Much of the research on ovarian cancer, including the current study, has been conducted on women who were white and generally older than age 55. However, the significant finding associating nonwhite race and lower education levels among the current study's Low Distress/APN only subsample begs for exploration of the influence of race and education on psychological distress among women with cancer, using larger more racially diverse studies. Further, although the study's results support previous research identifying various symptoms as prevalent among women with ovarian cancer, the novel use of the Omaha System identified unique issues which were not typically explored among this population of women. Specifically, the High Distress/APN only/Refused PCLN subsample may have been less forthcoming with problems and may also have been more distressed due to Environmental Problems such as issues with Income and Residence than either the High Distress/APN plus PCLN or the Low Distress/APN only subsample. Although such environmental issues are not typically associated with ovarian cancer, in the context of difficult ovarian cancer treatment, they may have contributed to already high distress levels. Accurate examination of the unpleasant symptoms and problems experienced by women undergoing ovarian cancer treatment should also explore additional sources of their distress so that appropriately targeted treatments may be initiated.
One-fourth of the women with high distress refused PCLN care; however, this ratio was better than has been reported by previous studies among cancer patients [42
]. The therapeutic relationship established between the APNs and their assigned subjects may have influenced many of the distressed women to accept mental health care. Since improvements in distress among cancer patients has been positively linked to better adherence to cancer therapies, it may be especially important to provide a mechanism for certain patients to establish such therapeutic relationships as a component of their chemotherapy plans, either within the clinic setting, or perhaps as a homecare adjunct to chemotherapy.
The use of the Distress Thermometer resulted in 24 of 32 subjects reporting high distress. This screening mechanism prompted mental health evaluations to be performed for eighteen women, which revealed that eight of the women were suffering from clinically significant psychiatric conditions, while ten of the women were evaluated as not having clinically significant psychiatric conditions. The most frequent conditions identified included anxiety, mood disorders (depression), adjustment disorders, and psychiatric disorders due to medical conditions. In this manner, the use of the DT in clinical practice, as endorsed by the NCCN guidelines, may be seen as effective in identifying and treating potentially serious psychiatric conditions among cancer patients. Since the DT was easy to use and has shown good reliability with the CES-D and similar measure of psychological distress, it may be advantageous for patients to complete the DT prior to every chemotherapy session, rather than at a single time at the onset of treatment, as occurred in the current study. More frequent monitoring of distress could improve the accuracy of psychiatric problem identification by offering opportunities to compare previous ratings, while also potentially targeting psychiatric evaluation and treatment for those who need it the most.
The Omaha System offered a unique method of capturing the broad array of patient problems within all four potential Problem Domains without simply identifying symptoms or targeting a single area of clinical concern among the universe of possibilities. The study findings show the complexity of the ovarian cancer patients' needs, the intensity of nursing care, and the value of a classification system to capture that description. The Omaha System also ensured a high degree of problem specificity by requiring that each active problem be counted only when clearly linked with at least one Omaha System-defined sign or symptom. Many of the Omaha System Problems found closely resembled problems identified among other samples of women with ovarian cancer using different measurement systems. However, the broad range of problems identified enhanced this body of knowledge by also identifying the effects of nontreatment issues sometimes experienced by women with ovarian cancer that may contribute to psychological distress. A major semantic problem occurred with respect to the issue of fatigue and may require a more in-depth examination of the Omaha System's ability to capture in detail the etiology and clinical significance of this problem.
Interventions identified using the Omaha System were classified into Surveillance, Teaching, Guidance, and Counseling, and Case Management interventions, with Surveillance comprising the largest category. This finding underscored the importance of careful monitoring during the postoperative phase. Although the three subsamples received relatively similar interventions within the Intervention Categories throughout study period, by the end of the six-month period, the High Distress/APN only/Refused PCLN subjects received more interventions overall than subjects in the other two samples. This finding also points to the possibility that this highly distressed subsample may not have initially been ready to discuss psychological issues and may have required additional time to feel comfortable disclosing sensitive information to the APNs. The six-month study period was only beginning to provide the opportunity for them to develop therapeutic relationships sufficiently meaningful to allow for such disclosure. This finding suggested that a six-month time period may be insufficient to allow some patients, even highly distressed ones, to accept certain interventions, but longer-term relationships among patients and clinicians may enhance this ability.
5.1. Implications for Research
Based on the current study's significant findings and methodological limitations, the following suggestions for future research are presented. First, the DT requires additional testing for reliability, validity, and stability among a racially diverse sample with different levels of education and cancer types. Such testing should also include sensitivity and specificity testing to reliably evaluate its use as a screening tool throughout the cancer treatment process in order to fully support its universal usage per NCCN Distress Management Guidelines.
