Contribution of the Assessment and Support provided by the eHNA (CASE)
Research type
Research Study
Full title
How does the eHNA contribute to the understanding, assessment and support of the holistic needs of women living with or beyond breast cancer?
IRAS ID
259760
Contact name
Holly Blake
Contact email
Sponsor organisation
University of Nottingham
Duration of Study in the UK
0 years, 7 months, 30 days
Research summary
There is a vast and ever-increasing population of individuals living with or beyond breast cancer, with the literature showing that these women often face a myriad of ‘unmet needs’ throughout their cancer journey. Holistic Needs Assessment (HNA) tools were created to identify and address these needs, one of which being Macmillan Cancer Support’s electronic version (eHNA). Embedding this tool is a national priority in the NHS, and minimal research has been conducted into the impact and implementation of this, and how it can be best utilised to support individuals living with or beyond cancer. The study aims to provide an understanding of how the holistic needs of breast cancer survivors are assessed and responded to, with a specific focus on the eHNA as a tool to facilitate this. An overarching, qualitative approach will be adopted, using a case study approach integrating observations, semi-structured interviews and document analysis with healthcare professionals and patients. A constant-comparison approach to analysis will be utilised.
This study will contribute to evidence gaps, alongside enabling a greater understanding of the phenomenon which may subsequently lead to greater awareness and more successful implementation of this tool into routine practice, therefore assisting with achieving the national priority and improving patient quality of life.Sumary of Results
How does the eHNA contribute to the understanding, assessment and support of the holistic needs of women living with or beyond breast cancer?
Aims
The study aimed to explore the delivery and impact of HNA from the perspective of healthcare professionals and patients with breast cancer. The primary focus was on Macmillan Cancer Support’s electronic HNA (eHNA) but the general concept of HNA was also explored.Methods
The study adopted a multiple case-study approach incorporating four hospital sites within two UK Acute NHS Trusts. In each Trust, 12 patients (various pathway stages) and 12 members of staff were recruited, at a total of 48 participants. Staff were recruited from various roles relating to HNA delivery or implementation, including nurse specialists, support workers, radiographers and project managers.Data collection involved semi-structured face-to-face and telephone interviews, observations and document analysis in order to present each case around HNA within that organisation. Framework Analysis has allowed multiple themes to emerge.
Results
Findings have highlighted four key themes within the data relating to:The impact of cancer
This theme incorporates the relevance of personal life circumstances and the disruption to these caused by cancer, individual reactions to diagnosis and attitudes towards moving forward, having control etc.)Informal vs formal assessment
The benefits/limitations of having a general conversation compared to use of a formal tool to assess patients, communication skills adopted to elicit concerns and use of the care plan are all covered in this theme.There was no overall consensus in whether a conversation or HNA tool was better for identifying and addressing concerns. Many staff felt they were ‘doing it anyway’, but it seemed generally that use of a HNA tool and a meaningful conversation together might be the most successful method.
“Just conversations are little gems, but the holistic one gives you more information about more than you know is out there, more than you think you can be asked.” (Patient)
Barriers to use of a tool is highlighted from a staff perspective below:
"I think if I then “sat there with my pen and paper and well I'm going to give you that information but I need you to answer all of these questions first, it doesn't need to be that way" (Staff)
Factors influencing decision-making
This theme covers wide-ranging factors influencing decisions made by both staff and patients, such as impacts of the perceptions of others, factors surrounding decisions to accept help, honesty with declaration of concerns, expectations, introductions to the assessment, perceptions of Macmillan, perceptions of their own ability to self-manage and overall understanding of what a HNA is.There were some evident gaps in understanding among patients, relating partially to how they had been introduced to the assessment, but also their expectations and wider life circumstances in some cases:
“To me this is was the most important thing I was given now I realise, but when it was given to me… it didn’t give me that impression." (Patient)
“Well it’s for support if you need it… but no I haven’t, to be honest I haven’t done any of that… I feel that it’s gonna take me away from my husband when he needs my full attention.” (Patient)
"I think I probably hold back, because I think, “I don’t know where that’s going to go to. That might be me asking for more than is allowed.” (Patient)
Many patients seemed to indicate an element of completing the assessment for the benefit of staff, even if they also felt this benefitted them.
“It was alright but I felt guilty cause everything was no” (Every question on the HNA) (Patient)
“Well I thought it was to sort of talk about things of how you feel, to help other people really… and like for research.” (Patient)
“It says it’s Macmillan isn’t it, and I suppose it’s all this well the breast care nurses aren’t Macmillan… you were filling it in but you weren’t sure who was possibly going to access the information, not from a security point of view but who was going to look at it to make it relevant... who was going to come back to you?" (Patient)
Format of assessment
This theme covers considerations around important considerations when using a formal HNA tool, such as timing, location, revisiting and re-using the data, overall usability and the importance of the scoring system.Scoring itself was not given much ‘weight’ by staff, and many patients indicated that they did not record this truthfully. Despite this, all of these teams used score as a cut-off to determine when a patient should be seen by a navigator or clinical nurse specialist, and also in some cases whether they were seen face-to-face or via the telephone.
Organisational culture
This theme incorporated culture in the workplace and wider team factors influencing engagement/delivery such as resistence to change and external/clinical pressures (such as the national targets to deliver HNA), alongside nursing practices including defensiveness, sharing of information and perceptions of different roles.The use of targets seemed to negatively impact perceptions among teams, although there was recognition that targets were required, but that perhaps they should incorporate more than simply number of assessments completed.
Conclusions
There is a vast amount of data within this study indicating the complexity of the impact and successful implementation of HNA. All themes strongly interlink, but the ‘Factors influecing decision-making’ theme appears central, which shows the myriad of individual perceptions, attitudes and interpretations from both patients and staff that then affect their subsequent actions, from patients not declaring their concerns on their HNA due to a perception of placing emotional burden on staff, through to staff fearing to declare discussions on the care plan in case this gives patients who are- for example suicidal- a licence to act. A greater understanding from a staff perspective (service management through to frontline delivery of HNA) around these impacts of individual perspective could enhance the quality and value of HNAs.REC name
East Midlands - Derby Research Ethics Committee
REC reference
19/EM/0076
Date of REC Opinion
12 Apr 2019
REC opinion
Further Information Favourable Opinion