The experiences of oncology and palliative care nurses when supporting parents who have cancer and dependent children
Anne Arber, PhD; Anki Odelius, PhD
Author Affiliations: Faculty of Health and Medical Sciences, University of Surrey,
Guildford, UK.
Correspondence: Anne Arber, PhD, Faculty of Health and Medical Sciences,
University of Surrey, Guildford, UK GU2 7XH ([email protected])
Acknowledgement: Sincere thanks to all the who generously gave of their time to take
part in the research. The research was funded by a grant from Jigsaw South East.
Conflicts of Interest: "The authors have no conflicts of interest to disclose."
1
Abstract
Background: It is important not to ignore the impact of parental cancer on children
and this is where oncology and palliative care nurses can play a key role; providing
support to parents as a regular aspect of oncological nursing care.
Objectives: This study explored the experience, needs and confidence of nurses
working in acute cancer services when supporting parents with cancer who have
dependent children.
Methods: Two focus group interviews were conducted with oncology and palliative
care nurses in one acute hospital trust in the south of England.
Results: Nurses described how they identified with their patients as a parent
themselves. This identification with patients added to the emotionally charged
context of care and resulted in nurse avoidance of the troubling issue of dependent
children. Nurses identified the importance of peer support with regular opportunities
to reflect on practice when dealing with issues relevant to parents and children.
Conclusions: Oncology and palliative care nurses take a reactive approach to family
centred care, taking their cue from patients to initiate or request support for their
children.
Implications for Practice: Guidance was needed on children's developmental stages
and how to communicate with children of different ages. Additionally, guidance was
needed on assessing family needs and access to up to date resources. To enable
nurses to engage with the issue of children, strategies of peer support and further
educational opportunities need to be implemented.
2
Background
The needs of children of parents with cancer are often not recognised by those
professionals supporting the parents1. Many families receive limited information from
nurses regarding the impact of parental cancer on dependent children2. Healthcare
professionals may be medically oriented as their primary role is to provide support
and medical care to the patient and issues regarding children may be avoided as this is
an emotionally charged and sensitive area1. It is important not to ignore the impact of
parental cancer on children and this is where oncology and palliative care nurses can
play a key role; providing support to parents as a regular aspect of oncological nursing
care2. Most children and families facing loss do not need specialist help nor
intervention but support at all levels of care are necessary to the well-being of patients
and their children3.
Providing support to parents of dependent children can be distressing and
emotionally draining and nurses were observed to use distancing tactics in one study
saying: ‘it’s terrible to say, but it isn’t any of our business how they cope as a
family’4. Furthermore, support may only be offered on an ad hoc basis4. However,
Fearnley found nurses used sensitive communication skills to assess what children
had been told: 'very gentle to test out what the children may have been told'1. It is
considered important that clinicians ask the patient ‘do you have children…do you
want to talk about them?’ and this opens up the possibility of further dialogue and is
supported by policy directives in Finland where the needs of children must be
considered when parents are treated in healthcare services5. Anxiety is reported to be
heightened when children do not receive information about their parent’s illness and
3
regular medical updates were found to be helpful to young children between the ages
of nine and eleven years 6.
Both professionals and parents have been found to be hesitant to delve into the needs
of children for a variety of reasons; including not knowing what to say and wishing to
protect children 1. In an interview study with women (n=8) with advanced cancer
Turner et al found that most women experienced avoidance of any discussions about
the impact of their diagnosis on children; despite the women identifying nurses as
being in a good position to provide support and resources7. Health professionals
understandably do not want to cause further emotional distress to the parent.
However, health professionals may not have the skills and confidence to assess the
impact of parental cancer on children7. It is important to note that around one third
of those with breast cancer have been reported to have dependent children8. Children
with a parent with a life limiting illness such as advanced cancer can manifest
significant distress6. Parents reported a lack of confidence and skills when talking to
children about cancer and children were found to have a number of misconceptions
and fantasies related to cancer9. Children and young people were found to have
unmet needs as parents struggled to meet the challenges of a life limiting illness10.
The research discussed in this article was prompted by a lack of knowledge about how
oncology and palliative care nurses supported families with dependent children. The
aim of the study was to explore the experiences, confidence and needs of oncology
and palliative care nurses who worked in the acute hospital setting with patients who
had dependent children.
4
Research questions
1. What are the experiences of oncology and palliative care nurses regarding
support for a parent with cancer who has dependent children?
2. How do oncology and palliative care nurses support parents who have
cancer in relation to their children?
Study Design
The study was designed as a descriptive qualitative study using focus groups methods
to study the experiences of oncology and palliative care nurses when supporting
parents with cancer who have dependent children. In the United Kingdom, oncology
and palliative care nurses working in specialist areas are graduate level registered
nurses, normally holding a Master’s degree, who specialise in a particular field of
practice such as cancer care, palliative care and/or an aspect of treatment such as
chemotherapy administration11.
The study took place in one acute hospital trust in the South of England, recruiting
oncology and palliative care nurses in the acute hospital (in-patient) setting. The Lead
Cancer and Palliative Nurse at the hospital was part of the of the principal
investigator’s professional network prior to the study. Communication between the
principal investigator and the lead nurse lead to an insight that it would be beneficial
to explore the issue of nurse’s support to parents with cancer who had dependent
children through a small scale study using focus group methods.
5
Method
The aim of focus group methodology “is to get closer to participants’ understandings
of and perspectives of certain issues” and these understandings partly develop through
communication between participants12.
