Patient Experiences Before and After the Implementation of Advanced Nursing Practice for Head and Neck Cancer

Abstract

BACKGROUND

Head and neck cancer and its treatments often lead to symptoms that affect patients’ and family members’ quality of life (QOL). To meet their needs, an advanced nursing practice program was implemented in a Swiss hospital.

OBJECTIVES

The impacts of the program on QOL, anxiety, depression, and satisfaction with outpatient care were evaluated in patients undergoing complex oncologic head and neck surgery. Anxiety, depression, and satisfaction with outpatient care were evaluated in family members.

METHODS

Sequential retrospective surveys of patients and family members in control and intervention groups were conducted in a single-center tertiary hospital.

FINDINGS

The control group had 29 patients and 20 family members, and the intervention group had 30 patients and 17 family members. Although QOL did not differ significantly between patient groups, patients in the intervention group indicated less anxiety and greater satisfaction with outpatient care. Anxiety, depression, and satisfaction with outpatient care did not differ significantly in family members.

IN 2020, HEAD AND NECK CANCER (HNC) accounted for 890,000 new cases and 450,000 cancer-related deaths worldwide. Risk factors include regular smoking and alcohol consumption as well as infection with human papillomavirus (Barsouk et al., 2023). Because HNC is often diagnosed at an advanced stage, multimodal treatments with radical surgery (e.g., laryngectomy, partial glossectomy), radiation therapy, and/or chemotherapy are required (National Comprehensive Cancer Network, 2024). The five-year overall survival rates from 2015 to 2021 in the United States were moderate at 62.1% for laryngeal cancer (SEER*Explorer, 2025a) and 69.5% for oral cavity and pharyngeal cancer (SEER*Explorer, 2025b).

Extensive tumor resections often lead to burdensome changes in breathing, chewing, swallowing, speech, and appearance in patients with HNC (Johnson et al., 2020). Disease-related sequelae and their treatment may impair physical and mental health and quality of life (QOL) (Liao et al., 2019; Perry et al., 2015). Therefore, holistic treatment of HNC requires interprofessional care, with numerous appointments requiring coordination (Jacobson, 2018). In addition, high levels of self-management are required (Jansen et al., 2018; van der Meulen et al., 2014), potentially resulting in unmet care needs in patients (Giuliani et al., 2016). Informal caregivers may also be affected by these challenges. Studies found reduced QOL and high levels of depression and anxiety among informal caregivers of patients with HNC (van Hof et al., 2022; van Hof, Hoesseini, Verdonck-de Leeuw, et al., 2023). In addition, informal caregivers frequently experience psychological distress because of the high burden and complex caregiving tasks like taking care of a tracheostomy (van Hof, Hoesseini, Dorr, et al., 2023).

To meet cancer-related challenges, an interprofessional approach is recommended for complex treatment and care (Scott, 2022). In HNC, interprofessional interventions like assessment and information days were associated with improved efficiency in the care pathway (van Huizen et al., 2018), lower costs, less severe complications, and reduced length of stay (Schmid et al., 2022). Another approach to support patients with cancer and their informal caregivers is to implement advanced nursing practice (ANP) programs. Studies have shown that patients and family caregivers value the relationship with an advanced practice nurse (APN) and feel emotionally supported. APNs may also facilitate communication with specialists and coordinate interprofessional care (Bachofner et al., 2021; Kobleder et al., 2017; Serena et al., 2018; van Dusseldorp et al., 2019). Literature on ANP programs in the HNC population is limited, but APN interventions have been reported to improve supportive care (Wells et al., 2008), reduce hospitalizations, and increase administration of the scheduled doses of chemotherapy (Mason et al., 2013).

To meet patients’ and family caregivers’ needs and to provide the interprofessional coordination and structured care recommended in the literature (Scott, 2022), the Department of Otorhinolaryngology at Inselspital, Bern University Hospital, in Bern, Switzerland, developed an ANP program for patients with HNC requiring complex surgery and their family members. The program was planned, implemented, and evaluated from 2019 to 2021 (Baumgartner et al., 2023).

Purpose

The purpose of this study was to compare experiences before and after the implementation of the ANP program regarding (a) general and disease-related QOL, anxiety, depression, and satisfaction with outpatient care in patients with HNC; and (b) anxiety, depression, and satisfaction with outpatient care in family members.

