VOLUME 21, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 79CJO.docx

VOLUME 21, NUMBER 1 CLINICAL JOURNAL OF
ONCOLOGY NURSING 79CJON.ONS.ORG
A
Detecting Distress
Introducing routine screening in a gynecologic cancer setting
Moira O’Connor, BA(Hons), MSc, PhD, Pauline B. Tanner, RN,
RM, CertOnc, SBCN, Lisa Miller, MBBS, DCH, FRACGP,
FAChPm, FRANZCP,
Kaaren J. Watts, BA(Hons), PhD, and Toni Musiello,
BA(Hons), MA, PhD
ALONGSIDE PHYSICAL SYMPTOMS AND SIDE EFFECTS
of treatment, cancer results
in psychological, social, and practical challenges, which can
contribute to
patient distress (Carlson, Waller, Groff, Giese-Davis, & Bultz,
2013). The
International Psycho-Oncology Society highlights distress as a
critical factor
affecting patients’ well-being and recommends that distress be
named the
sixth vital sign in oncology (Holland, Watson, & Dunn, 2011).
The report-
ed prevalence rates of psychological distress in patients with
cancer range
from 35%–49% (Carlson, Groff, Maciejewski, & Bultz, 2010).
However, the
actual rates of distress are thought to be much higher because of
underdetec-

tion. Clinician assessments have been shown to be inferior to
gold-standard
methods, such as validated screening tools and clinical
interviews (Werner,
Stenner, & Schüz, 2012), and distress is often missed by
clinicians (Mitchell,
Vahabzadeh, & Magruder, 2011).
Distress encompasses a range of issues, including
psychological, spiritual,
and existential distress, as well as juggling roles and having
financial concerns
and practical problems, such as needing help with
accommodation or travel.
Distress is associated with poorer physical and psychological
quality of life
(Carlson et al., 2010). Detecting distress in patients with cancer
can result in
early intervention, which helps avoid patients struggling with
unmet or com-
plex needs (Faller et al., 2013). Identifying distress early could
also reduce the
financial burden on health services (Han et al., 2015).
Healthcare profession-
als (HCPs) must recognize distress so it can be adequately
managed (Werner
et al., 2012); to do this, HCPs need to screen all patients
systematically.
Several organizations and professional bodies state in their
standards
for quality cancer care that psychosocial support should include
routine
screening for distress, followed by appropriate referrals targeted
to the needs
identified by patients (Holland et al., 2011; Werner et al.,

2012). Despite this,
uptake of routine distress screening in clinical oncology settings
has been
suboptimal (Mitchell, Lord, Slattery, Grainger, & Symonds,
2012). Many
barriers exist to the successful implementation of routine
distress screen-
ing in clinical settings, including a lack of training, clinicians’
perception of
limited skills and confidence in identifying distress, and
inadequate referral
resources (Absolom et al., 2011). A shortage of private space
has also been
identified (Ristevski et al., 2013). Many HCPs believe that
addressing distress
will take too much time. However, appropriate recognition and
discussion of
emotions can reduce consultation times (Butow, Brown, Cogar,
Tattersall, &
Dunn, 2002).
Roth et al. (1998) developed a single-item Distress
Thermometer (DT),
which the National Comprehensive Cancer Network (Vitek,
Rosenzweig, &
KEYWORDS
gynecologic cancer; oncology; distress
screening; Distress Thermometer
DIGITAL OBJECT IDENTIFIER
10.1188/17.CJON.79-85

