Introduction

During the cancer development a significant number of Physical, emotional and social changes are produced; as a result, it generates numerous needs in both, patients and families. This can change from an individual to other over the time ¹.

Most of the patients and caregivers do not expressed their worries to their doctors, and when the share their needs often they omit psychosocial important aspects.

Various factors cause this difficulty: many patients and their caregivers believe that problems such as pain, grief, anger and suffering are inevitable when dealing with cancer, others tend to think that doctors do not want to deal with it or to face such problems since they perceive the doctor's lack of interest, a key element in meaningful communication; as a result, there is a misunderstanding of the patient and family's needs, and the cost of health care and the unnecessary pain increases ². For health care professional in particular doctors, examined this aspects means see the patients as individuals through the different stages of the disease, from the diagnosis through the terminal phase ³.

According to Bonevski, there are three primary methods used to measure some results from the cancer patient's morbidity: life quality, patient's satisfaction, and necessities assessment ⁴. Cossich consider that the first two have failed because they blend the practical results of quality service with the patient perception about morbidity and treatment process ¹. The necessities assessment might provide a direct measure of the real necessity of help related to unidentified needs ¹.

Meanwhile the life quality assessment measure different aspects of life experience and surveys about patient's satisfaction have been focused on the patient's care quality perception; in contrast, life quality assessment looks after life quality and care quality, when the impact on the patient's necessities is valued. According to this authors, regardless of the methodologist the common goal is obtain information about health care results that are pertinent to support the improvement of the patient care quality and the reduction of morbidity related to cancer ⁴.

Cancer modified the order and nature of mind state health necessities, due to the necessities of cancer patients is different because of the situation the person is experience, as in the case of the first phase, the diagnosis, during the hospitalization or home care treatment, etc ³. Patients tend to report unsatisfied needs when either the disease or its treatment impose restrictions to daily activities, and particularly when their financial resources are reduced, or when they have been forced either to use public health services or to accept help from people other than their own relatives ³. This author sets out the concept of need as the subjective desire and the lack of something needed.

Studies conducted during the past two decades, underline cancer patients needs such as: family adjusts, health care system interaction, stigmas, need for information, sexuality and life style preservation. It has been found cancer patients have more needs in the area of personal care, control of activities and interpersonal interaction related to the way they are perceived by their families. Nowadays patient's needs have been increasing and have created a biggest necessity of assistance in aspects such as: patient's transportation, home care, daily activities development and cost reduction caused by the disease ⁵. When patients and family's needs cannot be support by informal support networks, formal support networks are needed; for example, community organizations and ambulatory care programs. This is a reason why the use of this services will increase in the future.

Information needs are expected to be greater immediately before medical treatment starts (the detection and diagnosis phase), during hospital or ambulatory treatment, and in the period after treatment (back home, during recovery or the terminal phase). These needs are particularly conspicuous during the diagnosis stage, when making decisions before the medical treatment, when patients must undergo invasive surgical procedures or when the treatment has significant secondary effects that change dramatically the patient's life style or physical appearance ⁵. Psychosocial needs appear more often when the patient perceives the situation is difficult to control due to physical and emotional reasons.

The patients who expressed the most unsatisfied needs where young patients, low-income patients, patients without relatives near who were able to give them support, patients who their caregiver was not their partner, patients with kids, and patients with low support systems and resilience ⁶.

The care necessities assessment in cancer patients is a critical phase to provide high quality attention and fulfill the patients and family's needs. In Colombia, were not found publications to identify specific needs of cancer patients, nor any form of register with systematized information on aspects related to the expectations of cancer patients regarding to the care required across all steps of the patient's journey. Usually, the care offered by nursing staff to cancer patients is based on their empirical perception since no systematic assessment is made to identify the needs of these patients during their illness and treatment. This is the first study in Colombia that is focus on the assessment of specific needs of cancer patient in order to guide the planning of future health care interventions and develop nursing programs care for cancer patients in ambulatory treatment. In this study we assessed the health care needs in five aspects as were described by authors of SCNC SF34 questionnaire, and these are referred as the domains of assessment.

