Received: 7 February 2018 Revised: 16 June 2018 Accepted: 19 June 2018

DOI: 10.1002/pon.4831

PAPER

Enhancing clinical practice in the management of distress: The

Therapeutic Practices for Distress Management (TPDM)
project
Deborah McLeod1 | Mary Jane Esplen2,3,4,5 | Jiahui Wong2,3,4,5 | Thomas F. Hack6,7,8 |

Lise Fillion9 | Doris Howell10,11,12 | Margaret Fitch11,13 | Julie Dufresne14,15

1
Psychosocial Oncology, NS Health Authority, School of Nursing, Dalhousie University, Halifax, NS, Canada
2
de Souza Institute, University Health Network, Toronto, Canada
3
Faculty of Medicine, University of Toronto, Toronto, Canada
4
Clinical and Basic Sciences, Department of Psychiatry, University of Toronto, Toronto, Canada
5
Princess Margaret Cancer Centre, Toronto, Canada
6
College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnepeg, Canada
7
Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnepeg, Canada
8
Psychosocial Oncology & Cancer Nursing Research, I.H. Asper Clinical Research Institute, Winnepeg, Canada
9
Nursing Research Unit, Centre de Recherche du CHU de Québec, L'Hôtel Dieu de Québec, Quebec, Canada
10
Oncology Nursing Research and Education, University Health Networks, Toronto, Canada
11
Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
12
Institute for Clinical Evaluative Sciences, Toronto, Canada
13
Canadian Association of Nurses in Oncology, Toronto, Canada
14
Yukon Chamber of Commerce, Whitehorse, Yukon, Canada
15
Touché Consulting, Whitehorse, Yukon, Canada

Correspondence
Deborah McLeod, Psychosocial Oncology, NS
Health Authority, School of Nursing,
Dalhousie University, QEII, Victoria Building
Rm 020, 1236 South Park St., Halifax, NS
B3H2Y9, Canada.
Email: deborah.mcleod@dal.ca
Funding information
de Souza Institute; Nova Scotia Health
Research Foundation; Canadian Partnership
Against Cancer; Canadian Institute of Health
Research, Grant/Award Number: 0001964
Abstract
Objective: The Therapeutic Practices for Distress Management (TPDM) project was
carried out to support clinicians in integrating recommendations from four clinical
practice guidelines (CPGs) in routine care at five Pan Canadian cancer care sites.
Methods: Using a concurrent, mixed‐method study design and knowledge transla-
tion (KT) activities, this project included two phases: phase I—a baseline/preparation
phase and phase II—an intervention phase plus evaluation. The intervention phase
(the focus of this report) included a one‐year education and supervision program
(24 hours in virtual class; 12‐hour group supervision). Primary outcomes were
knowledge and self‐efficacy in practicing CPGs as measured by a Knowledge and
Self‐Efficacy Survey (KSES). A secondary outcome was observer‐rated performances
with standardized patients (objective structured clinical exams). Participants included
80 (90%) nurses, and 9 (10%) social workers (N = 89).
Results: The TPDM program was effective in accomplishing change in knowledge,
self‐efficacy, and performance. All measures demonstrated significant change pre
and post module, with evidence of increasing knowledge (P < .01) and confidence
(P < .01) over time. Further, there was evidence of a shift in barriers and enablers
to practicing in alignment with the CPGs.