BACKGROUND: Cancer results in a wide range of
challenges that contribute to patient distress. De-
tecting distress in patients can result in improved
patient outcomes, and early intervention can avoid
patients having unmet needs.
OBJECTIVES: The aims were to determine the
prevalence of distress in patients with gynecologic
cancers, identify specific problems, and explore
staff perceptions of distress screening.
METHODS: A mixed-methods design was used.
Quantitative data were collected on distress
levels and problems. Qualitative interviews were
conducted with healthcare professionals.
FINDINGS: Sixty-six percent of women scored 4 or
greater on the Distress Thermometer, which was
used as the indicator for follow-up or referral. A
third reported low distress, and the same propor-
tion was highly distressed. The top five problems

identified by participants were nervousness, worry,
fears, fatigue, and sleep problems.
80 CLINICAL JOURNAL OF ONCOLOGY NURSING
VOLUME 21, NUMBER 1 CJON.ONS.ORG
DETECTING DISTRESS
“Some patient worries
can be allayed by
active listening, but
high anxiety levels
need referral.”
Stollings, 2007) paired with a Problem List (PL). The DT takes
one
to five minutes to complete. A meta-analysis by Ma et al.
(2014)
found the DT to be a valid tool for detecting distress in patients
with a cancer diagnosis. The DT is not a diagnostic tool
(Tavernier,
2014), but when combined with clear referral pathways, it
provides
an ideal way to streamline care (Snowden et al., 2011).
In 2006, the Australian Senate conducted an inquiry into gy-
necologic cancer in Australia (Parliament of Australia, 2006).
The
report highlighted the urgent need for appropriate and timely re-
ferral pathways, including psychosocial referrals. Screening was
also prioritized in models of care of the Western Australian
(WA)
Gynaecological Collaborative and the WA Psycho-Oncology

Collaborative (Department of Health, WA, 2008a, 2008b).
Despite this emphasis, screening has not been formally imple-
mented in a clinical setting in WA, and the practical
implications
of applying such a screening program remain unclear. Snowden
et al. (2011) stated that the DT has been validated sufficiently
and
that additional research should focus on its use in clinical
settings
to understand the complexities of implementation (Fitch, 2011).
The current study investigated the impact of screening for dis-
tress in patients with gynecologic cancer in WA.
The aims were to (a) establish the prevalence and level of dis-
tress and determine specific problems identified by patients and
(b) explore staff perceptions of the process of using the DT and
PL and referring patients.
Methods
A mixed-methods design was used. The current study was ap-
proved by the King Edward Memorial Hospital and Curtin
University human research ethics committees. Quantitative
data were collected on the DT and PL in a cross-sectional study.
Qualitative interviews were conducted with HCPs.
The setting was a WA public women’s and newborns’ tertiary
teaching hospital, King Edward Memorial Hospital, which is the
direct referral pathway for women with gynecologic
malignancies
in the state. It offers the full range of services for inpatients and
outpatients.
Sample
Sixty-two patients with gynecologic cancer in the pre-
admission clinic, where women are seen prior to surgery, partic-
ipated in the study during a six-month period. Women were in-

cluded if they were aged 18 years or older, were diagnosed with
a
gynecologic cancer, and were able to comprehend and complete
the DT and PL. Women who were aged younger than 18 years,
had not received a gynecologic cancer diagnosis, were unable to
comprehend or complete the DT and PL, or were unable to give
informed consent were excluded. The median age was 58 years,
and the range was 25–94 years (see Table 1). Six oncology
HCPs
were interviewed—three nurses, two social workers, and one
physiotherapist.
Procedure
At the pre-admission clinic, the research officer (RO) visited
each
patient, explained the research project, provided written infor-
mation, and invited patients to participate. If the patient agreed
to participate, she signed the consent form and was asked to
com-
plete the DT and PL on her own or with the RO. Following com-
pletion, the patient had a consultation with an oncology nurse
on
duty and, if necessary, the social worker who was present in the
weekly clinic. DTs and PLs were evaluated by the oncology
nurses
who could triage and refer women to appropriate interventions
according to distress and psychosocial management guidelines
(National Breast Cancer Centre and National Cancer Control
Initiative, 2003). The DT has a single item scored from 0 (no
dis-
tress) to 10 (high distress), and the PL has 39 problems in five
domains with “yes” or “no” responses.
At the completion of the project, HCPs were approached di-
rectly by the RO, consented, and interviewed at a time
convenient