Methods

Design, Setting, Participants, and Data Collection

For this pre- versus postimplementation study, retrospective surveys were conducted in Inselspital, Bern University Hospital, a single-center tertiary referral hospital. The study was conducted following the ethical guidelines of the 1964 Declaration of Helsinki. Based on Swiss law, a waiver to conduct the study was provided from the Cantonal Ethics Committee of Bern, Switzerland (BASEC-Nr: Req-2020-00796).

Patients who had oncologic or sequelae-related surgery from June 2019 to May 2020 (control group [CG]) and from June 2020 to May 2021 (intervention group [IG]) were recruited, if possible, together with family members. All surviving patients with HNC aged 18 years or older were included who were either undergoing complex HNC surgery with or without flap reconstruction or salvage surgery, or patients who had tracheostomy and were receiving palliative care, or patients who had complications needing extended care. In September 2020 and September 2021, questionnaires about QOL, anxiety, depression, and satisfaction with outpatient care were sent to eligible patients. Patients were asked to forward the designated questionnaire to their closest family member if possible. A family member was whomever the patient considered as such and could have been a friend. A standardized letter explained the study purpose, voluntary participation, and confidential data management and stated that returning the questionnaire was considered as informed consent. After one month, a reminder was sent to nonresponders. Demographic and clinical patient data were collected from medical records.

ANP Program

Prior to the implementation of the ANP program, an APN participated in the structured outpatient Multiprofessional Assessment and Information Day, on which a patient’s situation was comprehensively, systematically explored before surgery, as previously published (Schmid et al., 2022). During hospitalization for surgery, the unit’s nursing team cared for the patient and planned the discharge. Additional clinicians were involved as needed. The nurses in the outpatient clinic organized materials for the care at home and met patients prior to discharge. After discharge, patients met the nurses in the outpatient clinic mainly for wound and tracheostomy care. A stakeholder analysis then showed several challenges (Baumgartner et al., 2023). Some patients and family members were overwhelmed by the complexity of the treatment. They met multiple professionals without having a main contact person. The collaboration between inpatient and outpatient clinics was rather unstructured, and coordination was lacking regarding discharge planning and collaboration with other institutions. To meet these challenges, an APN was appointed and mandated to develop and implement an ANP program. APN roles are still quite new in Switzerland and not legally regulated.

The aims of the ANP program were to provide evidence-based (i.e., adapted to the local context and based on scientific evidence, clinical experience, and patient preferences [Rycroft-Malone et al., 2004]), continuous (i.e., with a person constantly available for contact), and person-centered (i.e., with a focus on patients and family members as individuals [McCormack et al., 2013]) care over the treatment continuum; to sustainably secure the needed expertise in the inpatient and outpatient nursing teams; and to facilitate collaboration and care coordination in the hospital, for home care, or at other institutions (e.g., nursing homes, homecare organizations). The APN first met patients and family members at the Multidisciplinary Tumor Board at the practice site, where the most adequate treatment was determined. Next, the APN participated in the structured outpatient Multiprofessional Assessment and Information Day. Subsequently, the APN attended to patients and family members during the hospital stay for surgery, during weekly outpatient visits after discharge, throughout survivorship, or into palliative care (see Table 1). Patients and family members could contact the APN on weekdays during office hours by telephone or email. The APN closely collaborated with all involved professionals (e.g., physicians, nurses, psycho-oncologists, social workers, dietitians, speech therapists) for inpatient and outpatient care. The APN used the competencies described by Tracy et al. (2023) to intensify patient and family member care in the areas of direct clinical practice, counseling, and coaching. In addition, the APN applied leadership capacities to improve interprofessional collaboration and care coordination. Finally, the APN adapted guidelines as needed for evidence-based practice.

TABLE 1.

