Background
The National Institute for Health and Care Excellence in UK (NICE) defines carers as follows: “Carers, who may or may not be family members, are lay people in a close supportive role who share in the illness experience of the patient and who undertake vital care work and emotion management” [
1]. The World Health Organization’s (WHO) definition of palliative care states that health care professionals (HCPs) should prevent and relieve suffering in carers. Early identification of carers’ physical, psychological, social, and spiritual pain and needs, as well as support to enhance carers’ coping during caring, and in bereavement, has been recommended [
2]. Guidelines for HCPs’ carer support endorsed by international organizations included needs assessment, development of a plan for carer support, and preparing carers for the patient’s death [
3]. In Norway, there were specific guidelines addressing these aspects for carer support in general [
4], and for carers in cancer palliative care in particular [
5].
Integration of oncology and palliative care has in randomized controlled trials (RCTs) shown to improve carers’ satisfaction with care, levels of depression, and stress burden [
6‐
8]. A meta-analysis of 29 randomized clinical trials analyzed interventions to support carers of cancer patients. The interventions delivered psychoeducation, skills training, and therapeutic counselling, and significantly lowered carer burden, and improved coping and quality of life [
9]. Despite positive effects of systematic carer support, carers still do not receive sufficient support [
9]. Carers of patients with advanced cancer have reported to be less satisfied with coordination of care and involvement of the family in treatment and care decisions than the patients [
10]. Carers reported that HCPs give limited information about available carer support, and that carers’ support needs are only occasionally addressed in discussions between nurses, patients, and carers [
11]. Studies have reported that HCPs misjudge what carers need [
12,
13]. A recent review including 50 RCTs investigating interventions to support carers, found that the majority of interventions demanded more than 3 h, usually performed by research staff. The authors concluded that there was a need for models of carer support being feasible in clinical practice, and recommended use of existing tools for assessment of carers’ needs [
14]. One example of a short and feasible tool for assessment of carers’ needs is the Carer Support Needs Assessment Tool (CSNAT) [
15]. Assessing carers’ needs was recommended in the recent Lancet Oncology Commision on cancer palliative care [
7]. CSNAT was recommended to achieve more systematic carer support in a Norwegian governmental report on palliative care [
16].
In Norway, health care services are mainly public, and oncology and palliative care are offered as an integrated part of the health care system. General practitioners (GPs), home care services, and nursing homes constitute community care. In specialist care, there are several local hospitals at secondary care level collaborating closely with community care, and six university hospitals offering tertiary care [
17]. The Norwegian cancer strategy [
18] underlined the need for integration between oncology and palliative care, and recommended the use of standardized care pathways to improve quality and coordination of care both for patients and carers, as also recommended in the recent Lancet Oncology Commission publication [
7]. The present study was performed in the context of a health care services development project in Orkdal, a rural region in Mid-Norway, aiming at improving cancer care through integration of oncology and palliative care services, and through improved coordination of care across specialist and community care [
19,
20]. ln 2012, a combined oncology and palliative care outpatient clinic (hereafter Integrated Clinic) was established at the local hospital, being organized as part of the Cancer Clinic at Trondheim University Hospital. A collaborative project between specialist and community care in 13 municipalities (about 56 000 inhabitants) was established with formal agreements, and evaluated in a prospective, still ongoing study, including both cancer patients, their carers, and HCPs [
19]. From 2013 a complex intervention was developed, consisting of a standardized care pathway (SCP), an educational program, and an information strategy [
20]. Qualitative studies to assess experiences of involved patients, carers, and HCPs were planned as part of the development process of the cancer palliative care services in the Orkdal region; the present study was one of these.
Discussion
This qualitative study aimed, through focus group interviews, to explore and describe how health care professionals (HCPs) in a rural district of Mid-Norway supported carers of patients with advanced cancer, how carers’ needs were assessed, and what hampered carer support. Through systematic text condensation [
29], ten categories were identified. In summary, these covered education, the personal relationship between HCPs and carers, and lack of organizational structures for carer support.
Lack of education in carer support was reported by all professions in the focus groups. Palliative care includes physical, psychological, social, and spiritual care, and is hence to be delivered by a multidisciplinary team [
2]. All professions in the team need palliative care competence, and building of competence is a national priority [
16]. A recent Lancet Oncology Commission Commission on cancer palliative care described a lack of basic and specialist palliative care competence at all levels of health care [
7]. The authors stated that there is much less focus on training in psychological and spiritual care than physical care training, and highlighted the need for education of all professions [
7]. In the present study, oncologists reported a lack of education in communication with carers. Physicians’ need for communication training has been addressed also elsewhere [
31]. The importance of a personal relationship between carers and HCPs reported in this study has been supported by a recent study in carers [
28], and underlined in the Lancet Oncology Commission report [
7]. Recommendations from the American Society of Clinical Oncology (ASCO) include building of relationship with patients and carers [
32]. Psychologists have regarded the quality of the therapeutic relationship as the most important factor for successful psychotherapeutic interventions [
33]. Carers of patients with advanced cancer have reported that not receiving personal attention and care from HCPs complicated their grief, e.g. creating feelings of anger and of being abandoned [
27]. Such a personal relationship between HCPs and carers early in the disease trajectory may be facilitated by achieving integration of oncology and palliative care, an essential element of the cancer palliative care offered in the Orkdal region. Early integration of oncology and palliative care has been reported to have positive effects for both patients and their families, and is recommended [
7,
32,
34].