Psycho‐Oncology. 2018;27:2289–2295. wileyonlinelibrary.com/journal/pon © 2018 John Wiley & Sons, Ltd. 2289
2290
Conclusions: A tailored education program using case‐based learning and supervi-
sion over time improves knowledge and practice among front line clinicians. The find-
ings have implications for quality improvement in cancer care.
KEY W ORDS
clinical practice guideline, distress management, online continuing professional development,
knowledge translation, mentorship, quality improvement
1 | B A CKG R O U N D
Cancer patients across the course of disease and treatment suffer
from a variety of emotional symptoms such as anxiety and depression,
and physical symptoms, including pain and fatigue, contributing to
psychosocial distress.1 Prevalence of distress ranges from 22% to
58%, depending on factors such as type and stage of cancer, measures
used, and settings.2,3 Emotional distress, especially depression, is a risk
factor for noncompliance to treatment,4 and is associated with worse
health‐related quality of life (HRQOL)5 and survival.6 Thus, screening
for distress has become a routine part of cancer care globally, and is
an accreditation standard for cancer organizations in the United States
and Canada.7,8
Recent years show an improvement in distress screening rates;
nonetheless, not all patients are screened. In 2015, 40% of patients
with cancer in the province of Ontario in Canada were not screened
for distress symptoms.9 Patients may not report their symptoms,10
and psychosocial screens may not be thoroughly completed11 or doc-
umented appropriately,12,13 raising concerns about compliance to care
standards. In addition is the challenge of implementing evidence‐
based psychosocial interventions.14 In one study, 30% of health
care/medical professionals reported rarely or never looking at screen-
ing scores and only 60% discussed the scores with their patients.15
Screening alone is ineffective if the distress is not addressed with
some form of psychosocial intervention.16,17
While attempts have been made to integrate distress manage-
ment through screening programs, there is a discrepancy between
the attitude and actual practice.15 Time, appropriate space needed
to address private concerns and emotional distress identified in psy-
chosocial screening, and skill are often cited as barriers by health care
12,17 15,18,19
providers. Buy‐in from health care professionals is another
significant barrier impeding the full benefit of screening programs on
patient health outcomes. To ensure high quality of care, education,
training, and support of health care providers in using evidence‐based
interventions for distress are recommended.14,18
Clinical practice guidelines (CPGs) provide evidence‐based strate-
20-22
gies to identify and manage distress. The quality of clinicians'
response to distress screening data could be improved if recommen-
23
dations from these CPGs were applied in routine practice. The
integration of recommendations for symptom distress is complex,
requiring a multifaceted knowledge translation process to address
multilevel barriers24,25 and demands a programmatic approach.26
The aim of the Therapeutic Practices for Distress Management
(TPDM) project was to support integration of recommendations from
CPGs for four common symptoms, fatigue, pain, anxiety, and
MCLEOD ET AL.
depression, in routine cancer care. Specific goals for phase II of the
project reported here were to increase knowledge, confidence, and
skill in intervening to address the target symptoms.
2 | METHODS
The study consisted of a multisite knowledge translation and imple-
mentation approach inclusive of an interactive educational interven-
tion designed to facilitate uptake of four CPGs (fatigue, pain,
depression, anxiety) within four provinces in Canada (Ontario,
Manitoba, Quebec, Nova Scotia). The TPDM project consisted of
two phases. In phase I (manuscript in preparation) baseline qualitative
data were collected using focus groups and key informant interviews
of key stakeholders (eg, nurses, social workers, patients, family mem-
bers) to understand the barriers and enablers to practicing in accord
with the CPGs. In phase II, the focus of this report, the intervention
was implemented with an assessment of feasibility, acceptability, pro-
cess, and pre‐post testing of effects of the complex intervention.
Ethics approval for the study was obtained from all study site ethics
review boards (Nova Scotia 1016965, ON site#1 13‐6895.6, site #2
2014‐0558, Manitoba H2014:081 HS17572 UM44463, and Quebec
106348PASS 110034 CPAC).
2.1 | Intervention
The intervention included four components: (1) a 16‐week, 4‐module
web‐based course, delivered over one year, that included real‐time,
case‐based virtual seminars (24 hours) with small groups of 5 to 10
learners, and (2) a series of group reflective practice/clinical supervision
sessions (12 hours). Virtual seminars and supervision were scheduled
within work hours where desired, or time in lieu was offered when
learning was offered after work hours, which was preferred by some.
The four modules focused on fatigue, pain, anxiety, and depression.
The course design drew on interpretive pedagogy and research in web‐
based learning27,28 and was informed by the experience of the IPODE
project.29 Course content focused on knowledge and core competen-
cies needed to implement the four target CPGs. Topics included thera-
peutic relationships, patient‐centered care, and distress assessment
and management, including interventions for fatigue, pain, anxiety,
and depression. The content was informed by the CPGs and developed
through literature searches and analysis of competency statements for
nurses and health care professionals in cancer care. The course curric-
ulum was validated by experts in psychosocial oncology, oncology
nursing, and psychiatric/mental health nursing and by end‐users
