Introducing a new role

‘Nurse Counselor’:
Attending to the psycho-emotional
needs of cancer patients in
Singapore

Li Hui, TAY Master of Counselling candidate, BSc Nursing (Hons), RN
Kok Wah Andrew, ONG BCoun, Dip Nsg, RN
 Overview

NCIS Nurse Counseling Service Description 
 Practice Gap
 Introducing Nurse Counseling Service
 Roles of a Nurse Counselor
 Tools & Workflow
 Continued Learning & Improvements

NCIS Nurse Counseling Service Data
 Overview
 Demographics
 Time Interval in‐between Sessions
 DT Scores Comparison
 Formal Closure ‐ Evaluation
NCIS Nurse Counseling
Service Description
 Practice Gap
 Cancer is one of the world’s leading health problems (Pinar, Okdem, Buyukgonenc
& Ayhan, 2012). 

 Cancer distress known to lead to (Agarwal, Hamilton, Moore & Crandell, 2010; Hsiao, 
Moore, Insel & Merkle, 2014):
(1) poor adjustment
(2) accelerated disease progression
(3) poor treatment compliance
(4) poorer outcomes and higher mortality

 Medical advances  Extending life expectancy
HOWEVER… little attention given to coaching patients how to live with cancer! 
(Tang, Chiou, Lin, Wang & Liand, 2011)

 JCI accreditation standards: Emphasized psychological assessment in care 
planning (Joint Commission International, 2014)
 Existing literature recommendations: Routine screening for distress & 
Provision of supportive interventions (Chen, Chang & Yeh, 2000; Middleton, 2014;  
Saevarsdottir, Fridriksdottir & Gunnarsdottir, 2010)

NCIS Nurse Counseling Service Description
 NCIS Nurse Counseling Service
 Setting: National University Hospital, Singapore

 New service: NCIS Nurse Counseling Service
*Fronted by two senior staff nurses with counseling backgrounds

NCIS Nurse Counseling Service Description
 NCIS Nurse Counseling Service
 Time‐frame:  Pilot Phase 1 Oct to Dec 2014
Pilot Phase 2 Jan to Mar 2015
Formal Service Commencement May 2015 onwards

 Objectives:
a) To implement universal screening using distress thermometer (DT) 
b) To provide counseling interventions – self‐help materials, psycho‐
education, individual counseling session etc.
c) To maintain patients’ distress levels at an acceptable range (≤ 4)
d) To identify patients in extreme distress and refer them to PSY for early 
management

NCIS Nurse Counseling Service Description
 NCIS Nurse Counseling Service
 Patient description: 

Inclusion criteria Exclusion criteria
Patients with malignancies Patients with active PSY symptoms
(onco/ haem) Cognitive/intellectual impairment
Out‐patients Speech impairment
≥21 years old Language barrier
DT ≥5 or via referral Unable to engage or cooperate with 
counseling processes

 Not limited to: 
 Cancer types or stages
 Curative or palliative treatment

NCIS Nurse Counseling Service Description
 Roles of a Nurse Counselor

• Cancer knowledge • See beyond the cancer
• Nursing care • Psycho‐emotional support
• Orientation • Strengthen patients’ innate 
strengths & resources
• Symptom assessment & 
management • Psycho‐education
• Right‐siting services • Assimilate adaptive thoughts, 
feelings & behaviours
NCIS Nurse Counseling Service Description
 Roles of a Nurse Counselor
Patient education Safe haven to express + Validation
Helping behaviors Manage distressing thoughts/emotions
Relevant info & explanations Regain self‐esteem/confidence
Proper self‐care Here‐and‐now

Gain insight in relationships Find peace with their diagnosis
Maintain social life Draw strength from faith
Connect to other services Reestablish meaning in life
Support groups

NCIS Nurse Counseling Service Description
 Tools

1. Distress Thermometer (DT)
• Every session

2. Depression Anxiety Stress Scale (DASS‐21)
• First & last session

NCIS Nurse Counseling Service Description
 Workflow
Routine screening using DT @  Patient appeared distressed  Patient appeared distressed 
Triage: DT ≥ 5 at doctor’s consultation at treatment area
Assessment

1st Session Introduce self & counseling service

Referral to Nurse Counselor Privacy & Confidentiality issues
Further assessment using DASS‐21 and/or other appropriate tools

DASS: normal to mild range DASS: moderate to severe range DASS: extremely severe range

Offer advice / resources Counseling Inform primary doctor to refer PSY
Interventions

• Individual counseling sessions • Review by a psychiatrist
‐ History taking • Medications
‐ Counseling treatment plan • Psychotherapy with psychologist
‐ Psycho‐education: relaxation techniques, coping skills, stress  *Nurse counselor will follow‐up if 
management, communication, sleep hygiene etc not for PSY referral

If patient’s distress worsens or identified suicide risk

Vulnerable individuals with complex social/financial/family backgrounds  to refer MSW

NCIS Nurse Counseling Service Description
 Continued Learning & Improvements
 Weekly clinical case review & consultation with Senior Psychologist

 Peer supervision & case discussions

 Psychotherapy Teaching Round

 Interactive Counseling Learning Rounds

NCIS Nurse Counseling Service Description
NCIS Nurse Counseling
Service Data
October 2014  to  August 2015
 Overview
A total of  122 patients have benefitted from the service.