Second, although the Omaha System is commonly used in practice within the homecare and other settings, more studies using the Omaha System exclusively among cancer patients may provide evidence as to the unique nature of problems experienced by them. One area in need of careful evaluation concerns the issue of fatigue among cancer patients. The Omaha System may offer a viable tool to uncover contributory and mediating factors associated with this elusive problem. In addition, semantic study of this problem for clarity in categorizing it according to Omaha System criteria is in order to improve standardization in documentation.
Third, the longitudinal nature of the current study provided an opportunity for the investigator to examine linkages between patient problems and APN interventions, while incorporating systems characteristics such as the timing of APN contacts and the use of the DT. Further studies which link patient problems, nursing interventions, and outcomes are essential in order for nurses to refine their practice through the merits of evidence. This need is especially important as populations become more diverse and complex, and as the shrinking nursing workforce struggles to meet patients' needs for quality health care. Although secondary analysis was an inexpensive and convenient method for designing and completing this study, future studies among patients with cancer, using the Omaha System in a prospective manner may prove more accurate in correctly identifying Omaha Problems related to specific symptoms and would eliminate the need for content analysis to categorize the data.
In addition to the Problem and Nursing Intervention Schemes, the Omaha System provides the opportunity to utilize the Problems Rating Scale for Outcomes Scheme, which would be helpful in determining linkages between patient problems, nursing interventions, and patient outcomes. This scheme would enable evaluation of changes within three subscales of patient conditions in relation to specific Omaha Problems: knowledge (patient's understanding about a Problem), behaviors (patient's actions/responses in relation to a Problem), and status (wellness or illness in relation to a Problem) using a five-point rating scale for each subscale.
Finally, it is possible that extraneous factors not identified may have influenced patients' inclinations to accept or decline PCLN or other mental health referrals. The analysis plan for future studies will need to adjust for these factors, and the results from these studies will need to be evaluated within the context of how these factors versus the intervention alone may account for the results so that the possibility of an artificial effect imposed by these factors is minimized.
5.2. Implications for Practice
The current study highlighted clinical outcomes resulting from distress screening for women in active treatment for ovarian cancer. The DT isolated unique phenomena among women who reported varying levels of distress at baseline, which may be helpful to clinicians who care for this cancer population. Women with low distress (the Low Distress/APN only subsample) appeared to be very open to communicating their needs and concerns, were able to articulate their needs to APNs, and became active participants in achieving their health goals, as evidenced by the clear reduction in their problems and interventions as the study period progressed. Those with high distress who were willing to receive services to treat this distress (the High Distress/APN plus PCLN subsample) also appeared to receive valuable assistance in caring for their health during the cancer treatment period through interactions with oncology and psychiatric APNs. Several of these women were identified to have psychiatric conditions worthy of further treatment and were referred appropriately. However, the High Distress/APN only/Refused PCLN subsample presented challenges unique to this subsample. These women may have experienced more Environmental Problems contributing to their distress; therefore, clinical settings need to provide ample opportunities for women to receive assistance in meeting financial, residence, and employment needs, which although not directly related to their disease process, may seriously degrade quality of life during already challenging health events. Clinicians need to be keenly aware of such patients and interact with them with particular sensitivity through continued support and gentle, repeated reminders of how they may be helped.
The DT was a simple screening tool which identified 24 patients in distress at baseline, with eight evaluated as needing further mental health treatment. The NCCN guideline suggests serial DT screenings to be useful for clinicians to use at baseline and throughout the treatment process, so that areas of distress may be identified and addressed promptly [1
]. This would be particularly helpful among women who may be reticent to disclose such problems in conversation, but may feel comfortable completing the DT. For these women, the DT in combination with astute, compassionate clinical assessments during oncology visits may provide the best opportunities to uncover clinically-significant psychological distress.
5.3. Implications for Policy
Key elements of quality care, including those providing psychological support services and compassionate care to individuals with cancer, are recognized as essential areas in need of improvement [23
]. The recently passed Patient Protection and Affordable Care Act (PPACA) increases funding for general care nurses as well as APNs, with the anticipated outcome being to expand the nursing workforce overall [44
]. An area of particular promise is a grant program to fund innovative safety-net programs, such as nurse-managed clinics. Although initially focused on primary care, these safety net programs may also include care for patients who may not be acutely ill, but require management of chronic conditions or support during times of transition (such as from hospital to home). The chronic nature of many types of cancer, including ovarian cancer, which is often characterized by bouts of exacerbations of symptoms over the course of months or years, may be ideally suited for this model of care. Further definition of the APN role in ensuring effective psychosocial care, including teaching, guidance, counseling, case management, and appropriate surveillance is essential at this time in order for these services to be recognized as worthy of reimbursement.