Department of Oncology, Aga Khan University Hospital, Karachi, Pakistan
*Shairoz Mevawalla, Department of Oncology, Aga Khan University Hospital, Karachi, Pakistan.
OBJECTIVE: This cancer not only causes physical, mental, economic, and social problems for the sufferer, but it also causes sexual problems. This problem is ignored in our society since it is seen as a taboo in our culture, and it is deemed unacceptable. Sexual problems caused by chemotherapy treatment are frequently ignored by both nurses and patients.
METHOD: A questionnaire form was developed based on quantitative data analysis to analyze the educational requirement of the staff. This tool aims to determine the level of staff understanding of the relevance of sexual concerns that patients experience during chemotherapy treatment. My preceptor checked the questionnaire and consent form and then I share the link with the staff. The survey's target sample size was 15 daycare oncology registered nurses with at least 2 to 3 years of experience.
RESULT: At least 70% of the staff is expected to get a better understanding of communication and how to deal with this problem. Because of the significance of this issue, the staff would make patients aware of it throughout the treatment plan, assessment, and teaching of the side effects on how to deal with it. Patients would be mentally prepared if they were made aware of this problem, which would reduce their anxiety and allow them to live a normal life.
CONCLUSION: This project aims to raise staff awareness, knowledge, and critical aspects of sexuality issues, which affect patients’ quality of life, to improve nurses' communication skills when discussing sexual concerns with patients.
KEYWORDS: Cancer patients, chemotherapy, sexual issues, nurses’ education
Cancer is rapidly spreading over the world, causing a slew of problems in society, particularly in the individual’s life. This cancer not only causes physical, mental, economic, and social problems for the sufferer, but it also causes sexual problems. This problem is ignored in our society since it is seen as a taboo in our culture, and it is deemed unacceptable. Sexual problems caused by chemotherapy treatment are frequently ignored by both nurses and patients. As a result, the staff is hesitant to discuss these issues. According to the research, the majority of nurses are uncomfortable discussing sexuality with patients and lack confidence in their competence to do so (Egholm, 2015). With this in mind, I’ve noticed that the staff finds it very difficult to give patient knowledge throughout the therapeutic regimen, assessment, and teaching about the side effects and how to address this sexual issue, and they are reluctant to initiate discussion. Being a part of senior electives in the daycare oncology department is an important feature to enhance to work on. I collaborate with my preceptor to take further action on this problem.
During my senior elective, I saw that staff inform patients about the adverse effects of chemotherapy and pre-chemotherapy drugs, but they seldom discuss one of the most serious side effects, which is a decrease in sexual desire. They find it difficult to begin, and if they do, they often leave the conversation unfinished since they believe it is not a big issue in the patient’s life. As a result, it is not seen as a significant aspect in increasing one’s quality of life. As a result, patients frequently struggle to cope with a difficulty, which has an impact on their daily lives and raises their anxiety levels. Chemotherapy and cancer treatment might have an impact on a person’s sexual health. Nurses must deal with sexual concerns that patients face since they are in direct touch with them while delivering personal nature care. According to research, a nurse’s role is to be aware of their patient and grasp the relevance of this problem, but they find it difficult to talk about it with them regularly. (Egholm, 2015) Moreover, this problem develops because nurses are not given the necessary resources, such as brochures and flyers that are accessible for other diseases to interact with patients. According to Wazqar, D. Y. (2020), stated in the research article.” The effect of cancer on sexual life (98.9%), the effect of cancer treatment on sexual life (97.7%), the attempts to deal with sexual problems throughout cancer treatment (95.9%), respectively (83.9 %) stated that there was an absence of a booklet, manual, etc.”
It is important to collect reliable and systematic data to analyze the issue and collect information that will be needed for our learning purposes. For the survey, I created a questionnaire tool based on quantitative data analysis using Google Forms to analyze the needs of the staff. This tool aims to determine the level of staff understanding of the relevance of sexual concerns that patients experience during chemotherapy treatment. My preceptor checked the questionnaire and consent form and then I share the link with the staff. The survey's target sample size was 15 daycare oncology registered nurses with at least 2 to 3 years of experience.