The findings of the present study revealed a lack of organizational structures for carer support. An overall hampering factor for good carer support was that the health care system was described as being mainly designed for the patients, and not for the carers. The World Health Organization (WHO) definition described palliative care for families as a support system to enhance their coping [
2]. Carers have reported lack of systematic care to cause distress [
35]. A study from Finland found that carers’ needs for information and emotional support in oncology were mostly unmet by HCPs, and that carers may easily be forgotten [
36]. The lack of system for systematic carer support was reported to cause extra work. E.g. the individual HCP had to ask each patient to bring the carers to consultations, thus entrusting care for carers to individual initiative. However, patients’ right to confidentiality is a considerable barrier to the implementation of systematic invitation to patient consultations and to systematic information to carers. Furthermore, the extent of communication between carers and HCPs, and between carers and patients, depends on how much communication the patients want [
37]. Carers receiving insufficient information about diagnosis and death due to the patient wanting less information, have reported that the lack of information led to negative consequences for their relationship to the patient, for their preparedness for death [
28], and for the bereavement [
27]. Information about diagnosis and dying is by HCPs in the present and in a previous study [
38] regarded as helpful for carers’ coping.
An overview of carer support needs through the cancer trajectory stated that HCPs tend to provide support based on their impressions, and not on systematic assessment directly with the carers [
39]. The present study confirmed this as use of personal skills, including intuition, was reported to be important in carer support. HCPs’ unstructured assessment of carers’ needs reported in this study, was also found in a recent study on the role of the Carer Support Needs Assessment Tool (CSNAT) in home care [
13]. The same study found that HCPs were surprised by the carers’ answers when actually assessing the carers’ support needs [
13]. Carers rarely ask, and have reported that they do not know what to ask about, or what support they may need to ask for, e.g. at discharge from hospital, but need concrete questions from HCPs like those in CSNAT [
40]. Implementation of CSNAT has been shown to reduce carer burden during caregiving [
41], improve carers’ psychological and physical health, make fulfillment of patients’ wish to die at home more probable, and improve grief after bereavement [
42]. Use of CSNAT is a professional way of assessing carer needs that allows the carers to define their needs and what support they prefer, thus empowering the carers, and involving them in decision processes [
43]. Personal skills including intuition, and systematic assessment should not be viewed as conflicting, but as complementary tools to improve care. This study suggests that use of CSNAT at transition from specialist to community care could be helpful, and contribute to a seamless transition of patients and carers between places and levels of care.
GPs may have a valuable knowledge about the patient and their family, acquired through years of follow-up. Collaboration between specialists and GPs has been recommended [
2]. However, GPs in this study said they often lost contact with patient and family during follow-up in specialist health care. Insufficient information to GPs from specialist care at patient transfer to community care has been reported [
44]. Collaboration between oncologists and GPs in palliative care improves patients’ health outcomes, and there is reason to believe that carers also benefit from such a collaboration [
45]. GPs in the present study suggested that a meeting with the carer, the patient, the patient’s GP, and staff be arranged at the hospital before transition from specialist to community care. Specialists were encouraged to motivate patients and carers to visit their respective GP during the cancer disease trajectory.
Health care professionals are supposed to document all information relevant for patient treatment and care. However, the patients’ right to read the patient record would require carers’ consent to document sensitive carer related information, including information relevant for patient treatment and carer support. In a recent British qualitative study, carers reported an unmet need for exchange of carer-information between HCPs in specialist to community care, and carers’ expectations for such information transfer to take place were low [
46]. As long as the patient record remains the only place for documentation of carer support, HCPs could make it a routine to ask for carer consent to document in the patient record. However, in order to make systematic carer support possible, a separate carer record was recommended in a recent Hospice UK report [
47], a recommendation supported by the present study.
Strengths and limitations
A strength of the study was that all HCPs consented to participate. The response rate probably reflected HCPs’ willingness to contribute to improve carer support within cancer care in the Orkdal region, and that competent and highly motivated HCPs were asked to participate. Another strength was that the HCP experiences explored, stemmed from various contexts across levels of care. A limitation was however that the study was confined to one geographical area, which may reduce the transferability to other settings. A further weakness was that the three professions secretary, pastor and nurse assistant were represented by only one each. This study has focused on a cancer population, but the findings may be relevant for HCPs’ carer support to carers of patient with incurable diseases other than cancer.
Conclusion
Health care professionals (HCPs) in specialist and community cancer care used their personal competence to build a relationship to carers of patients with advanced cancer as the fundament for provision of carer support. Health care professionals described the carer support offered as tailored to the individual carer and to the phase of the patient’s disease.
However, educational deficiencies were reported. Furthermore, the quality of the carer support depended heavily on the individual HCP’s competence and engagement, as systems to ensure systematic carer support were not implemented. Carer support was hampered by systems in health care being tailored to the patients, and not to the carers. Assessment of carer needs was unstructured. It may be hypothesized that these results are generalizable to other regions and other areas of medicine.
Organizational changes to improve carer support are needed, and may include: 1) education in carer support integrated in all professions’ educational programs and further education, including communication with families, and spiritual care, 2) use of standardized care pathways, including systematic carer needs assessment, 3) systematic involvement of General Practitioners, and 4) a system for separate, comprehensive documentation of clinical work with carers.
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