Assessing Oncology Inpatient Nurses' Knowledge, Attitudes, Beliefs,and Level of Confidence in Distress Screening

Patients with cancer commonly experience distress and the need for psychosocial care is well recognized as an essential part of cancer care worldwide. However, numerous studies have reported the failure to optimally manage distress. One factor contributing to this failure is underdetection. Identifying psychosocial distress in oncology patients can be difficult without systematic methods. Although the implementation of systematic distress screening among the National Comprehensive Cancer Network (NCCN) member institutions has progressed, oncology patients in inpatient settings continue to be underassessed. Because nurses routinely conduct patient assessments, they are in an ideal position to identify patients in distress and intervene on their behalf. This scholarly project aimed to improve oncology inpatient nurses' knowledge, attitudes, beliefs, and perceived level of confidence regarding distress screening. The Distress Education Module was developed and delivered to inpatient oncology nurses at a medical unit of an NCCN member institution, located in Salt Lake City, Utah. The effectiveness of the education module was measured by analyzing changes in nurses' responses in their level of knowledge, attitudes, beliefs, and confidence via the pre- and postsurveys. This DNP project also surveyed participants about their perceived barriers to distress screening. Over 60% (presurvey n=27 and postsurvey n=19) of the eligible nurses participated in the study. Of these, 85.2% (n=23) identified a lack of access to validated screening tools as a moderate to extreme barrier, followed by time constraints (59.2%, n=16). The majority of nurses (74.1%, n=20) did not perceive personal beliefs against distress screening as a barrier. The results from the Mann-Whitney U test demonstrated statistically significant improvements in nurses' knowledge (U=76.000, p=0.000), beliefs (subjective norm) (U=174.000, p=0.033), and confidence levels (U=155.000, p=0.013 and U=190.500, p=0.107). For instance, nurses who reported they were "moderate" to "extremely familiar" with the NCCN's distress guidelines increased by 57.9%. Also, nurses reported an increased frequency in distress screening (U=169.000, p=0.038) and validated tool use (U=173.500, p=0.047) in their practices after the educational intervention: nurses who reported they "often" screen or assess patients for distress improved by 31% and nurses who reported they "never" use validated tools decreased by 32.3%. All nurses who participated in the study responded that they intended to perform routine distress screening. This project provided the groundwork for future implementations of distress screening by identifying nurses' barriers and improving their knowledge, beliefs, and confidence levels regarding distress screening and management. Additionally, this project confirmed that the improvement in knowledge, attitudes, beliefs (subjective norm), and confidence levels could develop into actual practice changes. However, this study is limited by a lack of national representation of registered nurses in the US due to the small and homogeneous sample. Further quality improvement projects are recommended to address external barriers at the organizational level, followed by implementation of the formal distress screening and management protocol after barriers are addressed.

Assessing Oncology Inpatient Nurses' Knowledge, Attitudes, Beliefs, and Level of Confidence in Distress Screening Youngbeen Shamo The University of Utah College of Nursing 1 Abstract Background: Patients with cancer commonly experience distress and the need for psychosocial care is well recognized as an essential part of cancer care worldwide. However, numerous studies have reported the failure to optimally manage distress. One factor contributing to this failure is underdetection. Identifying psychosocial distress in oncology patients can be difficult without systematic methods. Although the implementation of systematic distress screening among the National Comprehensive Cancer Network (NCCN) member institutions has progressed, oncology patients in inpatient settings continue to be underassessed. Because nurses routinely conduct patient assessments, they are in an ideal position to identify patients in distress and intervene on their behalf. Objective: This scholarly project aimed to improve oncology inpatient nurses' knowledge, attitudes, beliefs, and perceived level of confidence regarding distress screening. Methods: The Distress Education Module was developed and delivered to inpatient oncology nurses at a medical unit of an NCCN member institution, located in Salt Lake City, Utah. The effectiveness of the education module was measured by analyzing changes in nurses' responses in their level of knowledge, attitudes, beliefs, and confidence via the pre- and postsurveys. This DNP project also surveyed participants about their perceived barriers to distress screening. Results: Over 60% (presurvey n=27 and postsurvey n=19) of the eligible nurses 2 participated in the study. Of these, 85.2% (n=23) identified a lack of access to validated screening tools as a moderate to extreme barrier, followed by time constraints (59.2%, n= 16). The majority of nurses (74.1%, n=20) did not perceive personal beliefs against distress screening as a barrier. The results from the Mann-Whitney U test demonstrated statistically significant improvements in nurses' knowledge (U=76.000, p=0.000), beliefs (subjective norm) (U=174.000, p=0.033), and confidence levels (U=155.000, p=0.013 and U=190.500, p=0.107). For instance, nurses who reported they were "moderate" to "extremely familiar" with the NCCN's distress guidelines increased by 57.9%. Also, nurses reported an increased frequency in distress screening (U=169.000, p=0.038) and validated tool use (U=173.500, p=0.047) in their practices after the educational intervention: nurses who reported they "often" screen or assess patients for distress improved by 31% and nurses who reported they "never" use validated tools decreased by 32.3%. All nurses who participated in the study responded that they intended to perform routine distress screening. Discussion: This project provided the groundwork for future implementations of distress screening by identifying nurses' barriers and improving their knowledge, beliefs, and confidence levels regarding distress screening and management. Additionally, this project confirmed that the improvement in knowledge, attitudes, beliefs (subjective norm), and confidence levels could develop into actual practice changes. However, this study is limited by a lack of national representation of registered nurses in the US due to the small and homogeneous sample. Further quality improvement projects are recommended to address external barriers at the organizational level, followed by 3 implementation of the formal distress screening and management protocol after barriers are addressed. Keywords: distress, mental health, psychiatric disorders, psychosocial care, distress screening, distress guidelines, inpatients, oncology nurses, NCCN 4 Introduction Problem Description Psychosocial health is an important part of patients' overall health and well-being. Patients with cancer commonly experience psychosocial distress. The collective results from multiple studies have suggested that approximately 35% to 45% of cancer patients report distress (National Cancer Institute, 2002). Also, patients with cancer, like those with other chronic illnesses, are at a higher risk for severe psychosocial distress, including mental disorders, particularly depression and anxiety. Although the prevalence of mental disorders in the oncology population varies, the shared claim from numerous researchers is that the prevalence of depression and anxiety in patients with cancer is higher than in the general population (Hartung et al., 2017). For example, in a metaanalysis of 70 studies with over 10,000 individuals with cancer in oncological and hematological settings, the prevalence of depression criteria as identified by the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria was 16.3%, whereas only 7.1% of all adults in the US were identified as having depression in 2017 (Mitchell, Vahabzadeh, & Magruder, 2011; National Institute of Mental Health [NIMH], 2018). The negative clinical outcomes of severe distress, especially mental disorders, have been well documented. Mental disorders such as depression not only are associated with somatic problems such as pain, fatigue, and sleep difficulties, but also can increase disability, morbidity, and mortality and decrease social, occupational, and physical functioning in 5 many medical conditions, including cancer (Office of Disease Prevention and Health Promotion [ODPHP], 2014). Available Knowledge The need for psychosocial care is well recognized as an essential part of cancer care, since sufficient evidence has shown the negative impact of distress on the quality of life and clinical outcomes, such as poor adherence to cancer treatment and decreased survivor rates of cancer patients (Hammelef et al., 2014). The International PsychoOncology Society [IPOS] (2010) emphasized that "psychosocial cancer care should be recognized as a universal human right … [and] quality cancer care must integrate the psychosocial domain into routine care" (para 2). Also, the Institute of Medicine [IOM] of the National Academies (2008) stressed that "it is not possible to deliver good-quality cancer care without … [addressing] patients' psychosocial health needs. All patients with cancer and their families should expect and receive cancer care that ensures the provision of appropriate psychosocial health services" (p. 1). Despite the importance of psychosocial care in cancer patients, the IOM (2008) reported a failure of the health care system as a whole to optimally manage psychiatric disorders and psychosocial needs in patients with cancer. Also, several researchers in the US and other countries have reported a high level of unmet treatment needs for mental disorders such as depression among patients with cancer (Kadan-Lottick et al., 2005; Nakash et al., 2014; Rhondali et al., 2012; Sharpe et al., 2004; Walker et al., 2014). One of the factors contributing to this failure is underdetection. Numerous studies have shown that severe distress, such as the depression experienced by patients with cancer, often 6 goes unrecognized and, therefore, untreated (Delgado-Guay et al., 2008; Domogauer, Colangelo, & Aggarwarl, 2017; Sharpe et al., 2004). Also, several studies have recognized the clinician factors as barriers to identifying mental disorders (Greenberg, 2004; Mitchell et al., 2011; Pincus & Patel, 2009). The IOM (2008) emphasized that "physicians substantially underestimate oncology patients' psychosocial distress." (p. 6). Also, the failure to recognize depression occurs in part because oncologists are focused on the medical management of the patient's cancer (Sharpe et al., 2004). Rationale Identifying psychosocial distress in the oncology population can be difficult without systematic methods. In countries such as Canada, screening for distress has been endorsed as the sixth vital sign, along with temperature, heart rate, blood pressure, respiratory rate, and pain. To increase timely and accurate identification of distress in the oncology population, systematic screening for psychosocial distress or mental health has been recommended by numerous professional and accrediting organizations such as the National Institutes of Health (NIH), the National Comprehensive Cancer Network (NCCN), the American College of Surgeons (ACoS) Commission on Cancer (CoC), and the American Society of Clinical Oncology. The implementation of