Reflection on previous experiences

As you start your preparation for this placement it is important to consider how you are feeling. This can be governed by two key perspectives; the public image of cancer and palliative care and your personal life experiences.

Some of you may have experienced a family member or a friend being diagnosed and treated for cancer. This might mean that this placement is a particularly challenging one for you. Preparation is therefore essential in order to make sense of your feelings and experiences.

Reflecting on our personal and professional experiences can be a good way of understanding what we have encountered. Using a ‘model’ to guide reflection provides structure and helps to devise an action plan in order to develop practice in the future. Although there are many reflective models available, we have used Driscoll’s (2007) reflective model as it is a simple, three-part model that can be adapted to a wide range of situations:

Writing a reflective account is also an excellent way of demonstrating the NMC competencies. We return to Driscoll’s model in Section 3 (see Appendix One) so it is good to start using it early on in your preparations. If you have used and feel confident using another reflective model previously, continue to use it instead.

What your perception of cancer may be

Cancer is a word we are all familiar with and it probably affects most of us in some way, directly or indirectly, but we rarely stop to consider what cancer is. What can we do to reduce the risk of developing cancer? What does a diagnosis of cancer actually mean? This first section helps you prepare for a cancer/palliative care placement by helping you to consider what your pre-existing attitudes and beliefs might be regarding the disease and outcomes. It also refreshes your knowledge and explores possible situations you may encounter, as well as identifying opportunities that might be available.

For many people, cancer is a bewildering disease and often a taboo subject. Some people cannot use the word ‘cancer’ as it evokes such a range of emotions and thoughts. There are many misunderstandings and assumptions of what cancer is and what causes it. You may have had contact with someone diagnosed with cancer, heard stories about treatment and watched media coverage. As a student, you may have an idea of what you will see and experience while on placement. However, it is important to remember that there are around 200 different types of cancer, each behaving differently (some spreading, some not, some causing death, some not). Each cancer is treated differently and each individual’s reaction to the diagnosis of cancer varies enormously, as does their experience.

Your placement will involve caring for patients who are living or dying with cancer. It is important to remember that patients with cancer do not always die and dying patients do not always have cancer. Much of what you will learn on this cancer/palliative care placement will be transferable to other care settings, as the majority of individuals with cancer are cared for in non-specialist healthcare environments (Gill & Duffy 2010).

Cancer is a chronic, complex and long-term disease that affects every aspect of an individual’s life. Caring for a person and their family starts before diagnosis is given, often in the setting of general practice surgeries and outpatient clinics. Once diagnosis is confirmed, the patient will be under the care of a specialist and may undergo a variety of treatment options which may include surgery, hormone therapy, biological therapy, radiotherapy and chemotherapy.

Even when treatment has been successful and individuals are disease free, patients may be monitored for years, many having to contend with numerous effects of cancer and the consequences of treatment. Alternatively, some may require end of life care. These patient pathways can span over many years or last for just a few days, can take many different routes, pose a range of challenges and bring great rewards.

High-quality and focused nursing care is central to supporting a patient and their family through such an experience and can be incredibly fulfilling. This placement should be a positive experience, and will equip you with essential skills that can be transferred to your next learning placement, into your theoretical work and a variety of assessments. It will result in a better understanding of what cancer is and how it affects patients and families.

The public image of cancer and palliative care

Within the United Kingdom (UK), cancer has a negative connotation often associated with pain, distress, suffering and death. However, the reality is very different and the majority of patients diagnosed with cancer in the UK will lead long and active lives. Some will live with cancer as a chronic disease, others will become disease free and a number will die prematurely from cancer.

Research has advanced our understanding of cancer on the cellular level and of how each type of cancer develops and behaves clinically. Subsequently, there have been developments in diagnostic techniques leading to earlier detection and more accurate staging. There is a wider range of evidence-based treatments available, carefully regulated by the National Institute for Health and Clinical Excellence (NICE).

In an attempt to reduce incidence and mortality rates, cancer has become a prominent focus of health policy. Since the Calman–Hine report (Department of Health (DH) 1995) identified a lack of consistency and the need for specialised cancer services across the country, The NHS Cancer Plan (DH 2000) and The Cancer Reform Strategy (DH 2007, 2008a) have set out specific targets and objectives to improve the prevention, diagnosis, treatment, care and research of cancer. A major focus has been to reduce the delay in diagnosis by improving waiting times, speeding up the time from diagnosis to treatment, improving access to treatment and reducing the number of UK deaths from cancer. The way that cancer healthcare professionals work has changed too. Now working in ‘cancer site-specific’ multiprofessional teams, decisions regarding treatment and ongoing care are made based on the expert knowledge, experience and collaboration between practitioners, and in partnership with patients. These developments have had a positive effect on survival of patients and their long-term quality of life.