APN ACTIVITIES ACROSS THE CARE CONTINUUM FOR PATIENTS WITH HEAD AND NECK CANCER

TREATMENT PHASE	APN ACTIVITIES
Multidisciplinary Tumor Board	■ Is the first contact with patients and family members, introduces advanced nursing practice program ■ Is present at the Multidisciplinary Tumor Board, which suggests the best possible treatment approach (surgery, radiation therapy, and/or chemotherapy) ■ Provides wound care if needed ■ Makes appointments with home health care if needed ■ Participates in morbidity and mortality conferences
Multiprofessional Assessment and Information Day	■ Welcomes patients and family members and explains schedule ■ Takes comprehensive history, including an evaluation of family relationships and resources ■ Performs assessments, including distress, alcohol screening, nutrition, and screening for frailty in older adult patients ■ Explains postoperative procedures and care during hospital stay (e.g., flap monitoring, tools for nonverbal communication) ■ Educates about management of tracheostomy and feeding tube ■ Participates in the interprofessional team’s discussion of collected information, interventions to address risk factors, readiness for surgery, and consensus on most appropriate treatment
Hospital stay for surgery	■ Provides wound care ■ Manages tracheostomy and feeding tube ■ Prepares and coordinates discharge, and educates patients and family members about suctioning and management of the tracheostomy and feeding tube ■ Counsels nurses and patients with tracheostomy in other hospital departments ■ Educates, supervises, and teaches RNs at the bedside in the Department of Otorhinolaryngology, Head and Neck Surgery
Outpatient care and survivorship	■ Holds regular consultation hours for patients and family members after discharge ■ Assesses patient nutrition, distress (as well as in family members), and other health concerns ■ Provides wound care ■ Counsels regarding tracheostomy, laryngectomy, and other procedures ■ Changes tracheal cannulas and vocal prostheses ■ Counsels nurses from homecare services in wound care and management of tracheostomy
Palliative care	■ Initiates and leads roundtable discussions ■ Counsels the hospital’s palliative care team regarding head and neck cancer specifics (e.g., tracheostomy) ■ Follows up with family members after patient’s death

APN—advanced practice nurse

Variables and Measurement

General and disease-related QOL in the week before completing the questionnaire was measured with the German versions of the European Organisation for Research and Treatment of Cancer (EORTC) QOL Questionnaire–Core 30 (QLQ-C30), version 3.0 (Aaronson et al., 1993), and the EORTC QOL Questionnaire–Head and Neck Module (QLQ-H&N43) (Fayers & Bottomley, 2002; Singer et al., 2019). Both EORTC questionnaires use four-point Likert-type scales ranging from 1 (not at all) to 4 (very much), and scores are transformed to a 0–100 scale according to the official scoring manual. A higher score for global health status or QOL means higher general QOL, higher scores on the functional scales mean higher levels of functioning, and higher scores on the symptom scales or items mean higher levels of symptoms or problems. Both questionnaires show good psychometric properties (Fayers & Bottomley, 2002; Singer et al., 2019).

In addition, the German version of the Hospital Anxiety and Depression Scale (HADS) was used (Bjelland et al., 2002; Herrmann et al., 1995). This screening instrument separately assesses anxiety and depression in the past week using a seven-item, four-point Likert-type scale ranging from 0 to 3. Higher scores mean more symptoms, and a total score of 11 or greater in either anxiety or depression is considered clinically significant, indicating the need for additional evaluation of affected individuals (Herrmann et al., 1995). Validity and reliability of the HADS are well established (Bjelland et al., 2002).

Finally, to assess care experiences in the outpatient clinic, the EORTC Satisfaction with Out-Patient Cancer Care (OUT-PATSAT7) questionnaire was used (Brédart et al., 2018). The instrument has two subscales, convenience and transition, with three items each, and a single item on continuity. Convenience refers to the process of making appointments, waiting time for appointments, and communication with the clinicians from the home. Transition refers to discharge information regarding care at home, intended checkups at the outpatient clinic, and contact to the hospital postdischarge. Continuity refers to meeting the same clinicians at the outpatient clinic over time. Questionnaire items are scored using a five-point Likert-type scale ranging from 1 (poor) to 5 (excellent), and scores are transformed to a 0–100 scale according to the official scoring manual. Higher scores mean higher level of satisfaction with care. Content validity was supported, and Cronbach’s alpha values for the convenience and transition subscales were 0.85 and 0.9, respectively, in an initial exploratory study (Brédart et al., 2018).

Data Analysis

Appropriate descriptive statistical analyses were used for categorical variables (frequencies) and continuous variables (means, SDs, medians). The analytical steps as defined in the scoring manuals for the EORTC QLQ-C30, QLQ-H&N43, and OUT-PATSAT7 (Singer et al., 2019) were implemented to assess the EORTC questionnaires. To assess the HADS, item scores were added to get the total scores for anxiety and depression. Because there is no formal standard for how to handle missing data in the HADS, the methodology proposed by Bell et al. (2016) was implemented, applying the half-rule as follows: If at least 50% of the items in a subscale (anxiety or depression) were completed, the mean of the completed items was imputed for the missing ones. Otherwise, the subscale score was considered missing. The Wilcoxon rank-sum test was used to analyze differences between scores of the CG and the IG. Two-tailed alpha was set at 5%. Because of the small sample size, sample characteristics were not compared statistically. JMP, version 17.0, was used for the statistical analyses.