(eg, through focus groups with patients/families). The emphasis
MCLEOD ET AL.
throughout was on helping nurses to integrate 10 to 15 minute
interventions for the target symptoms. Quebec participants received
two of the four modules (fatigue and anxiety) translated into French.
2.2 | Sample
The five participant sites represented a variety of settings, including
quaternary, tertiary, and community agencies in urban and rural set-
tings. Sites included two cancer centers in Ontario (Princess Margaret
Cancer Centre; Grand River Cancer Centre), cancer treatment centers
in Winnipeg and rural Manitoba, a cancer center and rural nurse nav-
igators in Nova Scotia, and one in Quebec. While our primary recruit-
ment targets were nurses, we also recruited front‐line social workers,
which allowed several learning groups (6/12) to include both disci-
plines, enriching interprofessional learning and providing some infor-
mal understanding of how social workers experienced the program.
Although the scope of practice is different, the CPGs are intended to
inform the practice of all disciplines. Posted advertisements, project
newsletters, presentations at clinical sites, and meetings with stake-
holders (eg, managers/leaders at each cancer center) were used to
recruit potential participants.
2.3 | Measures
The primary outcomes were changes in health professionals' knowl-
edge and self‐efficacy (KSES) in relation to practicing in alignment with
the CPGs. The KSES survey items were designed using guidelines for
the development of situation‐specific self‐efficacy measures30 and
matched the content and competencies of the target CPGs. Items
were summed separately for knowledge and confidence, ranging from
0 to 100, from not knowledgeable/confident at all to extremely
knowledgeable/confident. The survey was reviewed for face validity
by members of the research team, including psychologists and
advanced practice nurses. It was administered precourse (baseline)
and following each of the four modules for a total of five assessments
per participant (see sample items in Supplement Table 1).
The secondary outcome was performance in alignment with the
recommendations in the four CPGs as measured by Objective Struc-
tured Clinical Examination (OSCE). The ten OSCEs were specifically
developed for the study, based on previously published OSCEs
focused on patient‐centered communication.31 Exemplars were cre-
ated and extensively piloted to ensure clarity prior to the study. Scor-
ing was standardized to the competencies being taught. Standardized
patients presented scenarios of symptom distress for each of the
module‐specific symptoms. Objective Structured Clinical Examinations
(OSCE) were reviewed and scored independently by experts at each
site. Evaluators were not known to the participants, or, in a couple of
exceptions were known but did not work directly with the participant.
Each OSCE scoring grid included two dimensions—process and content.
The process dimension included person‐centered clinical skills
designed to ensure structure and attention to the person's priorities,
rather than the health care professional's priorities. Elements included
structuring the conversation, building relationships, and negotiating
priorities to ensure that the patient's key concerns were addressed.
Structure was understood to be essential in managing brief contacts
2291
well and included, for example, negotiating the time, the agenda, and
signposting. The content dimension of the OSCE included focused
assessment and intervention items in alignment with the CPGs (see
sample OSCE for the fatigue module, Supplement Table 2).
A postcourse survey was used to assess learner satisfaction, self‐
appraisal of learning, whether or not learners would recommend the
course to others, and recommended changes. The 18‐item survey
was adapted from standard course satisfaction instruments used pre-
viously by our team.
3 | ANALYSES
Descriptive statistics were completed for KSES and OSCE data. A
linear mixed‐effect model analysis was used to determine changes over
time for KSES between baseline (T1), postfatigue (T2), postpain (T3),
postanxiety (T4), and postdepression/end of course (T5), while control-
ling for baseline variables such as age, nursing experience, and oncology
experience. The linear mixed‐effect model analysis was also used for the
OSCEs to determine participant performance changes for each CPG (2
cases per symptom). For open‐ended questions in the survey, a content
analysis was completed. Triangulation using data from phase I and phase
II was used in the overall mixed‐method approach of the whole study.
4 | RESULTS
In phase II, a total of 103 participants provided written informed con-
sent. From these, 89 (86%) completed the baseline survey and entered
the course. Participants had a mean age of 43.9 years and an average
of 8 years of specialty practice in oncology (see Table 1).
Of the 89 participants to receive the intervention, 60 (60/89 or
67%) completed the study and the post course evaluation on knowl-
edge and confidence. Completion rates varied significantly across sites,
from a low of 53% at one site to a high of 86% in another. The comple-
tion rate among nurses (53/80 or 66.2%) did not differ statistically from
TABLE 1 Sample description
Participants
(N = 89)
Age (mean, sd) (range) 43.9 (9.9) (25‐71)
Provinces (%)
Manitoba 18.0%
Ontario 34.8%
Quebec 18.0%
Atlantic provinces 29.2%
Profession (%)
Nursing 90%
Social worker 10%
Years of oncology experience (mean, sd) (range) 10.2 (7.5) (0‐33)
Years of ambulatory care experience (mean, sd) 8.3 (6.1) (0‐25)
(range)
Specialization in oncologya (nursing only) (%) 55%
a
Specialization in oncology refers to nurses who successfully wrote the
Canadian Nurses Association Oncology Speciality Certification Exam.
Some Canadian provinces require RNs achieving national certification
within 5 years of their employment in the cancer program.
2292 MCLEOD ET AL.