Goals

The main goal of this study was to establish the health care necessities of cancer patients in ambulatory treatment. We focused directly on the assessment of support needs as is perceived by the patients themselves and to later use this information to prioritize the services they require in order to prevent (or at least reduce) the possible problems by early and appropriate interventions.

Methodology

Cross-sectional study: 173 adult patients receiving ambulatory chemotherapy or radiotherapy treatment in three specialized oncology units at two hospitals in Bogota.

Procedure

The results of the validation process of the SCNC SF34 questionnaire in its Spanish version, led the authors to identify the care needs of cancer patients in the oncology units selected for the study to promote, the planning of nursing care specific to address these needs. This study was approved by the Institutional Ethics Committee of the Nursing School from the Pontificia Universidad Javeriana, Bogota, Colombia.

Once each of the institutions gave their ethical approval and authorization to carry out this study, the researchers trained two oncology nurses on how to apply the questionnaire on the regular procedures, after obtaining the participant's informed consent and how to guide and support them while they filled in the questionnaire.

The oncology nurses got in touch with the patients during the period of the chemotherapy or radiation treatment. Each participant was fully informed on the nature of the study, its aims and the procedures behind gathering the relevant information. They asked for their consent and once they had expressed their willingness to participate, each participant received the questionnaire to be answered individually. In all cases, during this activity the nurses offered the patients their help (if needed) to fill in their answers. Each patient answered the questionnaire only once.

Results

Discussion

Holistic assessment of necessities should be part of the care provided to all cancer patients. It can make a big difference in the overall experience of the patient and can improve the results through the effective identification and soon solution of problems⁷. The holistic approach as philosophy, takes into consideration the physical, social, psychological and spiritual aspects of human beings as being closely related. Thus, a holistic assessment sees all these aspects as one, rather than being a goal in itself, this kind of assessment is a way of guaranteeing that the patient's worries and concerns are clearly a priority to be attended.

This approach matches the general objective of warranting a type of care that takes into account the individual's state of health, and his care needs. The relevance of a holistic assessment of cancer patient's needs may be summarized as follows ⁷; it identifies people who need help. It provides patients with the opportunity to think about their personal needs, and to plan along with their health caregivers how to satisfy those needs. It helps patients to self-manage their condition. It helps health care teams to work more efficiently by focusing their support and making appropriate and well-informed decisions.

The survey applied in this study allowed us to explore the needs in five domains. In general terms and for all five domains approximately, half of the patients identified unfulfilled needs and the remaining half claimed not being aware of such needs or having fulfilled them. This is one of the main findings of this study, since it underlines how important it is for oncology nurses to be capable of making individual assessments and then identify those needs in order to plan and execute the direct care and educational activities required by each patient so he/she can care for him/her-self and follow the required therapeutic measures at home.

Over 39% of the participants expressed having psychological needs in all aspects assessed; uncertainty about the future was manifest in slightly less than half of them. The psychological aspects allude to the emotions and feelings that at a particular moment, a patient perceives related to his/her oncology illness and the effort of coping with the particular therapeutic treatment he/she receives. The needs for psychosocial support are more frequent when patients find it difficult to control the situation due to physical or emotional reasons.

Patients tend to report unsatisfied needs when either the disease or its treatment impose restrictions to daily activities, and particularly when their financial resources are reduced, or when they have been forced either to use public health services or to accept help from people other than their own relatives. Overall, it is clear, that at any given moment of the illness, cancer patients can feel despondent, depressed, or anxious; they can also fear to the expansion of the cancer or that the treatments will not have positive results, thus generating uncertainty as to their future lives; if individual assessments are not carried out, or if tools that allow the patient to report the aforementioned anxieties are not used on many occasions, it would not be possible to identify these emotional needs.

Psychological distress was high among both, patients and careers; although well within the levels of distress previously reported from other cancer patient groups and their careers. According to our hypothesis, psychological distress was closely associated with greater supportive care needs and similar results have been reported previously in other studies ⁸⁾⁽⁹.

