCPs affect on survivors’ confidence in cancer self-care knowledge and care satisfaction to that of standard follow-up care; however, when comparing the pre/post questionnaire averages an improvement was noted across the board.The prospect of this project is to unveil the impact SCP delivery at a survivorship visit has on the selected metrics. This project aids as a director for organization wide implementation for CoC standard 3.3 requirement compliance.