TABLE 2 Knowledge and confidence change overtime

T1 (N = 89) T2 (N = 73) T3 (N = 48) w/o QCa T4 (N = 47) w/o QC T5 (N = 60)

Knowledge (mean, sd) 68.8 (12.5) 78.1 (10.7) 79.0 (10.1) 80.2 (9.4) 85.9 (8.2)
Confidence (mean, sd) 70.7 (13.4) 79.8 (10.1) 80.1 (11.3) 81.5 (10.1) 86.7 (8.4)
Linear fixed effects models
Estimate Std. error df t Sig.
Knowledge Intercept 85.6 1.4 191.7 62.8 <.01
T1 −16.7 1.6 310.1 −10.62 <.01
T2 −7.6 1.5 304.4 −5.08 <.01
T3 −5.1 1.5 255.4 −3.51 <.01
T4 −4.3 1.2 203.2 −3.71 <.01
T5 (reference) ‐
Confidence Intercept 86.2 1.4 182.0 61.2 <.01
T1 −15.2 1.6 308.7 −9.5 <.01
T2 −6.7 1.5 298.5 −4.5 <.01
T3 −5.0 1.4 249.8 −3.5 <.01
T4 −4.0 1.2 200.8 −3.5 <.01
T5 (reference) ‐
a
Quebec (QC) participants received two of the four modules and completed three KSES survey (T1, T2 and T5).