to them. These interviews were conducted by a trained
interview-
er with extensive experience working with vulnerable
populations.
Interviews were digitally recorded.
Analysis
Data were entered into SPSS®, version 22.0. Descriptive
statistics
were used to describe the DT scores and problems identified. To
examine between-group differences, Pearson chi-square test for
independence and a one-way analysis of variance (ANOVA)
were
used. A Pearson product–moment correlation coefficient was
used to look at the correlation between the number of problems
and distress score.
Qualitative data from interviews conducted with HCPs were
analyzed using directed content analysis (Hsieh & Shannon,
2005) because the focus was on how distress screening worked
in clinical practice. Deductive category application was used;
the
text was read, and salient points were highlighted before
develop-
ing the categories, using the interview questions as a guide. The
analysis was undertaken by two of the authors. Rigor for the
study
was ensured by employing transparency, consistency, neutrality,
applicability, and credibility (Emden and Sandelowski, 1998).
An

CJON.ONS.ORG
audit trail of decisions was maintained, and the team met to dis-
cuss emerging themes and reach agreement.
Findings
Twenty-one participants scored from 0–3 on the DT, 20 partic-
ipants scored from 4–6, and 21 participants scored from 7–10.
For additional descriptive statistics, see Table 2. Of the prob-
lems identified on the PL, 207 were physical, 53 were practical,
24 were familial, 147 were emotional, and 2 were spiritual (see
Figure 1).
Pearson chi-square test for independence indicated a signif-
icant association between age group (three categories: aged 40
years or younger, aged 41–64 years, and aged 65 years or older)
and the three different distress score categories (0–3, 4–6, and
7–10) (x2 = 10.181 [4, N = 62], p = 0.04, Cramer’s V = 0.29 [a
medi-
um effect]). Nine participants aged 40 years or younger scored
in
the 7–10 range on the DT, compared to 10 participants aged
from
41–64 years and 3 participants aged 65 years or older.
On average, patients aged younger than 40 years listed 8.31
problems (SD = 4.7), ranging from 2–19; patients aged 41–64
years
listed 8.42 problems (SD = 6.35), ranging from 0–22; and
patients
aged 65 years or older listed 5.89 problems (SD = 5.18),
ranging
from 0–16. A one-way ANOVA showed no significant
differences
between age groups on the number of problems listed (F[2, 54]

=
1.2, p = 0.31).
A Pearson product–moment correlation coefficient was used
to determine the relationship between distress scores (continu-
ous) and number of problems. A strong positive association was
found between the two variables (r = 0.53, n = 57, p < 0.0005),
with high levels of distress associated with a greater number of
problems.
A Pearson chi-square test revealed significant differences be-
tween the specific types of gynecologic cancers and the three
dis-
tress levels (x2[8] = 21.41, p = 0.006, Cramer’s V = 0.42 [a
large
effect]). A larger proportion of participants with a diagnosis of
cervical cancer scored in the 7–10 range on the DT (n = 10),
com-
pared to participants diagnosed with another gynecologic cancer
(endometrial = 4, uterine = 4, ovarian = 3, vulvar = 0).
The main themes that emerged from qualitative data were
benefits to patients and staff, challenges faced, and the impact
of routine screening on services. Overall, HCPs indicated little
impact on services. No increase in overall referrals or referrals
to
the social work department was noticed, and no extra need for
counseling was identified.
Patient Benefits
Several perceived benefits to the patients were found, mainly
around validating patients’ concerns and issues: “includes ques-
tions they may not have been expecting (allows them to think
more broadly),” “gives patients permission [to talk] and
includes
questions not usually asked (sexual concerns),” and “normalizes

TABLE 1.
SAMPLE CHARACTERISTICS (N = 62)
CHARACTERISTIC n
Age (years)
Younger than 41 13
41–55 12
56–70 20
71–85 14
86–100 3
Cancer diagnosis
Cervical 12
Endometrial 9
Ovarian 17
Uterine 19
Vulvar 4
Missing data 1
Time since cancer diagnosis
2 months or less 38