systematic screening should be improved. Despite the recommendation to better address psychosocial needs, including the mental health of cancer patients, "distress continues to be under-assessed and under-estimated in patients with cancer" (as cited in Tavernier, Beck, & Dudley, 2013). NCCN surveyed 20 NCCN 7 member institutions in 2012: 70% of these intuitions reported routine screening for distress, with only 25% screening inpatients and 60% screening outpatients. Among institutes screening outpatients, only 50% screened all outpatients, and 50% screened specific subgroups of outpatients (Donovan & Jacobsen, 2013). Also, Tavernier et al. (2013) found that almost 60% of the respondents in their study, including nurses, did not use any systematic tool to assess mental disorders or emotional distress in their clinical practices. According to Doorenbos and her colleagues (2008), nurses can ensure highquality and cost-effective oncology care through implementation of evidence-based practice guidelines. Moreover, many researchers have emphasized the important roles of nurses in distress screening. Loscalzo (2011) identified nurses as "natural allies" to patients by supporting their psychosocial needs. The critical roles of nurses in distress screening include in-depth assessment, patient education, symptom management, and appropriate referral to the psychosocial team (Fitch, 2011; Vitek, Rosenzweig, & Stollings, 2007). Also, nurses in Canada have facilitated a change in clinical values and culture by implementing distress assessment as the sixth vital sign (Dudgeon, King, & Howell, 2012). Specific Aims This scholarly project aimed to improve oncology inpatient nurses' knowledge, attitudes, beliefs, and perceived level of confidence regarding distress screening, and determine if NCCN's clinical practice guidelines in distress screening would be considered a beneficial adjunct to the inpatient medical oncology team. The objectives of 8 the project include: ⦁ assessing medical oncology nurses' knowledge, attitudes, beliefs, and perceived confidence in screening for distress; ⦁ developing an educational module, titled the Distress Education Module, that addresses information gathered in objective 1; ⦁ implementing the Distress Education Module with nurses of the medical oncology unit; ⦁ evaluating the effectiveness of the Distress Education Module by measuring changes in nurses' knowledge, attitudes, beliefs and perceived confidence regarding distress screening; ⦁ disseminating study findings to key stakeholders in the Huntsman Cancer Hospital. Methods Context This project took place at a medical oncology unit of one of the NCCN member institutions located in Salt Lake City, Utah. This cancer hospital is the only National Cancer Institute-Designated Comprehensive Cancer Center in the Mountain West, including Utah, Idaho, Montana, Nevada, and Wyoming. It is also "a member of the National Comprehensive Cancer Network, a not-for-profit alliance of the world's leading cancer centers. NCCN members write best-practice standards for cancer care that are used around the world" (University of Utah Health, 2018, para 7). This cancer hospital 9 serves patients with all types of cancer. Patients are admitted to the unit for cancer treatments such as systemic chemotherapy or immunotherapy, treatment-related complications, or other cancer-related medical conditions requiring a stay in a hospital setting. The inpatient medical oncology unit is a 25-bed unit with several attending, fellow, and resident physicians; 6 advanced practice clinicians; 40 nurses; and 26 health care assistants. All nurses working in this unit met eligibility criteria to participate in a presurvey of this project. Although a nurse unit manager, clinical nurse consultant, and nurse educator have limited direct-care clinical activities, they were not excluded since identifying barriers to implementing a distress screening program is one of the purposes of this scholarly project. The participant criterion for a postsurvey was medical oncology nurses who attended the nursing staff meeting, where the implementation of the Distress Education Module took place, or watched the recorded video of the meeting. Intervention(s) The first step in the project involved assessing current nurses' knowledge, attitudes, beliefs (subjective norms), and confidence level as well as perceived barriers to distress screening via survey questionnaires. The second and third steps comprised developing an educational module and implementing it with staff nurses. The educational module, Distress Education Module, delivered via a PowerPoint presentation and handouts during the monthly staff meeting, included the overview of distress in the oncology population; NCCN and HCI's distress screening guidelines: timing of screening, screening interval, screening tools, assessment, referral options, documentation, and follow-up. The fourth step involved compiling data from the pre- and 10 postsurveys using descriptive and inferential statistics indicating any changes in nurses' knowledge, attitudes, beliefs, and confidence as well as actual practice. Lastly, presenting the executive report to key stakeholders of HCI comprised the final step, followed by incorporating stakeholder feedback into a final manuscript as potential implications for practice. Study of the Intervention(s) The evaluation of the effectiveness of the Distress Education Module consisted of conducting a presurvey and a postsurvey, with data collection at two time points, preimplementation and postimplementation, of the Distress Education Module. The survey included self-report self-administered questionnaires via REDCap, a web-based application for clinical research databases and projects. The presurvey took place over 3 weeks in November 2019, prior to the implementation of the PowerPoint presentation of the Distress Education Module and hand-outs during the monthly