1. Empowerment and Team Work:
a complex symptoms management
care model
Anne Plante, M.Sc.inf.
CSIO, CSISP
Centre intégré de lutte contre le
cancer de la Montérégie
Vancouver
AstraZeneca
Septembre 2004

2. Regional Cancer Centre (Monteregie)
Réseau Cancer Montérégie
Hôpital
Hôpital
Hôpital Charles
Charles
Hôpital Hôtel-
Hôtel-
Brome- LeMoyne
LeMoyne
Brome- Dieu de
Dieu de
Missisquoi-
Missisquoi- Sorel
Perkins Sorel
Perkins
Hôpital
Hôpital Centre
Centre
du Haut-
du Haut- Hospitalier
Hospitalier
Richelieu
Richelieu Pierre-
Pierre-
Boucher
Boucher
Centre
Centre Centre
Centre
Hospitalier 19 local Hospitalier
Hospitalier Hospitalier
Régional
Régional community de Granby
de Granby
du Suroît
du Suroît centers
Centre
Centre Réseau
Réseau
Hospitalier
Hospitalier Santé
Santé
Anna-
Anna- Richelieu-
Richelieu-
Laberge
Laberge Yamaska
Yamaska

3. 1995- Task force committee on Cancer
Care
1998- Quebec strategy for cancer Care
(P.Q.L.C.)
2000- The philosophy of Monteregie
Comprehensive Cancer Care
Center (CICM)
2001- 9 hospitals /12 nurse navigators

4. 2002- Regional committees:
Head nurses
Psychosocial workers (social workers, psychologists)
Oncologists
Surgeons
Pharmacists
Nutritionists
Physiotherapists
Volunteers
2002- Regional oncology training
program
Evidence based practice
Interdisciplinary team work
Health promotion : the patient as « Captain of the
boat »

5. P.Q.L.C.’s objectives
↑ prevention
↑ early detection
↑ quality of life
↑ quality of care and support
↑ patient satisfaction
↑ patient breathing space and adaptation
↑ professional satisfaction
↑ team stability
↑ everyone potential and resources
↑ flexibility

6. Flying 101 – Team Work 101

7. Model of care: Complex symptom
management
Diagnosis
Oncologist referral
to nurse navigator
Nurse navitator meets with
the patient and his family
Assessment Teaching Support Empowerment Referrals
(related to Related to
practice complex
limits) symptoms

8. Model of care: Complex
symptom management
Nurse navigator presents the complex cases at
the interdisciplinary weekly meeting
Specific care plan is designed for every patient
and family (team coherence and continuity) (unity
of action)
Every professional is responsible for his/her
assessment, teaching, support, referrals, work
analysis process: Symptoms → Hypothesis →
Interventions
The patient is « The captain of the boat » with his
resources and strengths

9. Flying 102 - Team Work 102

10. Care plans and speciality referral criteria
Criteria are developed for referral to:
Nurse navigator
Pain management nurse specialist
Oncologist
Pharmacist
Psychologist
Social worker
Pastoral worker
Physiotherapist
Nutritionist
Psychiatrist
Occupational therapist

11. Symptom assessment
Patients are asked to complete their ESAS (self-
management)
Patients are invited to prepare their interview with
the oncologist with the help of a check list
The oncology clinic nurse discusses the
symptoms with every patient (Q.O.L.)
He/she makes the appropriate interventions
He/she may consult a colleague
Work analysis process: - Symptoms
- Hypothesis
- Interventions
If the symptom is complex, a referral is made with
a specific description of the request

12. Patient, family centered care
Team-Building care strategies
Family systems nursing approach
Nurse navigator’s major role
Reflective practice
Symptom Hypothesis Interventions

13. Flying 103 - Team Work 103

14. CICM
CLINIQUE D'HÉMATO-ONCOLOGIE
Hôpital Charles-Lemoyne
Report ESAS
Auto-évaluation des symptômes
Système pour l'évaluation des symptômes (ESAS) Symptom Assessment system scale
Mettre une barre ci-dessous à l'endroit qui correspond à ce que vous ressentez actuellement
Please make mark that best describe how you are feeling
0 10
Pas de douleur/ Douleur maximale/
no pain Worst possible pain
0 10
Pas de fatigue/ fatigue extrême/
Not tired Worst possible tiredness
0 10
Pas de nausées/ nausées maximales/
Not nauseated worst possible nausea
0 10
Pas de dépression/ Dépression extrême/
Not depressed Worst possible depression
0 10
Pas d'anxiété/ Anxiété maximale/
Not anxious Worst possible anxiety
0 10
Pas de somnolence/ Somnolence extrême/
Not drowsy Worst possible drowsiness
0 10
Excellent appétit/ Pas du tout d'appétit/
Excellent appetite/ Worst possible appetite
0 10
Bien-être parfait/ Mal-être le pire possible/
Perfect feeling of well-being Worst feeling of well-being
0 10
Respiration normale/ Essoufflement maximal/
Not short of breath Worst possible shortness
0 10
Autres problèmes/
Others problems
ESAS- Système d'Edmonton pour l'évaluation des symptômes, Rev. 2/11/99

15. CICM
CLINIQUE D'HÉMATO- ONCOLOGIE
Hôpital Charles-Lemoyne
(Plotting to identify patterns)
Graphic report
Système pour l'évaluation des symptômes (ESAS) Symptom Assessment system scale
date
10
Douleur 8
(Pain) 6
4
2
0
10
Fatigue 8
(Fatigue) 6
4
2
0
10
Nausées 8
(Nausea) 6
4
2
0
10
Dépression 8
(Depression) 6
4
2
0
10
Anxiété 8
(Anxiety) 6
4
2
0
10
Somnolence 8
(Sleepiness- 6
drowsiness) 4
2
0
10
Appétit 8
(Appetite) 6
4
2
0
10
Bien-être 8
(Well being) 6
4
2
0

16. Patients and families are supported to
use their own resources and strengths
Teaching sessions are offered:
Cancer and nutrition
Cancer and sexuality
Cancer and family
Cancer and young children
Cancer and spirituality
Cancer and pain
Cancer and fatigue
Cancer and hope
Cancer and emotion

17. Patients and families are supported to
use their own resources and strengths
Complementary and alternative medicines
are offered:
Therapeutic group support
Art therapy
Mental imagery
Hypnosis
Metastatic group support
Nadeau technique

18. Model of care: Complex symptom management
Results
Planning for safe discharge
Discharge from the unit
Clinic treatment
↑ patient satisfaction
↑ doctor satisfaction
↑ professional satisfaction
Community nurses and psychosocial workers
↓ staff absenteeism (continuity of care)
↑ patient autonomy and adaptation
↑ administrator support
Evidence based practice for all disciplines

19. Flying 104 - Team Work 104

20. Conclusion
A well-defined philosophy
Educational Support
A new Captain: the Patient
A better attitude: everyone is responsible for
simple symptoms
The overwhelming role of the nurse navigator
A better continuity and
cooperation

21. Flying 105 – Team Work 105

22. Nurse navigators in Monteregie
Rachel Mélanie Blandine
Sonia Rémillard Fortier Danis Sylvie
Joanette CHAL CHG BMP Cartier
Lucie HCLM CHPB Louise
Laporte Leduc
Line CHRS Louise
HCLM
Roberge Raymond
RSRY HHR

23. Recognition award from Ministry of
health of Quebec
« Prix Mérites C.Q.L.C. »