2–12 months 16
12 months to 2 years 4
More than 2 years 4
Education
No formal education 1
Primary school 5
High school 27
Diploma, certificate, or trade qualification 18
University degree 7
Missing data 4
Occupation
Paid employment 1
Pensioner 5
Self-funded retiree 27
Other 18
Missing data 11

DETECTING DISTRESS
patient concerns (interview focused on the patients’ needs).” It
was also seen as a way of introducing a conversation about con-
cerns by offering the patient a prompt and an ice breaker. As
stat-
ed by one participant, “[Patients are] stoic, not wanting to be a
burden, don’t expect help . . . struggle on until crisis.”
Staff Benefits
HCPs saw the tool as adding value in their work by validating
what
they do, empowering patients to help themselves, asking more
de-
tailed questions than routine surgical admission, enhancing nor-
mal practice, offering a more holistic approach, giving guidance
on what the patients’ needs are, and avoiding missing important
issues. One nurse thought it was a good education tool for
honing
in on what is important to ask, particularly when time is
limited,
saying, “DT and PL is a good education tool to inform HCPs on
what to ask when limited amount of time.”
Another nurse talked about saving time by focusing on salient
issues: “Using DT and PL as a prompt for patients can speed up
assessment of needs by focusing on the items that matter to
them
at that moment in time.”
Challenges
Problems and barriers were perceived, mainly around time. The
tool requires knowledge, experience, time allocated, and a
sensi-

tive approach. Finding time in a busy pre-admission clinic is
dif-
ficult; extra time may be needed to complete the interview and
document, but that may prevent increased distress later. In ad-
dition, the HCPs developed strategies to reduce time, including
patients prioritizing issues and returning to others later, maybe
by phone.
Another issue was when to administer the DT and PL.
Participants found this difficult because patients need pain
management postoperatively, and sedation may affect them.
Participants said that ward staff should be able to administer the
DT and PL as part of the discharge process.
Discussion
Screening for distress in this setting was successful, and
patients
were receptive to completing the DT and PL. This supports pre-
vious research demonstrating that the DT was feasible among
pa-
tients with lung cancer (Lynch, Goodhart, Saunders, &
O’Connor,
2011) and acceptable for distress screening in men with prostate
cancer (Chambers, Zajdlewicz, Youlden, Holland, & Dunn,
2014).
The current study identified challenges, including timing,
access
to the social worker, and space, but the team found ways around
these barriers. The project proceeded in an iterative way, with
regular meetings to resolve emerging issues. The researchers
suc-
ceeded in securing a room to enable a social worker to be
present
for the pre-admission clinic to address patients’ needs. This
mod-

ified approach normalized the referral, and patients were able to
see the social worker as part of usual care during the same hos-
pital visit.
Twenty-one participants reported low distress, and the same
proportion was highly distressed. Forty-one women scored 4 or
higher, which is deemed to be the optimal cutoff (Chambers et
al.,
2014; Donovan, Grassi, McGinty, & Jacobsen, 2014) and an
indica-
tor of distress that requires follow-up. This is similar to the
57%
of women with gynecologic cancer scoring 4 or higher in a
study
by Johnson, Gold, and Wyche (2010). Twenty-one participants
scored 7 or higher, which has been suggested to be a more
appro-
priate cutoff than 4 (Lambert et al., 2014). This means that high
levels of distress are present and need monitoring. The current
findings closely mirror those from a WA study with clients of a
not-for-profit organization (Watts et al., 2015). Distress was
high-
er than reported in a study from Victoria, Australia (Williams,
Walker, & Henry, 2015). This could be partly explained by the
profile of participants; participants in the current study were all
female patients with gynecologic cancer.
Two hundred twenty-six problems were psychosocial, and 207
were physical; most problems were related to physical and emo-
tional symptoms. Nervousness, worry, and fears were the top
three
concerns. VanHoose et al. (2014) found that the greatest risk
factor
for distress was worry and suggested that worry may be a proxy
for
intensity of distress. Some worries can be allayed by active

