Background

Counseling is a brief psychointervention for rational-minded individuals who succumb to everyday-life stresses and difficulties.1 In general, counseling can take place in the form of directive guidance/advice, provision of information, facilitating the expression and understanding of inhibited or reactive thoughts/emotions, confronting unhelpful thinking and maladaptive behaviors, psychoeducation and more.2 Counseling is about providing a safe space to explore personal difficulties and facilitating intrapersonal growth through a therapeutic relationship built on empathy, unconditional positive regard and genuineness.3 Counseling is not about providing solutions but enabling individuals to derive their own personalized resolutions to their problems.4 Despite various approaches, counseling aims to enhance an individual's self-awareness and self-acceptance, provide empowerment by strengthening his/her internal and external resources and improve one's coping via acquisition of life skills such as problem-solving, decision making and effective communication.1,5

Conventionally, in Singapore, counseling or psychoemotional interventions are usually delivered by psychiatrists, psychologists or medical social workers (MSWs) in the hospital setting. However, it has been recognized that a referral to psychiatric services can seem intimidating to an individual - the stigma of being labeled with a mental disorder has increased one's reluctance to seek help from psychiatrists and psychologists.6 Medical social workers also play an important role in providing patient/family counseling and education, discharge planning, linking patient/family to community resources and financial assistance.7 However, they are often overwhelmed by the vast number of patients/families and are limited by their lack of knowledge/anticipation on patients' conditions, treatment plans and care management. Despite the known benefits of counseling support, counselors working in specialized areas in hospitals remain scarce.8 With an increased focus on supportive/holistic care, there is a growing trend for nurses to expand their roles in psychosocial care.9 Nurses are acknowledged as suitable candidates for therapeutic counseling work as they possess relevant background knowledge on disease presentations, treatment plans and side effects, as well as first-hand patient experiences across the illness-heath continuum.10 Patients with cancer feel less threatened speaking to a nurse about their physical, emotional and social problems compared with speaking to a mental health professional.11 They can engage more easily with nurses and also respond better in terms of their sense of empowerment, self-care and goal achievements after being counseled by a nurse.11

Nurses are generally recognized for their unique role in providing counseling as the majority of them have received training for therapeutic communication.10 In places like the United States of America, Australia and Singapore, all nursing diploma and/or bachelor graduates undergo core modules such as psychology and mental health nursing to gain some training in basic counseling and effective communication.12-18 Most places (e.g. the USA, Australia and the UK) have their own governing body that provides registration/licensure for counselors and regulate/standardize their practice and training.19-20 However, if a nurse wishes to provide counseling using more in-depth psychotherapeutic theories and techniques, he/she is encouraged to seek further education and training by taking up courses accredited by the governing body in the respective areas (e.g. the Australian Counselling Association, the National Counselling Society and the Singapore Association for Counselling) to ensure safe practice.20-22

Patient care nowadays emphasizes more on holism, and it is becoming more apparent that when dealing with physical illnesses, patients are also confronted with a variety of psychoemotional and social difficulties.10 In the hospital context, counseling has been used to provide psychoemotional support and education for patients with psychiatric disorders, oncological diagnoses and chronic conditions such as diabetes and stroke.23 Being one of the world's leading health problems,24 cancer is especially significant in the counseling context because being diagnosed with a life-threatening cancer condition often brings with it a multitude of psychoemotional struggles and spiritual crises such as self-blame, loss of roles and existential fears.25 It has been shown that mood disorders, such as anxiety and depression, which happen in about 30-40% of patients with cancer, can be moderated with therapeutic counseling work that facilitates the processing of psychoemotional difficulties related to cancer diagnosis or cancer treatment, and side effects such as altered body image, sense of uselessness or hopelessness, fatigue and sleep disturbances.2 By incorporating appropriate therapeutic theories and techniques, counseling can become the humanistic solution to patients' distresses through a process where patients can learn to understand and address their reactive emotions, challenge their unhelpful cognitions and change their maladaptive behaviors/defense mechanisms that have reinforced their distresses.11

Research findings on the experiences of cancer patients with nurses providing counseling appear varied. The literature has suggested several potential positive experiences in patients with cancer who have been seen by a nurse for counseling, specifically in the aspects of enhancing their emotional wellbeing and facilitating adjustment,26-31 as well as improving their overall physical health and symptom management.26-29,32 On the other hand, it has also been argued that counseling may be too subtle to produce observable benefits.5 There are also studies indicating that patients receiving counseling from nurses have not always generated positive experiences.28,30,31,33,34

According to the World Health Organization, the new cancer cases worldwide approximates around 14 million annually, and this number is expected to increase to about 22 million in the next two decades.35 With the increasing prevalence of cancer globally and heightened recognition of the psychological impact of cancer diagnoses in health care today,5 it is essential to obtain a clearer understanding of the experiences of cancer patients receiving counseling provided by nurses and consider the possibility of expanding the nurse's role to better cater to the psychoemotional care needs of this unique population. A preliminary search revealed no existing systematic review done on the experiences of adult patients with cancer receiving counseling provided by nurses. With the current varying patient experiences with counseling provided by nurses, the findings of this review will provide useful information on the subject and guide future practices in order to enhance patient care.

Inclusion criteria

Types of participants

The current review will consider studies that include adult patients (of at least 18 years of age) diagnosed with oncological malignancies of any type or stage. Patients may be at any phase along the illness trajectory, from newly diagnosed to treatment to remission or the terminal phase. This review will exclude participants with intellectual or cognitive disabilities.

Phenomena of interest

The current review will consider studies that explore the experiences of adult patients with cancer receiving counseling provided by registered nurses, which may include patient education, psychoeducation and/or supportive counseling that are conducted face-to-face or via other communication modes such as telephone, emails and videos. This review will exclude genetic counseling, as well as counseling interventions delivered by psychiatrists, psychologists and/or MSWs.

Context

The current review will consider qualitative findings on cancer patients' subjective experiences with counseling provided by nurses in the institutional or community setting.

Types of studies

The current review will consider qualitative studies, including but not limited to, designs of phenomenology, grounded theory, ethnography, action research, feminist research and mixed methods research.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe each article. A second search, using all identified keywords and index terms, will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies included will be limited to those published in English. The search strategy will be not be limited by year of publication.

The databases to be searched include

CINAHL, PsycINFO, EMBASE, JSTOR, Medline, PubMed, Scopus, ScienceDirect, Wiley Online Library and ProQuest Dissertations and Theses Global.

Keywords to be used in the search include:

Concept 1 - cancer, oncology and malignancy.

Concept 2 - nurse, patient, nurse counselor, cancer nurse, cancer survivor and cancer patient.

Concept 3 - counsel, coping and psychosocial intervention.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological quality prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the study methodology, methods, phenomenon of interest, setting/context, participant description and qualitative thematic findings that were of significance to the review question.

Data synthesis

Qualitative research findings will, where possible, be pooled in a meta-synthesis using JBI-QARI. This process will involve the aggregation of findings to generate a set of statements that represent aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Acknowledgements

The authors would like to thank the Evidence-Based Nursing Unit (EBNU) for their guidance in this review.

Appendix I: QARI appraisal instruments

Appendix II: QARI data extraction instruments

References