Although survival rates are improving, the incidence of cancer is still rising and there remains a great deal of work to do to improve public health. Having identified some key factors that influence the development of cancer, all healthcare professionals need to consider their role in the prevention of cancer rather than the current National Health service (NHS) focus on managing disease. Two-thirds of cancers could be prevented by simple changes to lifestyle. However, in reality, changing behaviour is not so simple! There are many reasons why people put themselves at risk of developing cancer: lack of knowledge, lack of skill, lack of money and lack of access to healthy living (water, food, shelter, etc.), for example. Consider the undeniable research-based evidence identifying tobacco as a cause of cancer – so why do people still smoke? We need to consider what beliefs and attitudes about the causes and outcomes of cancer people may have. Some believe that ‘it won’t happen to me’ or ‘I am going to get it no matter how I behave’. Some do not believe the evidence and may consider that the research is ‘propaganda’ or feel that ‘it’s a free country so I can behave however I like’. Many of our beliefs and attitudes are based on those of our parents and family. These become reinforced or challenged by life experiences and by the people around us (friends, colleagues, etc.). The media also play a role by sensationalising research and printing conflicting reports. One day they may report ‘Using sun cream reduces the risk of skin cancer’; the following day they may state ‘If you use sun cream you’ll get rickets’! People are left wondering what the most likely scenario is and have to appraise the evidence, for instance, does it question their behaviour? Which research ‘best fits’ with their existing beliefs and attitudes? Usually the information least likely to threaten the individual’s status quo is the one most likely to be believed and followed.

Many healthcare professionals working in the health service do not see their role encompassing public health and prevention of cancer. However, it is every healthcare worker’s responsibility to provide information and guidance and to signpost individuals to appropriate agencies to enable them to make changes to their lifestyle. Not only will this decrease the incidence of cancer, but it should have a positive effect on cardiovascular disease, diabetes and many other life-limiting conditions.

What the real cancer situation is

In the UK, more than one in three people will develop some form of cancer during their lifetime. There are around 298   000 new cases of cancer (excluding non-melanoma skin cancer) diagnosed each year (Cancer Research UK 2010). Over the past 30 years, the incidence of cancer has increased in the UK by 14% in men and 32% in women although, in the last decade, incidence rates have remained fairly constant.

Although there are around 200 different types of cancer, four of them – breast, lung, colorectal and prostate – account for over half (54%) of all new cases. Breast cancer is the most common cancer in the UK with 45   700 new cases in 2007. The incidence of cancer increases with age, with 75% of cases diagnosed in people aged 60 and over, and more than a third of cases in people aged 75 and over. This presents specific challenges as comorbidity may influence the tolerance and acceptability of treatment and the overall outcome. Cancer in children is very rare, accounting for less than 1% of all cases.

One in four (27%) of all deaths in the UK are due to cancer, more than 156   000 in 2008. Again, lung, bowel, breast and prostate cancer together account for almost a half (47%) of all cancer deaths. More than one in five (22%) of all cancer deaths are from lung cancer, largely due to smoking. Colorectal cancer is the second most common cause (10%) and breast cancer the third most common cause of cancer death (8%). The good news is that mortality has fallen by 20% in the past 30 years and continues to fall. This is primarily due to earlier detection through screening programmes; better body awareness; improved diagnostic techniques; organisational improvements, such as waiting times; and innovative developments in treatments.

Although the number of people surviving the diagnosis of cancer is improving year on year in the Western world, still a significant number will live with the life-limiting disease, affecting their quality of life and life expectancy. Therefore, it is imperative that the healthcare service provides support and care for this group of patients.

The End of Life Care Strategy (DH 2008b) suggests that, as a nation, we do not talk openly about dying and death, including the needs of people and their family members as they approach the end of life. In addition, relatively few adults talk about their death, tell family members what their choices would be or make funeral plans. The strategy also suggests the healthcare professionals find it difficult to initiate these discussions or help patients plan ahead. This has an impact on planning future care for individuals and can be very distressing for team members. This practice learning placement is an ideal environment to develop skills and competence in talking about advancing disease, patient choices and professional team working.

No matter what the overall outcome, all individuals with cancer require information and support throughout their experience, long after they finish treatment. It is therefore essential that all healthcare professionals are knowledgeable and able to provide this information as and when patients and their families require it. As a student nurse, you are not expected to know everything, but in the future (whatever type of health care you end up working in) you will come across individuals with cancer and should be prepared to answer basic questions. The remaining chapters in this section provide a foundation of knowledge of what cancer is and how the cancer situation can be improved.