Results

Questionnaires were sent to 47 patients who met the inclusion criteria before the implementation of the ANP program and to 52 patients who met inclusion criteria after implementation; these comprised the population of potential patient participants and those who may have sent questionnaires to family members. Regarding patient participants, 29 participated in the CG, and 30 participated in the IG. Patient characteristics are presented in Table 2. Patients in both groups were similar regarding sex, age, living situation, education level, employment status, diagnosis, and reason for inclusion in the program. The occupation rate of patients in the IG was 28.6% higher. Regarding family members, 20 participated in the CG and 17 participated in the IG. Characteristics of family members are presented in Table 3. Family members in both groups were similar regarding sex, age, and relationship to patients. Education level was slightly higher and the occupation rate was 14.8% lower in family members in the CG.

TABLE 2.

PATIENT CHARACTERISTICS

CHARACTERISTIC	CONTROL (N = 29)		INTERVENTION (N = 30)
	X̄	SD	X̄	SD
Age (years)	64.7	11.1	64.9	9.9
Occupation ratea (%)	57.1	32.9	85.7	19.9
CHARACTERISTIC		n		n
Sex
Male		18		19
Female		11		11
Diagnosis
Squamous cell carcinoma of oral cavity or mandibula		20		14
Squamous cell carcinoma of larynx		6		7
Other squamous cell carcinoma		2		4
Other cancer sequelae		1		3
Other laryngeal cancer		–		1
Other nose cancer		–		1
Reason for inclusion in program
Tumor resection: oral cavityb		17		15
Laryngectomyb		5		4
Tracheostomy management		3		2
Wound management		2		1
Counseling or patient education		1		2
Tumor resection: other sitesb		1		4
Surgery related to sequelaeb		–		2
Living situation
Living with others		18		21
Living alone		9		9
Missing data		2		–
Education level
Mandatory school		2		3
Apprenticeship		16		14
High school		–		3
Professional school		7		2
University or university of applied sciences		3		5
Missing data		1		3
Employment status
Retired		14		15
Employed		4		6
Unemployed		4		3
Self-employed		3		–
Homemaker		1		2
Other		2		2
Missing data		1		2

^aConsists of only patients who were employed or self-employed

^bWith or without flap reconstruction

Note. Mandatory school consists of 9 years of compulsory education, apprenticeship consists of dual education and vocational/practical training, and professional school indicates a post–high school education leading to professional qualification.

TABLE 3.

FAMILY MEMBER CHARACTERISTICS

CHARACTERISTIC	CONTROL (N = 20)		INTERVENTION (N = 17)
	X̄	SD	X̄	SD
Age (years)a	59.7	17.2	61.7	11.8
Occupation rateb (%)	68.1	29.3	82.9	20.6
CHARACTERISTIC		n		n
Sex
Female		13		11
Male		7		6
Relationship to patient
Marriage partner		11		11
Partner		4		3
Friend		1		–
Parent		1		1
Other		2		2
Missing data		1		–
Education level
Mandatory school		2		3
Apprenticeship		9		11
High school		–		–
Professional school		6		3
University or university of applied sciences		3		–
Employment status
Retired		9		8
Employed		5		6
Self-employed		3		–
Unemployed		1		–
Homemaker		–		3
Other		2		–

^a2 control group and 1 intervention group family members’ age data were missing.

^bConsists of only patients who were employed or self-employed

Note. Mandatory school consists of 9 years of compulsory education, apprenticeship consists of dual education and vocational/practical training, and professional school indicates a post–high school education leading to professional qualification.

General and disease-related QOL, as measured with the EORTC QLQ-C30 and QLQ-H&N43, did not differ significantly between patients in the CG and the IG (see Table 4). However, the scale for global health or QOL, as well as most scales/items for functioning and symptoms or problems, showed better scores in the IG. Only the scores for the role functioning scale and problems with shoulder item were better in the CG.

TABLE 4.