Possible outcome of the project's potential objective would be to improve the capacity of the staff to reorganize around the significance of sexual difficulties in cancer patients, which might aid in the healing process. In light of this difficulty, it may be possible to enhance the patients' quality of life if the staff nurses can effectively communicate by acknowledging the problem that is caused by chemotherapy treatment. At least 70% of the staff is expected to get a better understanding of communication and how to deal with this problem. Because of the significance of this issue, the staff would make patients aware of it throughout the treatment plan, assessment, and teaching of the side effects on how to deal with it. Patients would be mentally prepared if they were made aware of this problem, which would reduce their anxiety and allow them to live a normal life.
Analyze data with Evidence-based literature
After analyzing the data, it was shown that nurses are never scared to ask about sexual concerns because they believe the patient would not be offended, and they do not believe that this conversation will build a barrier between the nurse and the patient. Nurses, on the other hand, believe that patients should initiate the talk since they believe their privacy would be breached. Nurses are sometimes too self-conscious and ashamed to discuss sexuality with patients, fearing invading their privacy (Ferreira, Gozzo, Panobianco, Santos, & Almeida, 2015). Furthermore, nurses rarely give the patient possibility. They are having difficulty finding a suitable location and do not have enough time to explore this issue. Patients expect nurses to initiate a conversation, which results in a communication barrier because neither of them starts the conversation. The majority of researchers have found that nurses avoid discussing sexual issues due to a lack of time, a generalized viewpoint, and fears that patients may experience a loss of closeness and be unwilling to express this concern. Furthermore, nurses prefer to concentrate simply on the required treatment (Oskay, Can, & Basgol, 2014).
Furthermore, it was observed that nurses are uneasy discussing this issue because they believe the sexual topic is taboo in our society, and they find it difficult to discuss this issue. "The taboos and preconceptions of nurses might limit talks on sexual matters, according to a comprehensive study by Kotronoulas et al. (2009), which encompasses 18 studies" (as cited in Oskay, Can, & Basgol, 2014).
Comparing and contrasting the findings according to Reese et al., (2017), lack of adequate training is a key obstacle to addressing sexual concerns, coupled with a time constraint, awkwardness, prioritizing other physical complaints, and unfamiliarity with treatment options. In contrast, my study revealed that just 50% of the nurses are uncomfortable addressing sexual problems with cancer patients. According to Ferreira et al., (2015), 81.7 % of nurses do not believe that sexual concerns are a private topic to discuss. In contrast, 35.7 % of nurses occasionally believe that patient privacy has been invaded, according to the data.
Furthermore, one of the most significant findings in the daycare oncology study was that 64.3% of nurses believe it is difficult to discuss these matters with patients because they do not have enough time, and 21.4% of nurses state that they rarely provide patients the opportunity to discuss sexuality-related issues. In comparison, the researchers reported that 73.6% of nurses were too busy to deal with the problem, and 45.8% said they didn't have enough time to talk to patients about it. (Mansour & Mohamed, 2015). Furthermore, according to the study, 71% of patients believe that their health care providers would disregard any issues about sexual health, while also believing that providers should ask about the issue by starting the discussion, resulting in a patient communication barrier. (Leung, Goldfarb, & Dizon, 2016). A comparable study discovered that 57.1% of nurses believe that patients usually expect nurses to initiate conversations. According to reports, 87.4% of nurses believe this problem should be addressed as part of their professional duties. Despite this, 88.5% of nurses do not consider sexual issues. Patients should initiate the conversation, according to 67% of nurses, however, 86.8% of patients are unwilling to discuss the issue (Oskay, Can, & Basgol, 2014). In contrast to my findings, 92.9% of nurses feel that this issue is taboo and that discussing it with patients is difficult. Patients should initiate a conversation about sexual difficulties, according to 78.6% of nurses.
