I’m speaking about psychological distress in cancer patients and I think it’s important to recognise that when somebody is diagnosed with cancer with a potentially life-threatening illness, everyone is going to have some reaction, some degree of distress associated with that and I’m particularly concerned that as oncology nurses we have the capacity to identify the degree of distress, be able to assist individuals in ways that are going to be helpful and beneficial to them so that distress is contained, it’s reduced as appropriate for the patient.

I think of it as an emotional reaction but it’s an emotional reaction coming from physical issues or social issues or psychological issues or spiritual issues. The diagnosis of cancer really has an impact on all of those domains, it’s not just a physical impact and as an individual experiences the diagnosis, the treatment, there are just so many challenges in front of them. But those challenges can elicit an emotional reaction, we see that as distress; the person experiences it as an emotional distress.

How do you educate nurses in managing distress in patients?

I think it’s important that nurses learn about the phenomenon itself and recognise that there’s a whole gradation of distress from something that might be relatively low key, the person manages fairly well on their own, to a degree of distress that’s almost immobilising and that’s when we start hearing conversations about clinical depression or high anxiety. It actually interferes with the person problem-solving, managing, but there’s a whole gradation of distress between that. So we need to help nurses understand the phenomena; we need to help nurses understand how you assess, how you engage in the dialogue, in the conversation with people to understand what’s behind the distress, what’s contributing to it. Once we understand that then it’s much easier to figure out what is the intervention that’s necessary. For example, if they’re very, very upset or distressed around the fatigue they’re experiencing then it’s interventions around fatigue. If it’s an issue around talking with their children and trying to help the children understand what’s happening to a parent, those are different interventions and different strategies. We try to educate nurses in whatever way we can, whether it’s within formal courses or through newsletters or through online courses or through the internet. We’re really trying to work in a variety of ways to make sure that they have the information, the evidence about practice where they can be effective.

Are there other physical symptoms that oncologists should be aware of?

I must say that I put most of my energy in helping the nurses help the patients and I think there ought to be parallel kinds of activities to help the doctors help the patient. I do know that there is evidence available that would support the idea that physicians have difficulty with conversations that are emotionally laden and so we need to do a better job of helping them have effective conversations.

Are there different methods for dealing with this in Africa as opposed to America or Europe?

I think it’s appropriate that whatever interventions we use are contextualised for the culture, for the environment in which we all work. It’s very interesting, as I’ve had the opportunity to move around the world, the roles of nurses and the roles of physicians differ. So whatever is happening with the team needs to take into account what skills, what knowledge, how people work together in their local environment. In that regard I think everyone needs to understand about distress and everybody needs to have at least a basic conversation that allows the identification of concern by the patient and then if it’s an intervention by that practitioner or a referral to another practitioner, that’s perhaps an appropriate end result for whatever needs to happen.

Is distress something you try to manage through discussion rather than with medication?

From my point of view, if I go back to that notion of a continuum of distress, there is a long space on that continuum where the distress is almost normal to the situation the person is in. If anyone of us were told we have cancer we would experience some distress but that doesn’t mean we need medication. The medication comes into play if there are other kinds of factors of a more psychiatric nature or a situation where there may be biochemical kinds of issues occurring. So from my point of view there is a great deal that can be done for the distress long before you have to think about medications.

I think the only other time that medications might come into play is if there’s a symptom that people are actually experiencing. So if you think about pain or nausea, vomiting, we really do need to take care of the physical symptoms. If they’re in the way then people are not going to get to the emotional side of the equation. So we would have to think about medications in those kinds of instances.

Are there any programmes or organisations that are trying to take the lead on this?

The International Psychosocial Oncology Association, there are psychosocial oncology associations in countries, in Canada, in the United States, in Europe. Probably the International Psychosocial Society is the one that’s doing most worldwide work at this point in time.