PATIENT SCORES FOR QOL, ANXIETY, DEPRESSION, AND SATISFACTION WITH OUTPATIENT CARE

QUESTIONNAIRE SCALE/ITEM	CONTROL (N = 29)				INTERVENTION (N = 30)				pb
	na	X̄	SD	M	na	X̄	SD	M
EORTC QOL Questionnaire–Core 30
Global health status/QOL	29	57.2	19.4	58.3	30	61.1	21.3	66.7	0.121
Physical functioning	29	75.6	20.4	80	30	83.3	17.7	90	0.138
Role functioning	28	67.3	38.9	83.3	30	63.9	28.4	66.7	0.349
Emotional functioning	29	64.4	26.3	66.7	30	70.8	23.9	75	0.363
Cognitive functioning	29	79.3	28.1	83.3	30	83.4	28.5	100	0.295
Social functioning	29	52.9	36.5	50	30	62.8	28.6	66.7	0.317
Fatigue	29	41	31	44.4	30	30	24.1	33.3	0.168
Nausea and vomiting	29	5.2	14.8	–	30	3.9	8.4	–	0.659
Pain	29	32.8	30.7	33.3	30	27.8	31.6	16.7	0.5
Dyspnea	29	25.3	32	–	30	23.3	27.9	16.7	0.993
Insomnia	29	26.4	31.3	33.3	30	25.6	33.5	–	0.798
Appetite loss	28	29.8	33.1	33.3	29	18.4	24.3	–	0.214
Constipation	29	24.1	32	–	30	13.3	20.7	–	0.232
Diarrhea	29	26.4	36.1	–	30	12.2	18.5	–	0.19
Financial difficulties	29	23	34.6	–	30	15.6	27.3	–	0.448
EORTC QOL Questionnaire–Head and Neck Module
Mouth pain	29	29.7	29.9	25	30	20.7	18.2	16.7	0.488
Swallowing	29	38.4	33.6	33.3	29	32.1	29.1	25	0.65
Problems with teeth	26	49.4	37.3	44.4	29	33.3	29	33.3	0.109
Dry mouth and sticky saliva	29	37.9	35.3	33.3	30	36.7	28.5	33.3	1
Sensory problems	29	37.9	35.3	33.3	30	22.2	32	33.3	0.062
Speech	29	47.5	29.5	46.7	28	38.1	24.3	43.3	0.212
Body image	29	37.2	27.9	33.3	29	33	29.5	33.3	0.513
Social eating	28	47.3	38.9	45.8	27	39.2	28.3	33.3	0.577
Sexuality	24	54.9	34.6	58.3	27	42.6	35	33.3	0.202
Problems with shoulder	29	28.7	35.3	16.7	30	32.8	33.5	33.3	0.607
Skin problems	29	19.9	25.6	11.1	30	16.7	17.9	11.1	0.988
Fear of progression	28	53	33	50	30	48.3	31.4	41.7	0.625
Problems opening mouth	29	37.9	36.4	33.3	30	37.8	38.9	33.3	0.943
Coughing	29	20.7	25.8	–	30	20	29.8	–	0.739
Social contact	28	34.5	40	16.7	30	23.3	30.5	–	0.388
Neck swelling	29	35.6	36.7	33.3	29	32.1	32.1	33.3	0.8
Weight loss	28	29.8	37.8	–	30	21.1	28.3	–	0.513
Problems with wound healing	28	31	32.6	33.3	28	28.6	33.6	33.3	0.733
Neurologic problems	28	27.4	37.5	–	28	14.3	21.1	–	0.307
HADS
Anxiety	27	5.8	3.9	6	26	3.7	3.6	2.5	0.04*
Depression	27	6.4	4.6	6	28	4.3	2.5	4	0.091
EORTC Satisfaction with Out-Patient Cancer Care
Convenience	29	59.6	22.4	50	29	71.6	19.2	75	0.03*
Transition	29	60.9	22.3	58.3	29	77.3	19.4	75	0.007*
Continuity	29	62.9	24.7	50	29	69.8	25.3	75	0.225

^*p < 0.05

^aNot all participants answered every question.

