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Benefits of using a chemotherapy symptom assessment scale

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Symptoms are also subjective and patients have to describe their effect to the health care professionals involved in their treatment and management. Using reliable and valid assessment tools can help patients to verbalise and clarify their symptom experience into a more objective form, which can then be measured.


VOL: 99, ISSUE: 39, PAGE NO: 50

Clare Dikken, MSc, RGN, is senior sister, Worthing and Southlands Hospitals NHS Trust


Symptoms are also subjective and patients have to describe their effect to the health care professionals involved in their treatment and management. Using reliable and valid assessment tools can help patients to verbalise and clarify their symptom experience into a more objective form, which can then be measured.



The importance of systematic symptom assessment
Nurses are constantly using assessment skills while caring for patients. Many of these forms of assessment are informal and not systematic. The disadvantage of this approach is that problems can be overlooked or missed and inconsistencies in practice may occur (Benham et al, 2003; Ahern and Philpot, 2002).



Chemotherapy results in negative side-effects, which affects patients’ well-being and quality of life. There is evidence that health staff underestimate the number and frequency of these side-effects, and the distress caused by them (Dikken and Sitzia, 1998; Tanghe et al, 1998; Macquart-Moulin et al, 1997; Sitzia and Dikken, 1997).



Without some form of systematic assessment, patients have been found to under-report their symptoms. Reasons given for this include:



- The symptom was expected to happen anyway;



- Nothing could be done for the symptom, so they saw no need to report it;



- Staff were too busy;



- When nurses ask ‘How are you?’, they think it is just a greeting (Brown et al, 2001).



The use of assessment tools enhances effective communication between the patient and health professional (Detmar and Aaronson, 1998). This results in better assessment of the range and number of symptoms experienced. It also impacts on emotional and psychological well-being, and contributes to both patient and staff satisfaction (Fallowfield and Jenkins, 1999).



Structured symptom assessment results in health professionals having a greater awareness of the patient’s experience of symptoms. This enables more informed and accurate identification of the problems associated with symptoms. The problems can then be targeted for symptom relief and this can improve patient outcomes (Ingham and Portenoy, 1996).



Chemotherapy Symptom Assessment Scale (C-SAS)
This was developed with the involvement of patients and health professionals. It differs from other symptom assessment scales because it focuses on chemotherapy-related symptoms and is completed by the patient rather than the health professional. It is ideally suited for patients receiving outpatient chemotherapy.



The C-SAS contains 24 questions, plus a section for spontaneous reporting of symptoms. It not only measures incidence and severity of symptoms but also how ‘bothersome’ they are to the patient. It is designed to record symptom experience and to focus on subsequent communication between the patient and the health professional about the symptoms that are particularly severe or bothersome to the patient.



There is a section for nurses to document any action so that the efficacy of treatments used in controlling the symptoms can be evaluated. The C-SAS is a reliable and valid tool and is clinically useful (Brown et al, 2001).



Aims of the C-SAS These were:



- To empower the patient in reporting chemotherapy side-effects to health professionals. To improve both nurses’ and doctors’ knowledge/understanding of side-effects experienced by patients undergoing chemotherapy, which are specifically caused by different regimes;



- To reduce under-reporting, and encourage reporting of symptoms;



- To improve nursing practice by developing an evidence-based side-effects management file.



Anticipated benefits These were expected to be:



- Improved communication between patients and health professionals about side-effects experienced by patients;



- Better knowledge of the particular side-effects caused by certain regimes;



- Improved side-effect management;



- Improved patient experience and quality of care.



Clinical experience of using C-SAS:
The C-SAS was introduced into clinical practice on Edburton Day Ward at Worthing Hospital in March 2002. The initial problem we needed to resolve was the optimum time to give the patient the C-SAS form to complete.



Giving out the C-SAS with each course of treatment, as originally planned, was not effective. This method of administration relied on the staff on duty that day remembering to give the patients their next form.



Reasons for omitting to give it to the patient included the ward being too busy or a member of staff not understanding that the patient was due to receive one. It was also observed that the action plan was of little use unless the staff were able to review each of the C-SAS forms at any given chemotherapy course.



To resolve these problems the nursing team decided to make the C-SAS up into packs that would resemble a patient-held record of treatment. For example, a patient receiving eight courses of 5-fluorouracil, epirubicin and cyclophosphamide (FEC) chemotherapy for breast cancer receive a pack of eight C-SAS’.



These are labelled courses one to eight, stapled together and placed inside a plastic pocket. The patients fill in one after every course of treatment. Each time they come for treatment, their attending chemotherapy nurse looks through the pack and can see how they have been getting on and whether the side-effect management is effective (Box 1).



Changes in practice
As a result of systematic assessment, we have introduced a change to our practice. Questions 21-23 on the C-SAS give the patients a chance to inform staff of any psychological and sexual problems they may be experiencing. The ward is not a purpose-built chemotherapy unit - it is very busy and noisy and there is very little privacy for patients who may want to talk about sensitive issues.



Once we started to notice that patients were having some psychological and sexual problems, we realised our practice needed to change. We now offer all our patients allocated time with their chemotherapy nurse in ‘the quiet room’. It is interesting that not many have asked for this service - perhaps just knowing it is available is enough to help them cope.



Sex and sexuality are subjects that are often ignored by nurses. There are numerous reasons why sex and sexuality may be problematic for patients who are receiving chemotherapy. For example: toxic drugs cause symptoms of tiredness, loss of libido, nausea and hair loss; weight gain is a side-effect of steroid treatments; and surgery such as mastectomy may cause changes in body image.



We have found that by introducing the C-SAS we have given the patients permission to talk about their problems. Once we know about a problem we can give information and sometimes suggestions on how to manage it. This is often enough to help patients cope (Box 2).



Difficulties with the C-SAS:
There are three main difficulties that need to be overcome:



- Ensuring that staff use it. The ward is busy and using the C-SAS takes time and thought;



- Encouraging patients to use it. Some do not see the point if they have been symptom-free. Others have said that no one had looked at it so they had not bothered;



- Introducing it for multidisciplinary use. Currently, the patients use the C-SAS with their chemotherapy nurse. They also bring the C-SAS to doctors’ appointments, but the doctors are not using it.



We have found that the advantages of systematic symptom assessment outweigh any disadvantages. We are now keen to introduce further forms of systematic assessment as we start to develop our side-effects management file; oral assessment is currently being devised. We now have a better understanding of what our patients are going through during treatment, which enables us to give them more accurate information at the start of their chemotherapy and better support during treatment.

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