nurse staff meeting on November 21st, 2019. The postsurvey followed 6 weeks after the implementation, in January 2020. No other competing projects of a similar nature were being conducted at that time in the unit. The survey questions in this study aimed to measure changes in nurses' responses in their knowledge, attitudes, beliefs, and confidence regarding distress screening. Numerous studies have used the Theory of Planned Behavior (TPB) to measure the influence of attitudes and beliefs on the behavioral intention of health care professionals or patients. TPB explains an individual's personal motivation and intention of performing a particular behavior at a specific time and place (Ajzen, 1991). Ajzen claimed that TPB 11 predicts individuals' behavior by their intention, and three components determine behavioral intention: attitude, subjective norms, and perceived behavioral control. Using the TPB framework, the project chair, statistician, and content experts who were working with oncology patients with psychosocial distress assisted in developing a survey based on TPB. This scholarly project considered oncology nurses' behavior in performing distress screening for patients with cancer, and measured their behavioral intention by the three components: attitude, nurses' opinion about distress screening; subjective norms, nurses' motivation to comply with others' expectations; and nurses' perceived level of control, the internal factors (confidence) and external factors that may facilitate or hinder the implementation of distress screening. In addition, the self-reports of the nurses regarding the frequency of distress screening and the use of a validated tool formed the basis for assessment of the practice change. Also, the survey aimed to assess any changes in nurses' knowledge regarding NCCN and HCH's clinical guidelines of distress screening. Measures Recruitment of participants (i.e., the current nursing staff in the medical oncology unit of HCI) for the project took place in three phases: round one, questionnaire email out; round two, reminder email out; and round three, repeat questionnaire email out. The presurvey questionnaires consisted of 35 items divided into seven sections: knowledge, past behavior, attitudes, beliefs (subjective norm), perceived behavioral control (internal factors of self-efficacy or confidence), barriers (external factors), and demographics. The 12 postsurvey questionnaires consisted of 21 items divided into seven sections: knowledge, past behavior, attitudes, beliefs (subjective norm), perceived behavioral controls (internal factors), behavioral intention, and demographics. See Appendix A for the pre- and postsurvey questions. Analysis The project's statistical analysis comprised of the descriptive statistics and inferential statistics. The descriptive statistics, such as mean, median, mode, standard deviation (SD), and frequency distributions, summarized the demographic of the study participants and survey outcome variables. Also, nonparametric statistics determined the variation of the study participants and their survey responses between the pre- and postimplementation groups. A Fisher's exact test was conducted to compare the difference in the demographic of the participants in the pre- and postsurveys. A MannWhitney U test examined the changes between the pre- and postsurvey scores in nurses' level of knowledge, attitudes, beliefs (subjective norm), confidence, and nursing practice of distress screening. The statistical analysis was completed using SPSS and with support from a statistician from the College of Nursing. Ethical Considerations Prior to the implementation of this DNP scholarly project, the University of Utah Institutional Review Board (IRB) determined the study to be a quality improvement project and nonhuman subjects research. Also, there were no ethical conflicts in the 13 project. Participation in this scholarly project was voluntary, and no personal identifiers were used for the survey. Additionally, there was no incentive or deterrent to participation and no conflicts of interest discovered or disclosed by any of the project team members. Results Participants Characteristics Of 43 eligible nurses, 27 (63%) participated in the presurvey of the project. Of the 31 nurses who either attended the presentation or claimed to have watched the video version of the presentation, 19 (61%) participated in the postsurvey. The demographic characteristics of study participants in the presurvey and postsurvey included age, gender, race, professional roles, years of oncology experience, and the highest level of education. Demographic characteristics are shown in Table 1. In the pre- and postsurvey, the average age of participants was 35.9 years and 35.2 years, respectively. The percentage of nurses who participated in the pre- and postsurveys did not differ by gender and professional role (Fisher's exact, p=1.000). Also, there was no significant difference in the proportion of participants' race (Fisher's exact, p = 0.999). The majority of participants were female and White. The primary role of participants was staff nurse, and the highest level of education was a bachelor's degree. The participants' years of oncology experience varied but 2 to 4 years were the most common. See Table 2 for more details (Appendix B). Table 1 Demographic Characteristics of Study Participants Pre (N=27) 14 Post (N=19) Pre (N=27) n Post (N=19) % n % Gender Male 0 0 0 0 26 96.3 19 100 Other 1 3.7 0 0 White 24 88.9 18 94.7 Black 0 0 0 0 Asian 2 7.4 1 5.3 Native Hawaiian/Pacific Islander 0 0 0 0 Native American 1 3.7 0 0 Latino/Hispanic 0 0 0 0 Multiracial 0 0 0 0 Professional role Staff nurse 25 92.6 17 89.5 Nurse manager 1 3.7 1 5.3 Nurse educator 1 3.7 1 5.3 Case manager 0 0 0 0 Social worker 0 0 Pre (N=27) 0 0 Post (N=19) n % n % 1 3.7 0 0 2-4 years 11 40.7 6 31.6 5-7 years 6 22.2 3 15.8 8-10 years 3 11.1 4 21.1 Over 10 years 