In relation with worries concerning to the health system and general information, over half of the participants expressed their need to receive written information, about the most important aspects of the type of care he/she might require and about dealing with the ailment and the treatment's side effects. Information needs are defined as an experience where the patients lack of information concerning to their life control. It has been observed that most cancer patients have unsatisfied information needs, and that there are misunderstandings amongst health care providers in terms of such needs¹⁰. When trying to satisfy patient's needs, there are discrepancies in the perception of such needs by patients, doctors and nurses ³. Not all health professionals share the same ability to obtain relevant information; likewise, not all patients are equally able to express their worries and anxiety.

Many caregivers and patients do not manage to communicate their concerns to doctors. When they do so, they often omit important psychosocial aspects. Various factors cause this difficulty: many patients and their caregivers believe that problems such as pain, grief, anger and suffering are inevitable when dealing with cancer, others tend to think that doctors do not want to deal with it or to face such problems since they perceive the doctor's lack of interest, a key element in meaningful communication¹¹.

Andreassen et al, describe that it is evident that patients and family members consider most information to be of high importance; yet, certain areas of information were considered more important than others. The high rating for information about tests/treatment and self-care means that both patients and family members, consider this to be the most important areas of information ¹². In this study, physicians, registered Nurses, and Assistant Nurses, underestimated both, patient´s and family member´s need for information, which is consistent with the findings reported by others authors. This lack of information must be recognized and used by physicians, as they are reported to be the main source of information for patients with cancer and their family members.

Even though health professionals are the most common sources of information for cancer patients, it is worth-mentioning that most patients also consult non-medical information sources; this has implications for practice: while healthcare professionals must continue to fulfill their role as information provider, they must also recognize the importance and range of other media to supplement their consultations ¹³. Unsolved information queries increase the patient's general discomfort; i.e. they raise anxieties and depression levels thus hindering the patient's efforts to adjust to their ailment ¹⁰.

Information needs are expected to be greater immediately before medical treatment starts (the detection and diagnosis phase), during hospital or ambulatory treatment, and in the period after treatment (back home, during recovery or the terminal phase). These needs are particularly conspicuous during the diagnosis stage, when making decisions before the medical treatment, when patients must undergo invasive surgical procedures or when the treatment has significant secondary effects that change dramatically the patient's life style or physical appearance.

The physical aspect, was the one in which more needs were explicitly expressed by the participants. Over 54% of them identified at least one need in each of the assessed aspects. Weariness and energy lost are conspicuous among cancer patients at different stages of their illness and not always specifically or necessarily related to a particular type of treatment, thus both can be presumed as discomforts ―natural to cancer and therefore many times ignored by health professionals without giving them the attention needed to identify and alleviate them. Patients under these conditions feel discomfort most of the time, stop doing the activities they used to do, and even feel that they cannot carry out to the daily household chores. These physical aspects are the easiest to identify, yet, if they are not, it is impossible to alleviate them thus affecting the patient's overall well-being.

One very important symptom in oncology is pain. Usually associated to advanced stages of the illness or related to invasive procedures; in this study we found that 54.35% of the patients suffered uncontrolled pain while they received either chemotherapy or radiotherapy; this fact should force all health professionals to reflect on the importance of periodically assessing this particular symptom and take the necessary measures to effectively alleviate the pain.

The patient's support and care aspect showed the highest satisfied averages as manifested by 59.77% of the participants; nevertheless, it is essential to work towards satisfying the necessities expressed by the other patients. They expressed the need for the hospital´s staff to acknowledge and be sensitive to their feelings and emotional needs, or expected immediate attention in reference to their physical needs, and a reassuring attitude from the medical staff in relation to the patient's overall feelings.

The sexual aspect was the second less affected; nevertheless, an average of 41.61% of the participants expressed not having fulfilled this need and specifically demanded to be informed about the changes the treatments might bear upon their sexual life as well as on the possible changes of their own emotional feelings and emotions about their sexuality. If health professionals do not specifically explore the patient's sexual needs, they will not report it and the whole treatment might go ahead and the patients might never openly acknowledge their specific needs in this area, thus affecting the relationship with their sexual partners and therefore their life quality.