that of social workers (7/9 or 77.78%). For participants who dropped
out of the intervention, 75% of the withdrawals occurred prior to, or
during the first module. Where the reasons were known (35/43),
reported reasons were lack of time/personal scheduling conflict
(n = 9), work conflict or lack of support from work (n = 8), illness/per-
sonal reason (n = 7), change in position (n = 6), the course not being
applicable to field of practice (n = 4), and maternity leave (n = 1).
4.1 | Knowledge and Self‐Efficacy Survey (KSES)
The TPDM course was effective in accomplishing change in knowledge
and confidence across the five time points, from baseline to postinter-
vention for the four symptom modules. There was a statistically signif-
icant increase observed for both knowledge and confidence after each
first module, maintaining improvement over time (see Figure 1 and
Table 3). Improvements in process were also reported by participants
during the knowledge and confidence survey.
Further explorations on various components of the process grid
were carried out on the following areas of intervention around the
CPGs: initiating the conversation, gathering additional information
on screening results, providing structure for the conversation, sum-
marizing the discussion, and articulating next steps. Significant
improvements were found in “providing structure for the conversa-
tion” from T1 to T2 (Supplement figure 1).
4.4 | Content grid
In the “content” related to the four CPGs, including focused assess-

symptom module and at the end of the study (P = <.01) (see Table 2). ment and intervention for each symptom, there was relatively better

Participants reported an average of a 25% increase in knowledge and knowledge about the assessment and management algorithm on pain,

confidence for the assessment and management of the four symptoms. when compared to the assessment and management of fatigue, anxi-
ety, and depression (Supplement figure 2). The changes on the content
domain for the OSCEs were not statistically significant.
4.2 | Objective Structured Clinical Exams (OSCEs)
A total of ten OSCE assessments (two OSCEs per assessment point)
were used to measure the clinical competencies in symptom manage-
ment. For example, before the first module on fatigue (T1), there were
two OSCEs: Emily3 serving as baseline and Joan1 to document compe-
tency on fatigue before the training module. Similarly, following the
first module on fatigue but prior to the second module on pain (T2),
two different OSCEs were used for competency assessment: Joan2
to measure post module competency on fatigue as well as Trish1 to
measure competency on pain before the training on pain. The
approach of using two OSCEs before and after each module was
repeated at T3 (postpain/preanxiety), T4 (postanxiety/predepression),
and T5 (postdepression/postcourse).

4.3 | Process grid

Scores for the process grid of each OSCE are presented in Figure 1.
Participants received lower scores in the “process” subscale prior to FIGURE 1 Objective Structured Clinical Examination score on
the start of the course and demonstrated improvement following the process grid, pre and post each symptom module
MCLEOD ET AL. 2293

TABLE 3 OSCE score change overtime

Fatigue Pain w/o QC Anxiety Depression w/o QC Baseline/Postcourse

Prea Posta Pre Post Pre Post Pre Post Prea Posta
(N = 89) (N = 74) (N = 60) (N = 50) (N = 64) (N = 64) (N = 44) (N = 47) (N = 84) (N = 60)

Process (mean, sd) 48.9 (30.5) 62.5 (22.6) 61.2 (27.8) 68.0 (25.6) 63.2 (22.9) 67.3 (22.3) 67.3 (20.7) 66.8 (26.2) 48.5 (32.6) 76.3 (17.6)
Linear fixed effects models
Estimate Std. error df t Sig.

Fatigue Intercept 6.08 3.2 160.5 19.2 .000

Before module 1 −12.0 3.7 62.5 −3.3 .002
After module 1 (reference) 0 0
Pain Intercept 67.2 3.7 103.2 18.1 .000
Before module 2 −5.9 3.9 51.7 −1.5 .139
After (reference) 0 0
Anxiety Intercept 66.7 2.8 112.8 23.7 .000
Before module 3 −3.1 3.1 58.3 −1.0 .317
After (reference) 0 0
Depression Intercept 66.6 3.4 86.8 19.3 .000
Before module 4 1.32 4.4 47.0 .3 .764
After (reference) 0 0
Pre/post Intercept 69 3.5 136.3 19.9 .000
Baseline −19.9 3.3 45.0 −6.0 .000
Post course (reference) 0 0
a
Participants in the Quebec site completed the following OSCEs: T1 prefatigue (Joan1), T2 postfatigue (Joan2), T3 preanxiety (Emily1), T4 postanxiety
(Emily2), and T1 baseline (Emily3) and T5 post course (Pamela1).

