Feasibility of implementing the ‘Screening for Distress and Referral Need’ process in 23 Dutch hospitals

SDRN, consisting of DT&PL completion, patient-caregiver discussion of the responses, referral based on the discussion, and the patient’s wish, occurs in 21 of the 23 hospitals in the north and east of the Netherlands, and in two-thirds of these hospitals, for more than one patient group. This suggests that hospitals and healthcare providers view SDRN as a substantial improvement to oncology patient care. This success rate is high compared to most reports of distress screening guideline implementation [22, 23], but in line with two others, who also used a pre-developed, detailed implementation strategy [25, 26], although different from ours.

Breast cancer patients are targeted most often for SDRN. This can be explained by the presence in the Netherlands of specialist nurses responsible for these patients during the entire disease trajectory. These nurses were very motivated to implement SDRN, and can be considered early adopters [31]. Such nurse ‘navigators’ are often not available for patients with other tumour types such as prostate cancer [32].

The IKNL-G’s roadmap proved helpful for the implementation process. The adoption of roadmap elements varied between 84 and 100 %. Because of this high adoption rate, we cannot be certain which elements of the roadmap contributed to its success. Clinical experience shows that centralized project management by IKNL-G and the IKNL-G roadmap both provided structure and continuity to implementation. This is underlined by the finding that implementation time was the longest in the hospital that began implementing SDRN before the IKNL-G initiative. Another explanation for the longer implementation time could be that initiative came from a psychosocial caregiver. Normally, their role comes later in the SDRN timeline; carrying out SDRN requires involvement of caregivers directly responsible for oncological treatment and patient care. Therefore, we recommend appointing as team leader a nurse who performs SDRN daily.

This study reveals that care providers were moderately satisfied with how SDRN was performed in their hospital. Many respondents, speaking for their colleagues executing SDRN, specifically remarked how satisfied they were with how their clinic had embraced and implemented SDRN and with the structural attention they now give to patients’ psychosocial functioning. Some point to the benefit patient experience, such as structural attention now given to patients’ psychosocial and physical functioning. They remarked that SDRN led to correct and more sensible referrals, not necessarily to an increase in referrals. This is reassuring because a barrier to the implementation of screening mentioned in the literature is that distress screening would lead to an increase in referrals for which not enough professionals would be available [32]. The correctness of referrals may have increased because referral to a specific healthcare provider for a specific problem is discussed with each patient needing additional care. Also, beneficial was that, as a consequence of the implementation process, interdisciplinary communication increased, and subsequently increasing insight into each discipline’s specific expertise. This may have positively affected multidisciplinary collaboration and timely and correct referrals.

Participants’ opinion on the DT&PL was mainly positive. They evaluated the instrument as a useful, valuable, and practical tool for recognizing and discussing patients’ problems, conforming previous research [33]. The vast majority of respondents appreciated the DT&PL’s function as a communication tool, structuring and streamlining communication with the patient. Also, they valued that it provides insight into referral wish. However, some participants have negative opinions and find that DT&PL completion is time-consuming, difficult for patients, or a burden for themselves, possibly due to a lack of acceptance, of skills to discuss the DT&PL, and/or to provide psychosocial care [34‐36].

Care providers’ moderate satisfaction with SDRN as presently performed in hospitals suggests room for improvement. Overall satisfaction was significantly related to satisfaction with SDRN frequency and how well agreements were kept. These are both related to consistency in executing SDRN. In hospitals where SDRN took place ≥3 times and throughout the entire disease trajectory, participants were more satisfied with how SDRN is executed than those who felt that SDRN occurred too infrequently or during part of the treatment. No evidence is available in the literature on the ideal timing of SDRN [37], although suggestions have been made, such as at every outpatient clinic visit, the beginning and end of each treatment modality, when treatment phase changes (from treatment to follow-up), and when treatment intent changes (from curative to palliative) [11, 38]. Consequently, IKNL-G did not give clear advice about this. Decisions on this subject were based on consensus within each hospital/department. Based on results, satisfaction would likely increase if clear advice was available about frequency and timing, during treatment as well as follow-up. Future studies could gain more insight into this subject.

Respondents were less satisfied when patients had been given responsibility for completing the DT&PL. This resulted in many patients forgetting to fill in the instrument or taking it with them when visiting the hospital. Effort should be made to empower patients to also take responsibility for informing their care providers about their problems and referral needs. One such effort is that an online tool has been developed enabling patients to complete the DT&PL online and email it to their care provider, wherever and whenever they want (www.​lastmeter.​nl).

Additionally, respondents who felt that logistical agreements were not adhered to strictly enough were less satisfied. We did not investigate why agreements were not kept. However, comments of dissatisfaction offer possible explanations: shortage of time to screen and properly discuss results. While research on the use of distress screening instruments cites this as an impediment to SDRN [25, 34], there is also research that shows that care including screening takes equal or even less time [39, 40]. Training caregivers how to efficiently screen and discuss DT&PL answers and allowing caregivers sufficient time and means can facilitate adherence to agreements, thus improving continuity of SDRN.

Finally, satisfaction seems to be negatively affected when SDRN is not fully embraced as part of oncological care for all patients. Half of the respondents believe that SDRN should be implemented for all oncology patients. Broader implementation would increase consistency and continuity. Appointing specialists nurses, like with breast cancer patients, would facilitate broader implementation.

A limitation of the present study is that from each hospital/department only one representative, a key informant, participated. This may affect reliability, validity, and representativeness [41]. However, this key informant was the team leader of the implementation process and was instructed to represent the generalized opinion of all those executing screening in daily practice in that particular hospital. A second limitation is that the small sample limits power for the identification of significant correlations. Further, the experience with SDRN in daily oncologic practice differed, which may have affected answers. In fact, one respondent was in the process of implementing SDRN while in other hospitals, SDRN had been fully implemented. The strengths of this study are that all but two hospitals participated and IKNL-G provided centralized project management. Additionally, we assessed not only the feasibility of implementation, but also healthcare providers’ opinions on SDRN in practice. Their evaluation provides suggestions for improvement.

Summarizing, this study shows that implementing (with the aid of a pre-developed strategy) SDRN in oncology practice is feasible, though it does require care providers and organizations to make adjustments. Continual attention to daily execution of SDRN and expansion of SDRN for all oncology patients and during the complete disease trajectory are necessary to improve consistency in and satisfaction with SDRN in oncology care.

Future research should examine how well hospitals continued to adhere to SDRN after support from IKNL-G ended and how to sustain SDRN long-term. Additionally, it would be interesting to focus on how hospitals broadened SDRN for all types of cancer.