Improving the quality of nursing care: systematic nurse-led monitoring and implementation of a clinical tool for symptoms of acute toxicity in patients undergoing radiation therapy for head and neck cancers

Abstract

Many patients with otolaryngological (ENT) cancers are treated with various combinations of surgery, radiation therapy and chemotherapy. Acute toxicity from radiation therapy can be experienced during and after treatment. Managing toxicity can be a complex process, often requiring the involvement of a multidisciplinary team. Early detection and management of treatment-related toxicity can improve short- and long-term outcomes for patients. Nurses, being at the heart of patient care, are in the best position to detect and treat acute toxicity. This paper explores a systematic nurse-led approach to monitoring acute toxicity. This approach was developed and implemented by a clinical oncology nurse in a university-affiliated cancer care centre to facilitate the early detection and management of symptoms in these patients.

INTRODUCTION

In Canada, head and neck cancers represent approximately 4.7% of all cancers diagnosed in men and 1.8% of all cancers diagnosed in women in any given year. In 2023, an estimated 7,900 Canadians were diagnosed with head and neck cancer, and an estimated 2,100 died from it. (CCS, 2024). Statistics show that 1 out of 43 Canadian men and 1 out of 103 Canadian women will be diagnosed with head and neck cancer in their lifetime. Nearly 90% of head and neck cancers are squamous cell carcinomas that develop from the mucosal epithelium (Vigneswaran et al., 2014). The most frequent sites of occurrence are the oral cavity, oropharynx and larynx, although the nasopharynx, hypopharynx and salivary glands can also be affected (Barsouk et al., 2023). Tobacco, human papillomavirus (HPV), alcohol and areca nut consumption are the primary risk factors linked to head and neck cancer (Barsouk et al., 2023).

The therapeutic approaches used to treat head and neck cancer vary depending on the anatomical site, TNM (tumour, node, metastasis) staging, medical comorbidities and the patient’s ability to tolerate treatment. In the case of oral cancer, treatment generally consists of surgery accompanied by adjuvant therapy (mainly radiation therapy) and chemotherapy, which is administered in cases where there are high-risk characteristics associated with the pathology such as positive margins, positive lymph nodes, extracapsular tumour extension, locally advanced tumours invading adjacent structures including muscles and bones, or perineural or lymphovascular invasion (Johnson et al., 2020). Although surgery is still used to treat some cases of oropharyngeal and laryngeal cancer, non-surgical options are more common. This generally involves curative radiation therapy, sometimes with concurrent chemotherapy, (Johnson et al., 2020). The aim of treatment, wherever possible, is to eliminate the cancer while preserving organ function and minimizing morbidity. The treatment options used to eradicate head and neck cancer can, in some cases, cause severe acute and late toxicity.

Adverse events that occur during treatment or in the post-treatment period (the duration of which can vary up to 12 weeks once treatment ends) (Byhardt et al., 1998) are referred to as acute toxicity and tend to be temporary (Majeed & Gupta, 2023). Acute toxicity most frequently presents as mucositis, dysphagia, aspiration, dermatitis, nausea, vomiting, anorexia, weight loss or pain (Muzumder et al., 2019). These symptoms can sometimes be severe enough to make it necessary to stop treatment for a matter of days, or even longer, to give patients time to recover. This situation can be a problem in the treatment of head and neck cancer in that any such delays have been found to affect local recurrence and overall survival rates (Thomas et al., 2017). An analysis of the National Cancer Database (NCDB) shows that even short interruptions in treatment (two to eight days) are associated with a 7% absolute decrement in the five-year overall survival rate (Xiang et al., 2020). The most common regimen for radiation therapy used as a curative or adjuvant treatment for head and neck cancer is daily administration from Monday to Friday over a period of six to seven weeks. Adverse effects that occur months or years after treatment has ended are referred to as late toxicity and are more likely to be permanent (Brook, 2020). Late side effects include permanent dry mouth, burning mouth syndrome, dental caries, skin changes (including skin fibrosis and colour swelling), lymphedema, endocrine system dysfunction (including hypothyroidism and hypopituitarism), stenosis, neurological damage, secondary cancer and impaired wound healing (Brook, 2020). The goal is, therefore, to maximize the benefits of treatment while limiting the side effects of radiation therapy, so as to maintain patients’ quality of life.