PLISSIT Model According to recent studies, nurses should apply the PLISSIT Model in combination with chemotherapy and radiotherapy to teach patients problem-solving skills and encourage them to share their feelings and attitudes about their personal lives to improve the quality of their sexual lives (Faghani & Ghaffari, 2016). As a successful intervention, nurses can initiate the conversation and counseling utilizing the PLISSIT model, which has four phases: Permission, Limited Information, Specific Suggestion, and Intensive Therapy (Annone, 1976). During my implementation, I use the PLISSIT model to help nursing staff acquire therapeutic skills and provide a safe environment for discussing this sensitive issue with cancer patients. As a first step, give the patient permission to discuss any sexual concerns they may have. For this reason, I suggest nurses help the patient in initiating discussion without causing discomfort throughout the training session. The staff should only discuss these issues in the second step of minimal information with the patient. Similarly, I instruct all staff to contribute in an appropriate and relevant conversation. Recommend strategies for patients to deal with sexual concerns in the third step of specific recommendation. For this purpose, I encourage that employees provide practical answers. Refer the client to another specialist as the final phase of intensive therapy. To integrate this concept, I inform the staff that I will be providing expert consultation.
An action plan, according to the guideline for action planning (2012), states the aim of resolving a crucial issue and identifies when, how, where, and what actions must be taken to achieve the goal. My project aims to raise staff awareness, knowledge, and critical aspects of sexuality issues, which are highly significant aspects of a patient's quality of life, as well as to improve nurses' communication skills when discussing sexual concerns with patients. As a primary source who directly interacts with patients, it is necessary to minimize communication barriers between nurses and patients
For this, I have prepared the following set objectives:
- Ensuring that the staff is aware of, considers, and prioritizes sexual issues.
- To break down barriers in nurses' communication when it comes to discussing sexual issues with cancer patients.
Prepare educational materials, such as a brochure, to raise awareness and improve communication about sexual problems. The implementation action plan is detailed in the appendix below.
Facilitators and Barriers to change
Throughout my project work, my preceptor was very cooperative and supportive. She supports me in all aspects of my project work, including helping me in the preparation of educational materials and reviewing all of my educational materials, such as brochures, questionnaire tools, project plans, communication cards, and presentations. They give me constructive feedback on regularly give her suggestions for improvement. (refer Appendix D) She assists me in coordinating the staff nurses and conducting the session on the scheduled days. In addition, my preceptor and faculty-guided me through the project and assessed where I was unclear to ensure that it runs efficiently. During my project work, on the other hand, I ran into a few obstacles. For example, there was a shortage of people to evaluate. Second, there was not enough time to prepare all of the materials. Multimedia arrangements, as well as logistical (venue) and technological resources, were tough to organize.
Outcome Indicator to measure the change
Education materials such as brochures were used as an outcome indicator to evaluate changes in staff knowledge. This will help them in properly communicating with patients. In addition, I prepared an instruction card for the nurses to use as a reference guide during their duties. I make a checklist to examine the changes in the staff's practices and determine if they have been modified or not.
Evidence of the project implementation
The PowerPoint presentation, attendance sheet, photographs, instruction card, and educational materials are all attached as evidence of implementation (Appendix E). Although these learning materials are designed to improve the understanding of the staff, they can also be utilized as indicators of the project's long-term sustainability.
Measures were taken for the sustainability of the project
Given the significance of this issue, staff can use educational materials such as brochures to raise awareness among patients during the treatment plan, assessment, and teaching about side effects and how to manage them. They can also communicate effectively by overcoming the entire barrier with the help of the instruction card. As a result, PowerPoint presentations, brochures (see Appendix E), and instruction cards were used to ensure the project's long-term sustainability.
Modifications in project
The change I made for implementation was that I initially thought only of taking education sessions and materials for the nurses, but as I observed and realized, we should also consider an appropriate way of informing the patients, such as flyers and brochures, which are commonly available for many diseases. However, because there were no brochures or flyers relevant to the topic, I created interactive brochures. Although the staff provided training to the patients, it was limited so that they may improve their knowledge by thinking about the key elements that were emphasized during the session. Nurses' education is critical since they are the ones who engage directly with patients and provide them with holistic care. As a result, I revised my plan and discussed it with my preceptor.
Expected and unexpected outcome
My preceptor and staff have given me valuable input (see Appendix F) that I believe will help them think more deeply about the challenges. Furthermore, a staff analysis (refer to Appendix G) based on a checklist demonstrates that the majority of the staff had improved their behaviors. It is difficult to change the nurse's beliefs and hurdles to discussing the cancer patient's sexual concerns in a short amount of time. However, the predicted outcomes of this initiative on such a sensitive topic are that nurses will gain awareness and understanding of this issue, which is critical for the patient's recovery. Using my resources, I hope to see a significant improvement in staff behavior in the future. The staff's other expectation is that they will follow the recommended strategies to reduce the communication barrier.