6 22.2 6 31.6 Associate diploma 2 7.4 2 10.5 Bachelor's degree 20 74.1 16 84.2 Master's degree 4 14.8 1 5.3 Clinical doctoral degree 0 0 0 0 PhD 1 3.7 0 0 Female Race Years of oncology experience Less than 1 year Highest level of education 15 Barriers to Distress Screening In the presurvey, nurses' perceived barriers to distress screening were assessed. The possible barriers consisted of three internal factors (i.e., knowledge, belief, and confidence regarding distress screening) and six external factors (i.e., patient factor, time, accessibility of screening tools, interdisciplinary team support, availability of clinical guidelines and policies, and financial resources). The survey questionnaire asked nurses to rate the impact that each factor played as a barrier to distress screening in their practice using a 4-point Likert scale ranging from 0 = not a barrier, to 1 = somewhat of a barrier, 2 = moderate barrier, and 3 = extreme barrier. The majority of nurses (85.2%, n=23) identified a lack of access to validated screening tools as a moderate to extreme barrier. Other barriers recognized as moderate to extreme were time constraints (59.2%, n=16), a lack of clinical guidelines and policies regarding distress screening in HCI (55.5%, n= 15), and insufficient screening knowledge (55.5%, n=15), followed by nurses' incompetence in distress screening (51.8%, n=14), limitation of financial resources (51.8%, n=14), and patient's unwillingness to discuss their mental health (51.8%, n=14). The majority of nurses (74/1%, n=20) did not perceive negative personal beliefs against distress screening as a barrier. Also, a large number of nurses (59.3%, n=16) identified poor interdisciplinary team support as "not a barrier" to only "somewhat of a barrier". A visualization of the findings is presented as a stacked bar chart in Figure 1 (Appendix C). Level of Knowledge Using the Mann-Whitney U test, this project analyzed changes in participants' survey responses between preimplementation and postimplementation of the Distress 16 Education Module in order to determine the impact of the intervention. The pre- and postsurveys mainly consisted of five sections: knowledge, attitudes, beliefs (subjective norm), confidence, and nursing practice of distress screening. Two questions were used to assess the level of knowledge: how familiar nurses were with NCCN's distress guidelines and with HCI's distress screening and management. Nurses answered the questions using a 5-point Likert scale ranging from 0 = not at all familiar to 1= slightly familiar, 2= somewhat familiar, 3= moderately familiar, and 4= extremely familiar. The median value of the postsurvey group was higher than that of the presurvey group regarding the participants' perceived level of knowledge in the NCCN's distress guidelines. Whereas 70.4% (n=19) of the participants in the presurvey group were "not at all familiar," the number of participants who responded that they were "not at all familiar" decreased to 21.1% (n=4) in the postsurvey. 57.9% (n=11) of the postsurvey participants responded that they were "moderately familiar" with the NCCN's distress guidelines. A Mann-Whitney test indicated a statistically significant difference in the level of knowledge regarding the NCCN's distress guidelines between the pre- and the postsurvey groups (U=76.000, p=0.000). Also, the median value of the participants' perceived levels of knowledge in the HCH's distress guidelines increased after the intervention. Whereas 25.9% (n=7) of the presurvey participants responded that they were "slightly familiar" with the HCH's distress screening and management, 63.2% (n=12) of the postsurvey participants responded that they were either "moderately" or "extremely familiar." A Mann-Whitney test showed that there was a statistically significant difference in the level of knowledge 17 regarding the HCH's distress guidelines between the pre- and the postsurvey groups (U= 119.500, p=0.002). These results suggested that the Distress Education Module led to higher levels of knowledge in the postsurvey group versus the presurvey group. The results are presented in Table 3 and in Figure 2 (Appendix D). Attitudes Four questions were used to assess the participants' attitudes toward distress screening for the oncology patients: if they believe that distress screening is important in nursing practice; if the screening is beneficial for oncology inpatients; if it increases the quality of care; and if it is helpful to identify patients who need intervention. The participants answered the questions using a 5-point Likert scale ranging from 0= strongly disagree to 1= disagree, 2= neutral, 3= agree, and 4= strongly agree. The majority of participants in both the pre- and postsurveys demonstrated positive attitudes toward distress screening. On average, 95.4% (n=26) of the presurvey participants and 96.6% (n=18) of the postsurvey participants responded that they either agree or strongly agree to the positive statements regarding distress screening. Although the median values of the four questions appeared to increase from either "agree" or "strongly agree" in the presurvey group to all "strongly agree" in the postsurvey group, a Mann-Whitney U test indicated that there were no statistically significant differences in the participants' attitudes regarding distress screening between the two groups. These results suggested that the Distress Education Module did not change the participants' attitudes regarding distress screening. The results of a Mann-Whitney U test on the nurses' attitudes are shown in Table 4. 