^bWilcoxon rank-sum test

EORTC—European Organisation for Research and Treatment of Cancer; HADS—Hospital Anxiety and Depression Scale; M—median; QOL—quality of life

Note. The EORTC QOL Questionnaire–Core 30 and EORTC QOL Questionnaire–Head and Neck Module use 4-point Likert-type scales ranging from 1 (not at all) to 4 (very much), and scores are transformed to a 0–100 scale according to the official scoring manual. A higher score for global health status or QOL means higher general QOL, higher scores on the functional scales mean higher levels of functioning, and higher scores on the symptom scales or items mean higher levels of symptoms or problems. The HADS separately assesses anxiety and depression in the past week using a 7-item, 4-point Likert-type scale ranging from 0 to 3. Higher scores mean more symptoms, and a total score of 11 or greater in either anxiety or depression is considered clinically significant. The EORTC Satisfaction with Out-Patient Cancer Care uses a 5-point Likert-type scale ranging from 1 (poor) to 5 (excellent), and scores are transformed to a 0–100 scale according to the official scoring manual. Higher scores mean higher level of satisfaction with care on the subscales of convenience, transition, and continuity.

Regarding the HADS, the following two results are reported for anxiety and depression: (a) mean scores and (b) the numbers of participants with clinically significant scores (i.e., scores of 11 or greater [Hermann et al., 1995]). Mean anxiety scores differed significantly (p = 0.04) between the CG (X̄ = 5.8, SD = 3.9) and the IG (X̄ = 3.7, SD = 3.6). Mean depression scores did not differ significantly between the groups. Four patients in the CG and one patient in the IG showed clinically significant scores for anxiety, and six patients in the CG and one patient in the IG showed clinically significant scores for depression.

Results of the EORTC OUT-PATSAT7 showed that patients in the IG were more satisfied with outpatient cancer care than patients in the CG group regarding convenience (X̄ = 71.6, SD = 19.2 versus X̄ = 59.6, SD = 22.4; p = 0.03) and transition (X̄ = 77.3, SD = 19.4 versus X̄ = 60.9, SD = 22.3; p = 0.007). For continuity, no significant difference was found between the groups.

For family members, results for anxiety and depression did not differ significantly between groups, although scores were lower in the IG. Two family members in the CG and one family member in the IG had clinically significant anxiety scores. One family member in the CG had a clinically significant depression score. Experiences with outpatient cancer care did not differ significantly for family members, but scores in the IG trended higher (see Table 5).

TABLE 5.

FAMILY MEMBER SCORES FOR ANXIETY, DEPRESSION, AND SATISFACTION WITH OUTPATIENT CARE

QUESTIONNAIRE SCALE/ITEM	CONTROL (N = 20)				INTERVENTION (N = 17)				pb
	na	X̄	SD	MEDIAN	na	X̄	SD	MEDIAN
HADS
Anxiety	19	6	3.8	6	16	4.4	3.3	4	0.143
Depression	18	4.1	4.3	3	16	3.1	2.6	3	0.636
EORTC Satisfaction with Out-Patient Cancer Care
Convenience	19	65.8	22.7	58.3	17	71.1	20.9	75	0.44
Transition	19	62.7	23.5	58.3	17	75	19.5	75	0.104
Continuity	19	59.2	25.3	50	17	69.1	25.8	75	0.186

^aNot all participants answered every question.

^bWilcoxon rank-sum test

EORTC—European Organisation for Research and Treatment of Cancer; HADS—Hospital Anxiety and Depression Scale

Note. The HADS separately assesses anxiety and depression in the past week using a 7-item, 4-point Likert-type scale ranging from 0 to 3. Higher scores mean more symptoms, and a total score of 11 or greater in either anxiety or depression is considered clinically significant. The EORTC Satisfaction with Out-Patient Cancer Care uses a 5-point Likert-type scale ranging from 1 (poor) to 5 (excellent), and scores are transformed to a 0–100 scale according to the official scoring manual. Higher scores mean higher level of satisfaction with care on the subscales of convenience, transition, and continuity.

Discussion

This study was the first evaluation of an ANP program directed at patients with HNC undergoing oncologic or sequelae-related surgery. Patients who were supported by an APN were significantly more satisfied with outpatient care regarding convenience of appointments and communication, as well as the transition from hospital to home, than patients in the CG. Mean anxiety and depression scores were below clinical relevance for both patient groups, but mean anxiety was significantly lower in the IG. Although patients and family members in the IG scored better for most other items, these differences were not statistically significant.