In many cancer care centres, nurses are the main providers of care who see patients as they undergo treatment. Nurses are, therefore, in the best position to recognize signs of acute toxicity in patients and treat them using an evidence-based approach in order to limit the side effects that adversely impact their quality of life during and after treatment. This approach can also help avoid the need to postpone treatment and the negative oncological outcomes brought on by any such delays.

ROLE OF THE RADIATION ONCOLOGY NURSE

Nearly two-thirds of cancer patients will be administered radiation therapy at some point in their treatment journey (Radiation Oncology Nursing Position Statement, 2016). The complexity of this type of therapy and the cancer itself requires a swift response and the proactive management of side effects to ensure that the symptoms, which are often complex and unpredictable, and the associated psychological and social concerns, are addressed as effectively as possible (Radiation Oncology Nursing Position Statement, 2016). The role of nurses is to provide care tailored to the needs of each patient, which requires conducting detailed assessments, implementing the established care plan and taking action in complex situations. Nurses assess the biopsychosocial condition of symptomatic individuals and provide nursing care to those presenting with complex health problems such as cancer (Ordre des infirmières et infirmiers du Québec, 2024). The services provided by nurses must, therefore, be delivered using a comprehensive approach. In radiation oncology, this approach can include screening, initial assessment, triage, management of cancer symptoms and side effects of treatment, and patient and family education (Association canadienne des infirmières en oncologie/Canadian Association of Nurses in Oncology, 2018). Nurses are an integral part of the healthcare team for patients undergoing radiation therapy, and they work with various medical and other professionals to ensure the care provided is the best and safest it can be (Ordre des infirmières et infirmiers du Québec, 2024). Nurses can be found at every point along the patient continuum of care.

The purpose of this paper is to describe the development and implementation of a tool for clinical nurses to assess potential acute toxicity through weekly monitoring while radiation therapy is underway.

Project context

The driving force behind the development of this systematic assessment was one of the authors (IM). In her clinical experience and her role as assistant head clinical nurse in radiation oncology, she quickly realized that the assessments conducted by the various healthcare professionals who treat head and neck cancer patients were not aligned. This discrepancy led to a lack of consistency in the management of the symptoms experienced by ENT cancer patients while they were receiving radiation therapy. Moreover, potential acute toxicity was not being assessed at each appointment. The author therefore decided to create a clinical tool that nurses could use to ensure patients were monitored systematically from one visit to the next, and thereby improve the quality and consistency of care.

Development and implementation of a systematic nurse-led monitoring approach

A clinical tool available to all professionals involved in the radiation therapy process was introduced in 2021 (see Figure 1). This tool is used by clinical nurses to detect signs of potential treatment-related acute toxicity. Systematic monitoring of each patient is done weekly (or more frequently as required) to assess their condition (see Figure 2). Monitoring begins the first week of treatment in order to establish the patient’s baseline and continues until treatment ends. The results of the nursing assessment are recorded in a shared file (clinical tool) so that any professional conducting an assessment can instantly compare their findings to previous reports on the patient’s clinical and physical circumstances.

Figure 1.

Nursing Assessment Chart to Systematically Monitor Patients Undergoing Treatment for ENT Cancer

Figure 2.

Decision-Making Algorithm for Nurses to Monitor ENT Cancer Patients Undergoing Radiation Therapy

This approach monitors the various symptoms that a patient may be experiencing. Using questions concerning potential acute toxicity related to radiation therapy, nurses can apply their clinical judgment to determine whether a patient’s condition has worsened. The tool contains a total of 20 questions, divided into separate sections, to detect the most common signs of acute toxicity for ENT cancer patients. The assessment starts with weighing the patient, using the same scale each time, to determine whether their weight is stable or decreasing from one week to the next. Blood tests may also be ordered by the attending physician to check for nutritional deficiencies. The nurse then enquires about the patient’s eating habits for the past 24 hours, asking about the consistency of the food in their dietary intake and determining whether they need any supplements to meet their nutritional needs. If they have become sensitive to food textures, it is important to take this seriously because it can lead to significant nutritional deficiencies. Then there are questions about other symptoms that the patient may be experiencing: nausea, dry mouth, pain, changes in taste or secretion volume, difficulty swallowing and more. There is also a section on tube feeding to check the positioning of the nasogastric tube and to note any dressing changes. This is followed by a physical examination of the oral cavity and grading according to the Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0, to screen for mucositis. The nurse then proceeds to update the treatment plan based on the problems identified during the checkup. This plan sets out clear instructions for the patient and healthcare professionals based on specific needs. The final section of the tool involves an examination of the skin to detect any signs of radiation-induced dermatitis (CTCAE). Depending on the grade of dermatitis, an observation or a suggested course of treatment may be made to the patient. The tool helps to guide the nurse’s assessment and provide a structure for monitoring the patient on a weekly basis to track any changes in their status. It is important to note that any problems identified by the nurse in the tool should be accompanied by a detailed description of all actions taken as a result.