listen-
ing and responding to emotions with empathy, but high anxiety
levels need referral. Sadness and loss of interest were in the top
10
concerns, which could be symptoms of depression. Fatigue,
prob-
lems with sleep and eating, and pain need to be looked at
carefully
by the team to see how they can be alleviated. The main
problems
TABLE 2.
TOP 10 INDIVIDUAL PROBLEMS IDENTIFIED
IN THE PROBLEM LIST (N = 62)
PROBLEM n
Nervousness (emotional) 39
Worry (emotional) 33
Fears (emotional) 31
Fatigue (physical symptoms) 24
Sleep (physical symptoms) 23
Sadness (emotional) 21
Treatment decisions (practical problems) 18
Eating (physical symptoms) 17
Pain (physical symptoms) 15

Loss of interest in usual activities (emotional) 13
IMPLICATIONS FOR PRACTICE
ɔ Have clear referral pathways, including psychosocial
referrals, for
appropriate and timely triaging after screening.
ɔ Normalize patients' experiences with distress screening,
which
allows them to voice their concerns and needs.
ɔ Offer information on anxiety management, particularly for
younger
patients who may be more vulnerable.
identified were similar to the study by Watts et al. (2015), in
which
the problems identified most frequently were psychological and
emotional issues and difficulties with fatigue and memory. The
current findings also reflect findings from Williams et al.
(2015).
Spiritual and religious concerns were reported by only two par-
ticipants in the current study. Spiritual well-being in patients
with
cancer is associated with anxiety, depression, and fatigue
(Rabow
& Knish, 2015), so spiritual and existential fears may be
incorpo-

rated into these areas. One item relating to spiritual and
religious
concerns on the PL may be insufficient to capture this issue.
Group differences were seen between older and younger pa-
tients for DT score, with a significant association between age
group (40 years or younger, 41–64 years, and 65 years or older)
and the three different distress score categories. Nine partici-
pants aged 40 years or younger scored in the 7–10 range on the
DT, compared to 10 participants aged 41–64 years and 3 partici-
pants aged 65 years or older. However, no significant
differences
were seen in the number of problems between age groups. This
supports VanHoose et al. (2014), who found that patients most
at risk for distress were younger, and Johnson et al. (2010), who
found that women aged younger than 60 years were more dis-
tressed in a sample of women with gynecologic cancers.
Significant differences also were found between the specific
types of gynecologic cancers and levels of distress. This
supports
previous findings that patients with cervical cancer report worse
quality of life than the general population and patients with
other
gynecologic cancers (Korfage et al., 2009).
Snowden et al. (2011) stated that qualitative data are almost
entirely missing from the distress screening literature and few
studies investigate how HCPs use the tool. Staff in the current
study indicated high levels of satisfaction with the tool and
found
many benefits. Particularly, it normalized patients’ distress and
gave them “permission” to open up. It also proved to be a con-
versation starter. These findings mirror conclusions by Carlson,
Waller, and Mitchell (2012) and Williams et al. (2015), who

found
that use of the tool promoted communication between the pa-
tient and oncology team; Lynch et al. (2011), who suggested
that
the DT helped patients discuss their feelings and issues with
HCPs and recognize the coping skills they already had in place;
and Snowden et al. (2011), who highlighted the DT’s function
as a
facilitator of consultations.
A benefit mentioned by staff members in the current study
was that they felt the tool validated what they do and provided
guidance, which enhanced usual practice. The key challenge
was
finding time. However, HCPs were able to identify a range of
strategies to overcome this barrier, including making follow-up
telephone calls and prioritizing. Continuing professional devel-
opment could help staff identify ways of managing time (Heyn,
Ruland, & Finset, 2012). One HCP stated that using the DT
saves
time by focusing on salient issues, which contradicts many
HCPs’
preconceptions that use of the tool can make consultations lon-
ger. Most of the support came from the nurses who were able to
talk to the patients about their concerns, listen empathetically,
normalize fears and anxieties, and assist in finding solutions.
This
could partly explain the perception that no additional referrals
were needed. Another explanation of this observation was that
the social worker was present at the clinic, so she may have
been
perceived to be part of the clinic team. In the current study, on-
cology nurses were seen as best placed to conduct the screening,
but other models could be applied, such as screening by
oncology
social workers (BrintzenhofeSzoc et al., 2015).