The Department of Human Services of Victoria, Australia ¹⁴, in its model for supportive care needs provision, defines supportive care as an ―umbrella term that covers all services, both generalist and specialized, that may be at any time necessary to support both, cancer patients and their caregivers. This term includes self-help and support, information, psychological support, symptom control, social support, rehabilitation, spiritual support, palliative care, and bereavement care. They specify that in the context of cancer, the main supportive requirements should attend all: physical, psychological, social, and spiritual needs plus the need for information.

They highlight the fact that patients with cancer that receive education and psychosocial interventions suffer lower levels of anxiety, mood disorders, nausea, vomiting, and pain, plus have a better understanding of both, their illness and their treatment. At the same time, they consider just as important the provision of psychosocial support and care to those diagnosed and treated for cancer as well as for their caregivers or family, since this kind of support is an all-round component of the best clinical supportive care practices as experience has shown. They set up that an important step in the provision of supportive care services, is to identify by routine and systematic questioning of the patient and family, views on issues they require help with for optimal health and quality of life outcomes ^14). In this model they recognize that while there are needs to be provision of general information to all patients, only a few will require specialized intervention.

It is important to consider not only the symptoms, but other factors which might be affecting the patient's daily functions and their particular support needs ¹⁵⁾⁽¹⁶. For health practitioners and particularly for physicians, analyzing these aspects implies paying more attention to patients throughout the different stages of the disease, that is to say, from diagnosis to the terminal stage ³. Whatever the reasons, patient's needs can be inadequately identified and thus bring about unnecessary anguish ¹⁷. As a result of the inadequate understanding of such needs, both health care costs and suffering are unnecessarily increased. Professional nurses must remember that many patients (as well as their caregivers) do not always manifest their worries to their doctors, and even when they do, they frequently leave out important psycho-social factors ¹¹.

Therefore, all health related staff should be prepared to show their interest in these matters by asking questions and attempt to establish an appropriate communication strategy to better understand their patients and their family's needs, thus avoiding needless suffering and contributing to change the idea that pain, grief, anger, and suffering are unavoidable in patients with cancer ⁷. These concerns should be attended by explicitly informing all patients not only orally but in writing, and this should be done not only by the practitioner but also by the oncology nurse. The professional nurse plays a relevant role to help to fulfill the cancer patient's informational needs and is usually the preferred information source of the patients under treatment ^{13)(16)(18)(19}.

Contemporary medicine has progressively become aware of the importance of the patient's perspective regarding to their health care and the need to better understand the value of the interrelationships established among health care needs, their satisfaction, and the patient's quality of life ²⁰. Having a customary assessment system available offers an excellent opportunity for health professionals to better understand and respond to the patient's needs.

There is growing interest in improving the assessment of those needs. Also, there is a manifest interest in tools which can be used during the periods of assessment in order to systematize the process of identifying the needs experienced by patients in search for help, attention, and support ¹⁷. Conditions derived from the new forms of medical care to cancer patients undergoing ambulatory treatments, shorter hospitalization and longer survival periods; increase the need for information about it and support to issues such as patient transportation, home care, daily activities and new expenses caused by the disease ⁵. Cancer patients have multiple needs including family adjustment, interaction with the health care system, stigma, information requirements, sexuality and life style preservation ¹⁸.

Conclusions

In this study, the Necessities Assessment for supportive care in Cancer Patient Care in ambulatory treatment, according to their classification in domains were reported in order of frequency as well: the physics and everyday life, those related to health system and information, then psychological aspects, aspects of sexuality and finally the needs of care and patient support.

More than half of the patients said that they have unmet needs in at least one of the domains of the questionnaire. This information obtained on the needs of unmet Delivery of Health Care in cancer patients in outpatient treatment, it is useful to plan care management of these patients in units where the study was conducted, and can also help to other similar units to establish strategies to improve the nursing care.