18 Table 4 Nurses' Attitudes Changes on Distress Screening Between the Pre- and the Postsurvey "Distress screening is important nursing practice" "Distress screening is beneficial for patients" "Distress screening increases the quality of care" "Distress screening is helpful to identify patients who need intervention" Mann-Whitney U 217.500 242.500 255.500 185.500 Asymp. Sig. (2tailed) or p value 0.309 0.715 0.979 0.073 Confidence Nurses' level of confidence regarding distress screening in the pre- and the postsurvey groups was assessed via two questions regarding their confidence in (a) assessing emotional distress in oncology inpatients and (b) identifying when patients with distress need interventions. The participants answered the questions using a 5-point Likert scale ranging from 0= very unconfident to 1= unconfident, 2= neutral, 3= confident, and 4= very confident. The median values of the two questions were "neutral" in the presurvey and "confident" in the postsurvey. A Mann-Whitney U test demonstrated a statistically significant difference in the nurses' level of confidence in identifying when patients with distress require intervention (U=155.000, p=0.013). In contrast, no statistically significant difference was found in the participants' confidence in assessing distress in oncology patients between the pre- and the postsurvey groups (U=190.500, p= 0.107). A visualization of the findings is presented in a stacked bar chart in Figure 3 (Appendix E). Beliefs (Subjective Norms) 19 In this DNP project, subjective norms refer to nurses' beliefs that an important person or group of people such as nurse managers or medical providers will approve and support the nursing practice of distress screening. Beliefs or subjective norms were measured in the pre- and postsurvey groups by asking for a response to "my professional colleagues think that I should screen patients for distress." The participants answered the questions using a 5-point Likert scale ranging from 0= strongly disagree to 1= disagree 2 = neutral, 3= agree, and 4= strongly agree. The median values of the subjective norm were "agree" in both the presurvey (63.2%, n=17) and the postsurvey (63.2%, n=12). The number of participants who reported "strongly agree" increased from 7.4% (n=2) in the presurvey to 26.3% (n=5) in the postsurvey. Mann-Whitney U test indicated a statistically significant difference in the nurses' perceived levels of the subjective norm (U=174.000, p=0.033). The result suggested that the Distress Education Module has positively influenced the nurses' level of motivation to comply with professional colleagues' expectations in distress screening. A visualization of the findings is presented in a stacked bar chart in Figure 4 (Appendix F). Nursing Practice Change This scholarly project analyzed changes in participants' nursing practice regarding distress screening in the pre- and the postsurvey groups via two questions: "How often do you screen or assess oncology patients for distress" and "How often do you use validated tools during distress screening or assessment?" The participants answered the questions using a 5-point Likert scale ranging from 0= never to 1= rarely, 2 = sometimes, 3= often, and 4= always. Although the median values of the frequency of 20 distress screening or assessment were both "sometimes" in the pre- (33.3%, n=9) and the postsurvey groups (47.4%, n=9), 14.8% (n=4) of the presurvey participants responded that they "never" screen or assess oncology patients for distress, whereas no one in the postsurvey participants responded "never." Large numbers of nurses in the presurvey said that they would "rarely" or "sometimes" screen or assess the oncology patients for distress. In contrast, the majority of nurses in the postsurvey said they would "sometimes" or "often" screen or assess the oncology patients for distress. A MannWhitney U test indicated a statistically significant difference in the nurses' practice in the frequency of distress screening or assessment between the pre- and the postsurveys (U= 169.000, p=0.038). See Table 5 for details. Table 5 "How often do you screen or assess oncology patients for distress?" Valid Never Rarely Sometimes Often Always Missing System Total Pre (N=27) Frequency (n) 4 8 9 3 3 0 27 Percent (%) 14.8 29.6 33.3 11.1 11.1 0 100 Post (N=19) Frequency (n) 0 1 9 8 1 0 19 Percent (%) 0 5.3 47.4 42.1 5.3 0 100 Table 6 "How often do you use validated tools during distress screening or assessment?" Valid Never Pre (N=27) Frequency (n) 13 21 Post (N=19) Percent (%) Frequency (n) 48.1 3 Percent (%) 15.8 Valid Never Rarely Sometimes Often Always Missing System Total 13 9 5 0 0 0 27 48.1 33.3 18.5 0 0 0 100 3 11 3 1 1 0 19 In addition, the change in the usage of validated tools in distress screening and assessment was positive between the pre- and the postsurvey groups. In both the presurvey and postsurvey, many nurses responded that they "rarely" used a validated tool in distress screening or assessment. However, the proportion of nurses who answered "never" using the validated tool decreased from 48.1% (n=13) in the presurvey to 15.8% (n=3) in the postsurvey. See Table 6 above for details. A Mann-Whitney U test demonstrated a statistically significant difference in the nurses' practice in the usage of a validated tool (U=173.500, p=0.047). These results suggested that the Distress Education Module increased the frequency of distress screening and assessment as well as the usage of a validated tool in nursing practice in the postsurvey group versus the presurvey group. A visualization of the findings is presented in a stacked bar chart in Figure 5 (Appendix G). Behavioral Intention The study participants who either attended the presentation or watched the video version of the presentation were asked if they would screen oncology patients for distress if challenges were addressed. The participants answered the questions using a 5-point Likert scale ranging from 0= strongly disagree to 1= disagree, 2= neutral, 3= agree, and 4 22 15.8 57.9 15.8 5.3 5.3 0 100 = strongly agree. All postsurvey participants responded that they intended to perform distress screening: 16 (84.2%) said they "agree" and 3 (15.8%) said they "strongly agree." Learner Satisfaction