When compared to general population data for the EORTC QLQ-C30 (Nolte et al., 2019) and EORTC QLQ-H&N43 (Ham-merlid et al., 2017), the current study’s findings show some negative impact of HNC on the general QOL and a considerable adverse effect on the disease-related QOL of patients. These findings are in line with previous publications (Johnson et al., 2020; Liao et al., 2019). A comparison of the current study’s results with those of other HNC studies using the EORTC QLQ-C30 and the EORTC QLQ-H&N43 or EORTC QLQ-H&N35 (previous version) is difficult because of different questionnaire versions, measurement time points, healthcare systems, and sociocultural backgrounds. Findings thus vary widely among studies (Davudov et al., 2020; Liao et al., 2019; van der Meulen et al., 2014). However, scores for HNC-specific symptoms or problems are higher than scores for general symptoms in the current study and in other studies (Davudov et al., 2020; Liao et al., 2019; van der Meulen et al., 2014), indicating disease-specific patient burden. In addition, mean and median scores in the current study and in other studies (Davudov et al., 2020; Liao et al., 2019) have large SDs and ranges, pointing to great variation in symptoms or problems among study participants. These findings highlight the need for clinicians who recognize HNC-related problems, apply an individual and continuous assessment of symptoms and problems with a focus on HNC-specific issues, and support patients to sustain the best possible QOL. The continuous APN–patient relationship and core competencies in direct clinical practice, coaching, and counseling (Tracy et al., 2023) qualified the APN to address patients’ problems.

Although differences in QOL were not statistically significant, the ANP program may be part of the explanation for the better scores in the IG. The APN provided individualized symptom management education before and after surgery. With outpatients, they regularly addressed symptoms like mouth pain, insomnia, swelling, weight loss, and body image perceptions, according to a literature-based checklist. If a problem was outside the APN’s scope of practice (e.g., dysphagia), they could refer the patient to a specialized member of the interprofessional team.

Sexuality and fear of progression scored highest in the CG and IG of this study. In addition, sexuality had the most missing data. Problems with sexuality may be explained by treatment- related effects that often cause distressing changes to appearance and can lead to social isolation (Liao et al., 2019). The ANP program could be improved with respective training for the APN (White et al., 2020) and regular counseling on sexual health for patients (Carter et al., 2018). Although fear of cancer recurrence is common in patients (Riggauer et al., 2023; Simard et al., 2013), this topic was not addressed by the APN. Because psychological interventions have shown small but robust effects in reducing fear of recurrence (Tauber et al., 2019), such approaches could be a valuable addition to the ANP program. The fact that two-thirds of the patients encountered no financial difficulties is likely because of the compulsory healthcare insurance in Switzerland. The IG may have had an extra benefit from quick referrals by the APN to the social worker.

Although mean anxiety and depression scores on the HADS were low in this study’s sample, anxiety was statistically significantly lower in the IG. The low anxiety scores could contribute to a better QOL. Comparing these results is difficult because limited research on patients with HNC reporting HADS scores was found. In a large prevalence study using the HADS, 14.8% of 418 outpatients with HNC had anxiety scores of 11 or greater (Zeilinger et al., 2022). This percentage is close to that of the CG of the current study (4 of 27, 15%) and higher than the percentage in the IG (1 of 26, 4%). The regular assessment of patients’ psychological well-being and prompt referral of distressed patients to the psycho-oncologist by the APN may have influenced this result. Regarding depression, 18.7% of the patients in the study by Zeilinger et al. (2022) had scores of 11 or greater. The percentage of the CG in the current study was slightly higher (6 of 27, 22%), and the percentage in the IG was lower (1 of 28, 4%).

This was the first study using the EORTC OUT-PATSAT7 in a population with HNC. Overall, with scores ranging from 59.6 to 77.3, patients seemed somewhat satisfied with their outpatient care, but there is potential for improvement. Although the APN likely had less influence on continuity because this item addressed continuity across all healthcare professionals from different disciplines (e.g., oncology, radiation therapy) who patients met in the outpatient clinic, the IG’s significantly higher scores regarding convenience of appointments and communication, as well as transition from hospital to home, seem explainable by the ANP program. The APN’s person-centered care, continuous relationship with patients, and focus on discharge preparation and care coordination among the interprofessional team in the hospital and providers outside the hospital, as well as telephone follow-ups in the week postdischarge, regular patient visits to the outpatient clinic in the first weeks after surgery, and the patients’ option to contact the APN directly during office hours, presumably facilitated communication and contributed to a smooth transition. The APN’s approach is in line with guidelines (Liao et al., 2019) and expert recommendations (Perry et al., 2015), and other studies confirm that a reliable, empathic relationship with healthcare professionals improves satisfaction in patients with cancer (Prip et al., 2018; van Dusseldorp et al., 2019).