Interdisciplinary collaboration is vital to the success of this tool. The involvement of various professionals is a major asset in providing comprehensive patient care. For example, a nurse should immediately refer to a physician if a patient is experiencing persistent pain despite the means taken to control it or consult with a nutritionist in the event of sudden or pronounced weight loss.

Using this approach, patients recommended by a radiation oncology nurse, based on a predefined list of patients undergoing ENT treatment (roughly 20 patients per week), go in for a weekly checkup. During an introductory session held for the entire department, the radiation oncology nurses were shown how to use the tool, complete the assessment and monitor patients’ condition.

Every component of the tool is designed to help in educating patients, prevent or reduce various side effects or keep them from getting worse, or ensure the appropriate healthcare professional responds quickly and optimally to manage a given symptom. Accordingly, the overall number of visits between nurses and patients fell significantly, as a result of the thorough monitoring process, which makes patients feel more secure and enhances trust.

DISCUSSION

Ever since this tool started being used, nursing assessments have been more consistent. Now, when different nurses assess the same patient at different points in their treatment, they can easily identify signs of toxicity documented in previous reports and keep an eye on how the situation progresses over the course of the radiation therapy. This makes it easier to manage acute toxicity if it arises and improve cooperation among healthcare professionals. It has been shown that the use of algorithms and automation tools generally facilitates communication between the members of the healthcare team, reduces fatigue, cuts down on medical errors and leads to better patient assessments overall (Johnson et al., 2002).

Implementing systematic nurse-led monitoring undoubtedly contributes to greater nursing autonomy and better nursing assessments. By going through each part of the tool, step by step, nurses can ensure that patients are assessed holistically and discuss with them any of the cancer-related problems they are experiencing. Given the collective prescriptions and prescriptive authority in place with regard to wound care, nurses can independently assess the situation and suggest solutions to patients based on this assessment, such as determining the optimal conditions for taking medication or establishing a treatment plan for radiation dermatitis.

Various initiatives aimed at improving the quality of cancer treatment have showed promise in terms of better compliance with national guidelines and reduced waiting and throughput times (Van Hoeve et al., 2014). In many cases, this has led to a lower number of missed visits, a higher level of patient satisfaction, improved patient safety and lower costs (Sohail et al., 2019; Amaratunga et al., 2016; O’Donnell et al., 2023). Nurses are ideally placed to implement and administer quality improvement efforts of this nature, given the trusting relationships they develop with patients and the working rapport they have with other members of the patient care team (Leslie & Lonneman, 2016). The doctors in the department in this study have approved this initiative, realizing its importance in providing optimal care to their patients. These same doctors have also confirmed that there has been a reduction in the number of patient complaints related to acute toxicity during treatment and credit the improvement to this proactive nursing approach.

CONCLUSION

This initiative to implement systematic nurse-led monitoring using a clinical tool to manage patients undergoing treatment for ENT cancer emphasizes the importance of the role of oncology nurses. They can be instrumental in driving innovation in healthcare delivery and advocating for quality health care for their patients. This helps ensure patients receive optimal care from the first week of treatment onward. As a result, a proactive approach can be taken to manage acute toxicity as needed, thereby facilitating collaboration with the other professionals involved in the care episode. Access to nurses and weekly checkups ensures that the continuum of care is smoother for patients and makes it easier for them to get answers to any concerns they may have.

Nurse-led quality-of-care initiatives hold promise in many healthcare fields and are a way for nurses to advocate on behalf of their patients (Davis et al., 2017). Future avenues to explore include the development of an algorithm to manage acute toxicity from radiation treatment in order to facilitate patient care, along with an analysis of the number of treatment interventions and their duration before and after the implementation of systematic care in order to evaluate the actual impact. An examination of patients’ satisfaction with this approach is also an area worthy of further investigation.