Additionally, following the PowerPoint presentation of the Distress Education Module, participants (n =12) who physically attended the meeting were asked to respond to two statements regarding their opinion of and satisfaction with the education: "This educational presentation was useful and beneficial for my work" and "Overall, I am satisfied with this educational presentation." Both questions used a 5-point Likert scale with possible answers ranging from 0 = strongly disagree to 1 = disagree, 2 = neutral, 3 = agree, and 4 = strongly agree. All participants who listened to the presentation reported that it was a positive experience. For the statement asking if the education was useful and beneficial for their work, 6 (50%) responded that they "agree," and 6 (50%) reported "strongly agree." For the second statement about their satisfaction regarding the education presented, 7 (58.3%) responded that they "agree" that they were satisfied, and 5 (41.7%) reported "strongly agree." Discussion Summary This DNP scholarly project successfully identified medical oncology nurses' perceived barriers to screen inpatients for distress. Among a total of nine internal and external factors, the majority of participants acknowledged poor accessibility to validated tools and time constraints as moderate to severe barriers to distress screening. Many 23 nurses did not perceive personal beliefs against distress screening and lack of interdisciplinary team support as barriers. As predicted, the results demonstrated that the Distress Education Module for nurses was a feasible and effective intervention for producing statistically significant improvements in knowledge, subjective norm, and confidence levels regarding distress screening. Although no statistically significant gains in participants' attitudes were demonstrated, the results showed some percentage increases in positive attitudes toward distress screening. Furthermore, this project confirmed that the improvement in knowledge, attitudes, beliefs (subjective norms) or confidence levels could develop into actual practice changes. The participants reported that both the frequency of distress screening and the usage of validated screening tools had increased after the Distress Education Module. Interpretation Because nurses routinely conduct patient assessments, they are in an ideal position to identify patients in distress and intervene on their behalf (Tavernier et al. 2013). Results of this project supported that educating inpatient nurses via the Distress Education Module was effective in increasing their knowledge or familiarity with the NCCN distress screening and management guidelines. Furthermore, the intervention not only improved nurses' confidence and subjective norms but also produced positive changes in nursing practice: an increased number of nurses participated in distress screening and assessment by using validated screening instruments. These findings are similar to findings from other studies: higher familiarity with the NCCN guidelines was associated with higher utilization of validated assessment tools and more evidence-based 24 practices regarding distress screening and management (Tavemier et al., 2013). There was no meaningful change in nurses' attitudes towards distress screening in this project, perhaps because positive attitudes towards distress screening were widely found in a large number of nurses (over 95%, n=26) even prior to the intervention. Nonetheless, an education module alone was insufficient to establish the routine nursing practice of distress screening in the inpatient unit. Although nurses who "often" to "always" perform distress screening and assessment increased from 22.2% (n=6) to 47.3% (n=9), still more than half of the nurses (52.7%, n=10) reported that they "rarely" or "sometimes" screen and assess patients for distress, despite the educational seminar. This result suggests that routine screening for distress among oncology inpatients should be improved. According to Horyna and her colleagues (n.d.), more than 70% of the eligible patients in the outpatient clinics of HCH were screened for distress in 2017. The inadequate distress screening and assessment rates in the inpatient unit aligned with findings from other studies. A recent study showed that despite the number of NCCN member institutions conducting routine distress screening increasing from 70% in 2012 to 85% in 2018, only 26% endeavored to screen all patients in both outpatient and inpatient settings, and 74% screened either outpatients or select groups of patients only (Donovan, Deshields, Corbett, & Riba, 2019). This DNP scholarly project identified nurses' perceived barriers to distress screening and discovered several areas that need to be addressed before the formal implementation of routine distress screening in the inpatient unit. Nurses recognized numerous distress screening barriers associated with either external factors, such as a 25 lack of access to validated screening tools, time constraints, and an absence of clinical guidelines and policies regarding distress screening in HCH, or internal factors, such as nurses' insufficient knowledge and incompetence in distress screening. The findings suggested that both individual and organizational efforts are required to reduce these difficulties. According to Donovan et al. (2019), numerous NCCN member institutions successfully improved the acceptance and implementation of the routine distress screening via a formal distress screening protocol or a systematic and organizational process in their institution. Limitations This DNP scholarly project has several limitations. First, the study sample size is small and relatively homogenous, and thus it is limited by a lack of national representation of registered nurses in the US. The study sample was younger, less racially and sexually diverse, and with a higher level of education than the national