Family members’ mean HADS scores were below the clinical significance threshold, and although scores in the IG were lower, the difference was not statistically significant. In two studies that reported HADS scores of family members six months post- treatment, mean scores were slightly lower than those in the current study (Lee et al., 2017; van Hof, Hoesseini, Verdonck-de Leeuw, et al., 2023). In a systematic review of 13 studies using the HADS, Benyo et al. (2023) found that 9%–57% of the family members had clinically significant anxiety or depression, but most percentages in the current study were below 9%. Only the family members in the current study’s CG were within the range indicated by the systematic review (Benyo et al., 2023), with 2 of 19 (11%) anxiety scores in family members being 11 or greater. Regarding satisfaction with outpatient care, family members’ scores on the EORTC OUT-PATSAT7 were similar to patients’ scores. However, although scores in the IG were higher, the difference was not statistically significant. This could be attributable to the small sample size of family members.

So far, the APN has invited only family members to join meetings with the patient. The lack of significantly improved findings for family members in the IG indicates that the ANP program could be supplemented. Because the prevalence of symptoms like depression and anxiety in family members may change over time (van Hof et al., 2022), and because they often experience reduced QOL and high burden of care (van Hof, Hoesseini, Dorr, et al., 2023), a more structured approach with distress assessments, regular counseling sessions, and adequate referrals to a psycho-oncologist or social worker would likely benefit family members.

Limitations

This study has several limitations. First, patients were recruited within a time frame from three months to one year after surgery. However, experiences may vary, and recollection may wane over time. Although the sampling strategy was consistent for both groups and the comparison of CG and IG was feasible, comparability of the results with those of other studies may be difficult. Second, the risk of a selection bias cannot be neglected. Patients who were deceased, severely cognitively impaired, or refused study participation were not included. Third, the design with two separate time frames has the risk of uncontrolled intervening variables. Fourth, only patients who underwent surgery were included, thereby missing patients treated with primary radiation therapy with or without concomitant chemotherapy. These patients were admitted to a different department of the hospital. For structural reasons, the ANP program could not be introduced in two different departments. Fifth, there may be a risk of response biases, and sixth, the high number of outcomes may put the study at risk for false-positive findings. Finally, the possibility of a type II error cannot be excluded because of the small cohorts and the lack of a power analysis. However, because of the short time frame and limited resources, the pragmatic approach allowed a modest evaluation of the ANP program.

Implications for Nursing

The findings of this study show that clinical oncology nurses can support patients with HNC and their families by individually and continuously assessing symptoms and problems, by focusing on HNC-specific issues, and by supporting the sustainment of the best possible QOL. In addition, an ANP program may improve anxiety and satisfaction with outpatient care in patients. Finally, the ANP program could be complemented by addressing fear of cancer recurrence and problems with sexuality, as well as by providing a more structured approach to family member counseling.

Conclusion

The ANP program resulted in reduced anxiety in patients and higher patient satisfaction with outpatient care. Although no significant difference in overall QOL in patients was demonstrated in this limited-size cohort, patients scored better for QOL-related items addressed directly by the APN. The study hints at the ANP program’s potential to address fear of cancer recurrence and problems with sexuality, as well as to provide family-specific counseling. These results warrant additional validation in larger cohorts.

IMPLICATIONS FOR PRACTICE.

• ■ Assess symptoms and problems individually and continuously in patients with head and neck cancer and their families with a cancer type–specific focus to support sustainment of the best possible quality of life.

• ■ Improve anxiety and satisfaction with outpatient care in patients using an advanced nursing practice program.

• ■ Complement advanced nursing practice programs by addressing fear of cancer recurrence and problems with sexuality, and take a more structured approach to family member counseling.

PROFESSIONAL DEVELOPMENT ACTIVITY.

EARN 1 CONTACT HOUR

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Consider how you can apply findings from this article to your own practice using the following questions:

• ■ How could the implementation of an advanced nursing practice program improve the quality of life and satisfaction with outpatient care for patients and their families in your setting?

• ■ What challenges have you or your coworkers experienced in managing the care of patients with head and neck cancer, and how might an advanced nursing practice program help to overcome these challenges?