Limitations
Uptake of referrals was not tracked because the patients were
difficult to contact. The researchers did not approach everybody
who attended the clinic because some people were seen quickly,
some were missed because of a busy environment, and, on some
days, no one was available to obtain consents. However, most
patients were approached and very few women (fewer than 5)
declined.
Conclusion
Findings will help to address the lack of systematic and
formalized
routine screening of patients for distress in WA. Screening
facili-
tates conversations, helps normalize patients’ distress, and
enables
staff to identify issues promptly so that preventive action can be
taken. This could prevent later intervention for crisis. Criticism
of
FIGURE 1.
PROPORTION OF PROBLEMS IDENTIFIED
ON THE PROBLEM LIST BY DOMAIN (N = 62)
Physical problems
Practical problems
Family problems
Emotional problems
Spiritual or religious
problems

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DETECTING DISTRESS
the DT has included that it lacks specificity in identifying
problems.
However, the current study demonstrates that the tool is useful
for
initial screening and identifying specific problems that can be
fol-
lowed up by appropriate HCPs. For oncology nurses, the key
impli-
cations are that screening is useful and acceptable, distress
levels
are high (particularly in relation to anxiety and nervousness, re-
sulting in the need for anxiety management), and younger
patients
may be more vulnerable to distress.
Moira O’Connor, BA(Hons), MSc, PhD, is a senior research
fellow in the School

of Psychology and Speech Pathology of the Faculty of Health
Sciences at Curtin
University in Perth; Pauline B. Tanner, RN, RM, CertOnc,
SBCN, is a cancer nurse
coordinator in the Department of Health at the Cancer and
Palliative Care Network
in Perth; Lisa Miller, MBBS, DCH, FRACGP, FAChPm,
FRANZCP, is a consultant liai-
son psychiatrist and lead clinician at Sir Charles Gairdner
Hospital in Perth; Kaaren
J. Watts, BA(Hons), PhD, is a researcher and project officer for
an independent
contractor in Scarborough; and Toni Musiello, BA(Hons), MA,
PhD, at the time of
writing, was a research psychologist in the School of Surgery at
the University of
Western Australia in Crawley, all in Australia. O’Connor can be
reached at
[email protected], with copy to [email protected] (Submitted
Novem-
ber 2015. Accepted April 20, 2016.)
The authors take full responsibility for this content. This study
was funded by the Cancer and
Palliative Care Research Evaluation Unit of the University of

Western Australia. The article has
been reviewed by independent peer reviewers to ensure that it is
objective and free from
bias.
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Week 6: Reading Research Literature Worksheet

Name:_______________________________________________
________________________
Date:________________________________________________
_________________________
Complete the following required worksheet using the required
article for the current session. Access the required article from
the assignment guidelines.
Purpose of the Study: Using information from the required
article and your own words, summarize the purpose of the
study. Describe what the study is about.
Research & Design: Using information from the required
article and your own words, summarize the description of the
type of research and the design of the study. Include how it
supports the purpose (aim or intent) of the study.
Sample: Using information from the required article and your
own words, summarize the population (sample) for the study;
include key characteristics, sample size, sampling technique.
Data Collection: Using information from the required article
and your own words, summarizeone data that was collected and
how the data was collected from the study.
Data Analysis: Using information from the required article and
your own words, summarizeone of the data analysis/ tests
performed or one method of data analysis from the study;
include what you know/learned about the descriptive or
statistical test or data analysis method.
Limitations: Using information from the required article and
your own words, summarizeone limitation reported in the study.
Findings/Discussion: Using information from the required
article and your own words, summarizeone of the authors'
findings/discussion reported in the study. Include one
interesting detail you learned from reading the study.
Reading Research Literature: Summarize why it is important
for you to read and understand research literature. Summarize
what you learned from completing the reading research

literature activity worksheet.

VOLUME 21, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 79CJO.docx

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