average. Second, time constraints limited the ability to measure the effectiveness of the educational intervention on knowledge retention and practice change over a greater length of time, such as 6 months to 1 year. Third, this project used Likert and Likert-type scales, which may be adequate to assess participants' attitudes, beliefs, or behavior but limit participants' responses to only five choices. Each choice cannot possibly be equidistant, and survey participants usually avoid choosing the "extreme" options on the scale. Thus, Likert and Likert-type scales may not have measured the true attitudes or values of study participants. Conclusions 26 This DNP scholarly project was the first distress education project that has been implemented in the inpatient oncology units of Huntsman Cancer Hospital. The project provided the groundwork for future implementations of distress screening by identifying nurses' barriers and impacting their practices by improving their intention to screen patients for distress. The Distress Education Module was feasible to implement, easy to utilize, and received high marks from study participants. The nurses' self-reported survey results demonstrated that the Distress Education Module increased their perceived levels of knowledge and confidence regarding distress screening and management. Furthermore, this project showed an initial positive impact on nursing practice in the identification of distress and utilization of validated screening tools. Thus, continued projects examining distress education of all inpatient oncology nurses are encouraged. The recommended next step is to address barriers to distress screening at the organizational level. Outpatient clinics of Huntsman Cancer Hospital are currently utilizing Patient-Reported Outcomes (PROs) via a portable tablet or patients' email to conduct distress screening. Since PROs are the measurements that come directly from patients by using validated screening tools, nurses do not necessarily need to conduct distress screening. After patients complete the distress screening, the results are readily available in the electronic health system, Epic. Thus, PROs eliminate some of the identified barriers, such as time constrains and lack of access to validated tools. Another recommendation is to establish and implement clinical guidelines about distress screening and management for the inpatient oncology units at Huntsman Cancer Hospital to facilitate nurses' distress screening practice. After establishing a distress screening 27 process, further research is proposed that focuses on the utilization and effectiveness of distress screening, such as distress screening rates in inpatient units, intervention and referral rates for patients with distress, and any positive changes in patient outcomes. Acknowledgements A special thanks to my project chair, Ana Sanchez-Birkhead, Ph.D., WHNP-BC, APRN, for her dedication and commitment to her students. I would like to express my gratitude to Rebecca Wilson, Ph.D., RN, a professor at the University of Utah College of Nursing, for her assistance and guidance with the surveys. Also, I would like to acknowledge two content experts, Cassidy Doucette, APRN, and Jennifer Shaw, APRN, for their input. This DNP scholarly project would not have been possible without the cooperation of the Medical Oncology Unit of Huntsman Cancer Hospital, including Nurse Manager, Jen Jones, BSN, RN, OCN, and Patient and Family Support Manager, Amy Horyna, MSW, LCSW, OSW-C. Lastly, my gratitude would be incomplete without acknowledging the encouragement and support of my family every step of the way. 28 References Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179-211. Delgado-Guay M., Parsons, H. A., Li, Z., Palmer, L. & Bruera, E. (2009). Symptom distress in advanced cancer patients with anxiety and depression in the palliative care setting. 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Error Error 11.64773 1.000 .448 .178 .872 35.8519 31.00 31 1.04 1.00 1 0.192 5.196 .448 27.000 .872 .30 .00 0 .912 3.289 .448 10.989 .872 34 Pre (N=27) Post (N=19) Age 35.8519 31.00 31 11.64773 1.000 .448 .178 .872 1.04 1.00 1 0.192 5.196 .448 27.000 .872 Race .30 .00 0 .912 3.289 .448 10.989 .872 Nursing role .11 .00 0 .424 4.046 .448 16.714 .872 Years of oncology experience 2.07 2.00 1 1.269 .461 .448 -1.175 .872 Highest level of education Age* (n= 18) Gender Race 1.19 1.00 1 .736 2.191 .448 7.951 .872 35.17 32.50 29 11.126 1.355 .536 1.687 1.038 1.00 .11 1.00 .00 1 0 .000 .495 ⦁ 4.359 .542 .524 19.000 1.014 1.014 .16 .00 0 .501 3.339 .524 11.190 1.014 Years of oncology experience 2.53 3.00 1 1.264 -.066 .524 -1.707 1.014 Highest level of education .95 1.00 1 .405 -.498 .524 4.645 1.014 Gender Nursing role Note. Only one system missing data in the participant's age of the postsurvey* Appendix C Figure 1 35 Nurses' Perceived Barriers to Distress Screening 36 Appendix D Table 3 "How familiar are you with the NCCN's clinical guidelines for distress screening and management?" Valid Not at all familiar Slightly familiar Somewhat familiar Moderately familiar Extremely familiar Missing System Total Pre (N=27) Frequency (n) 19 7 1 0 0 0 27 Percent (%) 70.4 25.9 3.7 0 0 0 100 Post (N=19) Frequency (n) 4 1 3 11 0 0 19 "How familiar are you with the Huntsman Cancer Hospital's clinical practice for distress screening?" 37 Percent (%) 21.1 5.3 15.3 57.9 0 0 100 Valid Not at all familiar Slightly familiar Somewhat familiar Moderately familiar Extremely familiar Missing System Total Pre (N=27) Frequency (n) 10 7 4 5 1 0 27 Appendix D Figure 2 Changes in Level of Knowledge Appendix E Figure 3 Changes in Level of Confidence 38 Percent (%) 37.0 25.9 14.8 18.5 3.7 0 100 Post (N=19) Frequency (n) 1 3 3 9 3 0 19 Percent (%) 5.3 15.8 15.8 47.4 15.8 0 100 39 Appendix F Figure 4 Changes in Nurses' Perceived Level of Subjective Norm 40 41 Appendix G Figure 5 Changes in Level of Practice 42 43 44