4.5 | Participant satisfaction
The Course Satisfaction Survey was sent to 60 participants who com-
pleted all four modules. Respondents reported overall high satisfaction
with the course with 86.5% agreeing or strongly agreeing to the item
“overall I was satisfied with this course.” The majority of participants
(86.5%) reported making changes in their practice as a result of the
course, in areas such as the increased use of tools to intervene with
patients (45.71%), improved psychosocial and communication skills
(37.14%), and increased use of the focused assessment tool (20%),
and there were improvements expressed in the ability to center on
patients' priorities and goals. Areas recommended for improvement
to the course were related to the course length, expanded time for
reflective practice/cases, and the importance of securing workplace
support from managers and leaders.
5 | DISCUSSION
The goals of the study were to increase knowledge, confidence,
and performance of interventions for four common symptoms causing
distress, as outlined by CPGs. Our study findings suggest that our
overall goals were met. There were statistically significant improve-
ments in both knowledge and confidence with all four CPGs and in
clinician performance as measured by the OSCEs. These findings are
striking, given that the majority of participants were very experienced
clinicians. The program was multimodal in nature, and used case‐based
learning, reflective practice/supervision sessions, and opportunities
for feedback. The one‐year process allowed participants to take
what they learned into practice before returning to reflect and learn
more. Although extensive in length, our program was similar in the
number of formal hours of education to other programs focused on
communication skills32 and distress management.33-35 Our finding
that clinicians improved their confidence following an educational
intervention was also consistent with the literature.33-35 Clark et al35
reported greater pre‐post improvements in confidence than our
study which could be because of study design: For example, the num-
ber and types of symptoms addressed by the intervention, the educa-
tion delivery method, as well as the number of competencies
measured by the survey.
The multifaceted nature of the intervention makes it difficult to
identify specific components associated with change in knowledge
or behavior. However, the tailoring and the use of a complex interven-
tion follow recommendations for successful practice change among
health care professionals.25,36 Our approach used a number of widely
documented KT strategies, including the inclusion of key stakeholders,
a phased approach to implementation of an educational intervention
that first obtained qualitative data to contextualize and to inform its
implementation, and strategies to support buy‐in from cancer care
leaders. Stakeholders were included as part of the study team. Inter-
ventions to support the uptake of recommendations were embedded
in the course, beyond the clinical knowledge and skill, such as how
to negotiate roles with colleagues. As well, the use of supervision as
a useful strategy is identified in a number of studies.34,37
Participants improved most in the symptom areas where they had
the lowest level of knowledge and skill at baseline, for example, anxiety
and depression, compared to pain or fatigue for nursing participants.
Similarly, for the social worker participants, greater gains were observed
for the symptoms of fatigue and pain, compared to depression. Over
time, even when an adequate baseline knowledge of a specific symptom
area was demonstrated, such as with fatigue, most participants gained in
the process of applying the guideline during their OSCE, with a pattern
that clearly demonstrated cumulative improvement.
The most dramatic improvement in process elements occurred
with the first module where emphasis was placed on negotiating an
2294
agenda for care that included, for example, (a) focusing on the
patient's concerns (the nurse's agenda as secondary), (b) negotiating
a timeframe of no more than 15 minutes, and (c) using process skills
for ending the conversation well, with clear plans regarding how to
address any remaining concerns at another time, or in another way.
These findings are important; while clinicians may be knowledgeable
about a specific symptom, or about an evidence‐based intervention
to address it, there are important skills involved in knowing how to
best engage and interact with patients in care planning and delivery,
as well as to how to quickly prioritize the most pertinent issues for
the patient within busy settings with time constraints.
Over time, by the third module, significant gains on process had
occurred, and therefore, changes in the process elements of the OSCE
pre and post some of the later modules did not reach statistical signif-
icance. In some areas of content, improvement over time occurred,