During implementation, I faced a couple of limitations: first, there was a limited number of people available; it was difficult to gather everyone at once; and second, there were no resources such as multimedia, computers, or sound systems. There was limited time to create teaching materials. Third, although I receive feedback from my preceptor, I have waited for feedback on the resources that I have developed for the management of daycare oncology. Furthermore, it was difficult to obtain the availability of space for the teaching session; as a result, the session was held in the staff lounge because the staff is continuously dealing with patients and providing outpatient care.
- Appropriate teaching materials should be accessible at the ward so that staff may take advantage of them
- Nurses must be re-emphasized regularly for the time being.
- Management and physicians should take the lead on this problem and approach nurses to educate them on the importance of the issue by conducting staff education sessions.
- During the treatment plan, assessment, and teaching about side effects and how to address this issue, staff should discuss this issue with patients.
- The head nurse should assess staff practices for attending to sexual problems of cancer patients regularly, and encourage staff to use educational materials for patients.
Impact of the Project
The project's impact on the patient is positive since it will reduce emotional and psychological distress, improving the patient's quality of life because emotional support from their life partner is essential in the healing process. Furthermore, the project's overall impact on staff would change their way of thinking and clinical practices addressing this issue, as well as utilize the knowledge learned through teaching sessions. As a result, by changing their clinical practices, they can able to effectively educate and counsel patients about this problem. Furthermore, the impact was visible when the staff enthusiastically reported on the technique they learned during the session, which was beneficial to them.
Sustainability of the Project
In terms of sustainability, I developed brochures and an instruction card for the staff guide that would help them in their future learning. Brochures and instruction cards can assist staff in better communicating with patients who have sexual problems. In addition, I gave my preceptor the PowerPoint presentation and evaluation checklist so that she could share it with their head nurses and CNI, which will help them in taking a staff session in the future. Finally, my instruction card and brochure would raise public knowledge of this topic, allowing the nurse to address it openly with cancer patients.
- Egholm, A. (2015). Nurses’ Attitudes and Beliefs towards Discussing Sexuality with Patients. Bachelor's thesis. Degree Programme in Nursing. 1- 36.
- Faghani, S., & Ghaffari, F. (2016). Effects of sexual rehabilitation using the PLISSIT model on quality of sexual life and sexual functioning in post-mastectomy breast cancer survivors. Asian Pacific journal of cancer prevention: APJCP, 17(11), 4845.
- Ferreira, S. M. D. A., Gozzo, T. D. O., Panobianco, M. S., Santos, M. A. D., & Almeida, A. M. D. (2015). Barriers for the inclusion of sexuality in nursing care for women with gynecological and breast cancer: perspective of professionals. Revista latino-americana de enfermagem, 23(1), 82-89.
- Leung, M. W., Goldfarb, S., & Dizon, D. S. (2016). Communication about sexuality in advanced illness aligns with a palliative care approach to patient-centered care. Current oncology reports, 18(2), 11.
- Mansour, S. E., & Mohamed, H. E. (2015). Handling Sexuality Concerns in Women with Gynecological Cancer: Egyptian Nurse's Knowledge and Attitudes. Journal of Education and Practice, 6(3), 146-159.
- Oskay, U., Can, G., & Basgol, S. (2014). Discussing sexuality with cancer patients: oncology nurses attitudes and views. Asian Pac J Cancer Prev, 15(17), 7321-7326.
- Reese, J. B., Sorice, K., Beach, M. C., Porter, L. S., Tulsky, J. A., Daly, M. B., & Lepore, S. J. (2017). Patient-provider communication about sexual concerns in cancer: a systematic review. Journal of Cancer Survivorship, 11(2), 175-188.
- Wazqar, D. Y. (2020). Sexual health care in cancer patients: A survey of healthcare providers' knowledge, attitudes, and barriers. Journal of Clinical Nursing, 29(21-22), 4239-4247