Patient satisfaction with nurse‐led end of treatment telephone consultation for breast cancer during COVID‐19 pandemic

Abstract

The COVID-19 pandemic has instigated significant healthcare delivery adjustments across specialities, with breast units being no exception. To minimize hospital footfall and infection risk, end of treatment consultations for patients within 3 months of completing hospital treatment has been undertaken via telephone rather than face-to-face. These time-dependent consultations encompass key aspects of the Macmillan Recovery Package,1 including the Treatment Summary, Holistic Needs Assessment and signposting to survivorship support services. While from a COVID-19 standpoint, the rationale for the change in consultation format for these potentially vulnerable patients was robust, it was recognized that the quality of the consultation might be compromised. A mixed-methods study was undertaken to evaluate patient satisfaction with a telephone consultation format and establish whether a permanent change was justified. Telephone consultations are not a new tool in medicine. Studies show patients to be equally satisfied with face-to-face and telephone consultations,2 but the literature regarding their efficacy lacks consensus.3 The challenge with a telephone consultation is maintaining clear and effective communication in the absence of nonverbal cues, with the elimination of silences in a telephone consultation providing less opportunity to raise concerns and ask questions.2. Distinguishing emotional tone in a patient's voice takes time to develop; clinical staff receive limited training in this area.4 However, telephone consultations are clearly beneficial from an infection control perspective and hence during a pandemic may result in patients who are more relaxed, receptive to information, and engaged.5 They may also be more cost-effective and convenient6 for both patients and clinicians. Sixty-two patients scheduled for an end of treatment consultation during lockdown had been informed their appointment would be by telephone rather than face-to-face. Telephone appointments were undertaken by a Breast Care Nurse and Cancer Support Worker. Thirty-one patients were randomly selected for this study; one patient declined; 30 gave verbal consent and completed a 12-point telephone questionnaire conducted by medical students seconded to the trust during the COVID-19 response and with no prior knowledge or experience of the service. Patient factors demonstrate a range of ages; treatments and prognoses had been included. Patient age (mean: 61.5 ± 12.0) ranged from 37 to 86 years; under 60s (n = 11), 60-69 (n = 10), and over 70s (n = 9). All had undergone breast surgery, plus or minus chemotherapy, radiotherapy, and hormone therapy. Nottingham Prognostic Index scores for patients with invasive breast cancer (n = 23) were excellent (2), good (n = 10), moderate (n = 7), and poor (n = 4). The remaining 7 patients had ductal carcinoma in situ (DCIS). Patients reported high mean satisfaction rates for the consultation format (8.7 ± 1.55/10); 90% scoring 8 or above, of which 59% scored 10. The consultation itself also received a high mean satisfaction score of 9.5 ± 0.81/10; 60% responded with 10/10 and no patient rated their consultation lower than 7/10 (Figure 1). All patients felt sufficient time was allocated, and were able to speak freely and ask questions. Ninety-three percent had their questions and concerns completely (87%) or mostly (6%) addressed. Seventeen percent of patients would have preferred to have spoken to a doctor rather than a nurse; this preference was not age-dependent and follow-on comments cited “more assurance” and “better knowledge.” Twenty-three percent thought a clinical examination was needed; of these, 43% wanted their surgical wound checked, 13% another symptom to be looked at and 72% “reassurance/peace of mind.” Half the patients would have preferred a face-to-face consultation (Figure 2). This was age-dependent with 73% of patients below the age of 60, and 37% above the age of 60 preferring face-to-face consultation. However, 5 of these patients stated they would be happy with either consultation format. Ten patients (67%) cited communication reasons for their choice (body language, more personal conversations, better explanations). Three patients felt face-to-face consultation was more reassuring. Of the 15 patients who preferred a telephone consultation, 6 (40%) gave convenience and 4 (27%) comfort as reasons. Two patients said that if they had been anxious or had a problem, they would have preferred a face-to-face consultation. The reasoning behind the 50/50 split between telephone and face-to-face consultation was consistent with much of the current literature; offsetting communication with practicality. We expected older patients to favor more traditional face-to-face appointments, yet they were generally more willing to sacrifice communication benefits and stay at home. However, appointments for these patients were scheduled during the highest-risk period for the coronavirus.7 It is likely government advice and the threat of COVID-19, particularly in this higher-risk age-group8 was a factor in their response and the preference for face-to-face consultations may therefore be an underestimate. Younger patients may have been more concerned by their diagnosis than the risks of COVID-19, hence favoring a face-to-face discussion. This project represents the patients’ perspective at the time of lockdown. Clinician views, time, cost-effectiveness, and the impact of COVID-19 should also be considered before any change in service provision. Other options include giving patients the choice of consultation format and exploring video consultations which could act as a compromise, but these may be more resource-dependent and logistically challenging. This project concluded that during COVID-19, patients were satisfied with their experience. of a nurse-led telephone end of treatment follow-up consultation, but at least half the patients would still prefer a face-to-face consultation and a minority would prefer to consult a doctor.

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