which fits with our knowledge that most participants knew less about
assessment and intervention with anxiety (a later module), compared
with fatigue, and therefore, demonstrated greater gains in this area.
Findings related to content versus process concerning a guideline area
also underline the complexity in learning needs among the participants.
There is variation in competency, and competencies are symptom
dependent, in how to optimally engage patients to address their con-
cerns (process) and deliver the appropriate intervention(s) (content).
The program was challenging to implement given the multiple
competing pressures on nurses' time. Although every attempt was
made to schedule formal education times when it was most convenient
or preferred, and support from managers to rearrange schedules was in
place, some nurses worried and felt guilty about causing increased bur-
den and inconvenience for colleagues. Where managers were less sup-
portive of the time needed for education, the difficulty was even
greater. Given that nurses self‐selected for the project and were there-
fore a more motivated group, it highlights the potential challenges of
expanding the project to larger numbers of nurses and more centers.
Our experience collectively as a team leads us to believe that this chal-
lenge represents a larger, systemic, and professional cultural issue in
which nurses' ongoing education is inadequately valued by nurses
themselves. This pressure was expressed much less by nurses who
had more autonomous practices, such as advanced practice nurses
and those in navigation roles, as well as by social workers.
One suggestion offered through the satisfaction surveys was to
divide the course into smaller sections, with one module at a time
being completed as a nurse is able to commit the time. This certainly
results in a shorter duration of commitment at any one time, however
may contribute to decreased momentum in skill development, as one
module builds on another.
6 | C O N CL U S I O N S
This study used a KT approach and mixed methods to evaluate the
implementation of a complex educational intervention for nurses
and social workers in real‐life practice settings. The use of a
multijurisdictional collaboration to test the impact of the intervention
across Canada was valuable, demonstrating that the intervention
improved knowledge, confidence, and performance at a variety of
MCLEOD ET AL.
clinical sites. Feedback from participants suggests that offering the
course module by module may allow a larger number of nurses to
participate in the courses. Ideally, real‐life practice should be evalu-
ated, but this is of course very difficult. Stakeholder and leader
engagement appeared to be a key ingredient for the successful
implementation of the education program. The multijurisdiction input
and outcomes provide greater generalizability to our results and
strengthen opportunities for successful uptake of the intervention
and its sustainability.
7 | STUDY LIMITATIONS
There are a number of limitations of the study to note. First, the study
did not have a comparison control group, and we have no available
data on those who declined participation in the study. We also do
not have data on the long‐term impact of the intervention on the
actual practice of the participants. Furthermore, although the course
was delivered by only two educators in English and one in French, in
a standardized fashion and guided by a manual, we do not have spe-
cific data on the fidelity on the delivery of the intervention. As well,
participants self‐selected for the intervention and are not likely repre-
sentative of the larger group. We felt this was a justifiable first step in
evaluating an education program designed to integrate recommenda-
tions from CPGs into routine care.
8 | CLINICAL IMPLICATIONS
A tailored education program using case‐based learning and supervi-
sion over time improves knowledge, confidence, and skills among
front‐line clinicians. Expanding the program to larger numbers of
nurses and other health professionals likely will require offering the
program in smaller sections. The findings have implications for quality
improvement in cancer care.
ACKNOWLEDGEMENTS
We would like to acknowledge the support of the nurses, social
workers, leaders, and decision makers who contributed their time
and ideas. We are grateful for the research grant and other in kind
support from the Canadian Institute of Health Research, Canadian
Partnership Against Cancer, Nova Scotia Health Research Foundation
and de Souza Institute.
ORCID
Mary Jane Esplen http://orcid.org/0000-0002-6034-2235
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SUPPORTI NG INFORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
How to cite this article: McLeod D, Esplen MJ, Wong J, et al.
Enhancing clinical practice in the management of distress:
The Therapeutic Practices for Distress Management (TPDM)
project. Psycho‐Oncology. 2018;27:2289–2295. https://doi.
org/10.1002/pon.4831