26
37

33
26
In‐pt/hospice/ 
nursing home 4
Deceased  7
Exclusion 11
Default tx 4
 Demographics

Gender Marital Status
80 78 90 85

70 80

70
60

60
50
44
50
40
40
30
30 25
20
20

10 10 7
5

0 0
Males Females Single Married Divorced Widowed

Breakdown of 122 Patients

 Demographics

Age Groups
40
35
35
30 30
30

25

20
16
15

10
7
5 4

0
20s 30s 40s 50s 60s 70s

Breakdown of 122 Patients

 Demographics
Diagnosis
45
42
40

12
35

30
No of patients 

25 11
20
20
Declined/Dropped

15 9 Formal Close
11 On Hand
10 9
19 4
6 7
5 5 6
5 4 3 4 3 4 3
4
7 4 1 2 4 2
1 2 3 3 1 3
3 2 3 1 2 1
0 1 1 1 1 1 1 1 1

Oncology 110 Haematology 12

Breakdown of 122 Patients

 Time Interval In-between Sessions
Session Interval Lapse (days)
70

59 75th percentile:
60 Less acutely distressed
52
49
50 46 46
45 45
42 42
NO. OF DAYS

40 38
35 25th percentile:
More acutely distressed

30 26
21 21 21
20 16
13

10 7

25 34 42 48 32 40 38 52 49
0
Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9

Time Interval
 DT Scores Comparison
Mean DT Scores 5
Median DT Scores
5.50 5

5.03 4.5

4.50 4

5.03 5
3.5
3.74
3.50 3 3
3
3.12

DT scores
DT scores

2.5
2.50 2 2 2 2 2
2.21 2
2.00
1.89 1.88
1.60 1.5
1.50
1 1
1.25
1
1.00
1
0.50 1.00 0.5

‐0.50

DT Scores Comparison
 DT Scores Comparison
S ES S I O N   S ES S I O N   S ES S I O N   S ES S I O N   S ES S I O N   S ES S I O N   S ES S I O N   S ES S I O N   S ES S I O N  
BRIEF 1 2 3 4 5 6 7 8 9
1
0.18
0 0.00 0.00
0 ‐0.29
0 ‐0.76
‐0.94 ‐1.03 Compared with 
‐1.18
‐1 previous session
‐1.54

‐2 ‐1.54
Difference in DT

‐3 ‐2.47

‐3.29
‐4 ‐3.62 ‐3.59

‐5 ‐4.55 ‐4.43

‐6 ‐5.60
‐6.00
Compared with 
‐7
Brief session
Comparison Comparison Linear (Comparison Linear (Comparison
To Brief Session To Previous Session To Brief Session) To Previous Session)

DT Scores Comparison
 Formal Closure - Evaluation
DASS ‐ Depression DASS ‐ Anxiety DASS ‐ Stress
16 10 10 18
15 17
9 16
14
8
14
12 7
7
12
10 6
6 10
10
8
7 5 5
4 8
4
6
5 5 6
3
4 2 4 3 3
3 2 2
2 2
2 2 2
1 1 1 1
0 1 0
0 0 0 0 0 0 0 0
norm mild mod severe ex sev norm mild mod severe ex sev norm mild mod severe ex sev
Pre Post Pre Post Pre Post

Formal Closure – Evaluation of the 19 (out of 26) cases

 Formal Closure - Evaluation
Formal Closure ‐ Evaluation Form (x/10)
8.4
Overall satisfaction

8
Overall effectiveness

7.9
Effective in managing stress

7.7
Effective in managing anxiety

7.5
Effective in managing low mood

7.9
Acceptance of illness

8.2
Self‐care & side effects

8.3
Knowledge & understanding of treatment

7 7.2 7.4 7.6 7.8 8 8.2 8.4 8.6

Formal Closure - Evaluation

 In a nutshell…
 A new Nurse Counseling Service was successfully introduced in NUH
cancer center

 Implementation of a universal DT screening tool as the 7th vital

sign has served its purpose

 Nurse Counseling is a service that other healthcare professionals can

turn to for further psycho‐emotional assessment/intervention in
patient care, especially for those refusing PSY referral

Overall…
 Patients found Nurse Counseling to be effective in addressing their
psycho‐emotional as well as informational needs
 Patients were satisfied with the Nurse Counseling service

Summary
 References
Agarwal, M., Hamilton, J. B., Moore, C. E., & Crandell, J. L. (2010). Predictors of depression among
older African American cancer patients. Cancer Nursing, 33(2), 156‐162.
Chen, M‐L., Chang, H‐K., & Yeh, C‐H. (2000). Anxiety and depression in Taiwanese cancer patients
with and without pain. Journal of Advanced Nursing, 32(4), 944‐951.
Hsiao, C‐P., Moore, I. M., Insel, K. C., & Merkle, C. J. (2014). High perceived stress is linked to
afternoon cortisol levels and greater symptom distress in patients with localized prostate cancer.
Cancer Nursing, 36(6), 470‐478.
Joint Commission International. (2014). Joint Commission International Accreditation Standards for
Hospitals: Including Standards for Academic Medical Center Hospitals (5th ed.). Available from:
URL:http://www.jointcommissioninternational.org/assets/3/7/Hospital‐5E‐Standards‐Only‐
Mar2014.pdf
Middleton, R. J. (2014). Meeting the psychological care needs of patients with cancer. Nursing
Standards, 28(21), 39‐45.
Pinar, G., Okdem, S., Buyukgonenc, L., & Ayhan, A. (2012). The relationship between social support
and the level of anxiety, depression and quality of life of Turkish women with gynecologic cancer.
Cancer Nursing, 35(3), 229‐235.
Saevarsdottir, T., Fridriksdottir, N., & Gunnarsdottir, S. (2010). Quality of life and symptoms of anxiety
and depression of patients receiving cancer chemotherapy: Longitudinal study. Cancer Nursing,
33(1), E1‐E10.
Tang, P‐L., Chiou, C‐P., Lin, H‐S., Wang, C., & Liand, S‐L. (2011). Correlates of death anxiety among
Taiwanese cancer patients. Cancer Nursing, 34(4), 286‐292.

References
References
Thank you.