Knowledge is scarce about the views and needs of nurses in relation to support of
children of a parent with cancer. The use of focus group methods offered opportunity
for nurses to be able to discuss experiences and views with colleagues in a safe
environment, which provided new knowledge about their experiences and insights
into their needs. Following on from this study was the potential for further in-depth
research in other settings and opportunities for the development of practice
interventions in the future.
Two audio recorded focus group discussions (n=12) were carried out with nurses
representing different oncology and palliative care practice areas (see Table 1) who
discussed their experiences and needs in relation to patients who have dependent
children. The interviews were guided by a topic guide, where open-ended questions
were used to facilitate the groups by a skilled qualitative researcher, experienced in
running focus groups. Each focus group lasted for approximately one hour.
Data Collection
This was a purposive sample of oncology and palliative care nurses who were invited to
attend one of two focus groups. A decision was made to limit the study to one trust
due to the small scale explorative nature of the research.
6
The study was presented to the nurses by the researchers at a regularly occurring
meeting at the hospital where nurses were also given written information on how to
contact the researchers if they were interested in taking part in the study. Twelve
nurses, 11 women and 1 man, with experience of working with parents with
dependent children attended one of the two focus groups out of a total of twenty-one
nurses who could have participated. Participants’ specialties as defined by themselves
during the introduction section of the focus groups are identified in Table 1. To
protect the anonymity of the small sample from one trust no detailed demographic
information was requested from the participants. However, the focus group data
indicated that although a few nurses had been in their posts for one to two years at the
time of the study, the majority had many years’ experience of cancer and palliative
care. Two further nurses had expressed an interest in participating but sent word that
they had to attend to urgent matters at the time of the focus group meeting. To
conduct research in a busy hospital environment is always challenging; however more
than half of the oncology and palliative care nurses in the trust made an effort to
participate and is a reflection of the importance they attribute to the issues discussed.
Data Analysis
The audio recordings were transcribed verbatim and closely read by two researchers
and systematically coded by one researcher using the software programme NVivo 10
developed by QSR International13.
The use of NVivo added transparency to the analysis and increased rigour. A thematic
analysis was used to analyse the qualitative data, which were organised in stages into
three superordinate themes by the researchers14. The initial themes were discussed,
revised and agreed by the research team. Findings were also presented to nurses from
7
the two focus groups and they agreed that the findings accurately reflected the focus
group discussions.
Ethics
The study was approved and given a favourable ethical opinion by the National
Health Service Trust’s Research Governance Committee and by the University of
Surrey Ethics Committee.
Results of the Study
Key themes that emerged from the data were: identifying with the parent, keeping the
door open, helping patients to help children and the needs of oncology and palliative
care nurses. Participants discussed how challenging and complex it was to support
families with children. It was found that there were no screening processes (or
guidelines) in place to identify patients who have dependent children who might
benefit from psycho-social support. Many of the participants described how they
quickly picked up on the fact that patients have children as many of the nurses have
children themselves. An unexpected finding in the study was that most of the cases
discussed by focus group participants concerned female patients, which is discussed
later in the article in relation to recommendations for further research.
Participants described how they drew on their own experience as parents themselves
to help them cope with patients who had dependent children. Being a parent meant
that nurses identified closely with the patient, which is discussed next.
8
IDENTIFYING WITH THE PARENT
Many of the nurses described identifying with patients who were described as of a
similar age to them with children of a similar age. Participants used words such as ‘I
am a mum’ and ‘speaking as a parent’. Although identification with the parents
‘aroused distressing thoughts’ it also was presented as a helpful coping strategy.
The identification as a ‘mum’ helped the nurse below to see the situation quickly and
helped her to connect with what is going on in the family situation:
When they come in you tell them the diagnosis, you then obviously ask about
what the family situation is at home, what else they have got going on so
recognizing that straight away you know, I am a mum as well. [FG – 5]
The participant’s identification with the patient gave her confidence to assess the
family situation. However, this connection and identification can also be emotionally
challenging and participants also reported feeling out of their depth, especially when
the situation with the parent was quickly changing. One nurse had been asked to
speak with a couple of teenagers, which she found challenging:
I had never ever had to sit and speak to teenage children the same age as
mine… so that was fairly difficult. [FG1 – 6]
Although being able to connect as a mum was described as helpful, it also made the
interaction more difficult. The nurse above had no experience of speaking with
teenage children about their mother’s illness and felt totally unprepared. On top of
9
that the children were close in age to her own children and brought the very serious
situation for this family close to the nurse’s own experience of parenting teenagers.
Although there was some awareness of the negative impact of parental cancer on the
family children were reported to generally cope well:
Most of the stories I hear from my patients are mostly positive, how these
children are coping. [FG1 – 2]
And
On the whole recently all of our patients seem to be quite open in discussing
things with their children and they say how well their children have adapted.
[FG1-7]
An environment is described where by parents can be open and positive about their
children who are described as coping well; this does however conflict with extant
literature pertaining to the long term impact of serious illness and loss on children’s
emotional and mental health5. There was little recognition of the long term impact on
children of having a parent with cancer. This seemed to be because the situation of
children was viewed as the private domain of the parents and a highly sensitive area
of close identification for the nurses making them feel apprehensive and
uncomfortable.
KEEPING THE DOOR OPEN
Participants reported how they work hard to support patients who are parents but they
sometimes waited for the parent to introduce the topic of children. Hence in the next
10
data extract although the nurse described wanting to ‘keep the door open’ this is
balanced by cautiousness about delving into the needs of children:
Just keep the door open you can’t be too involved, can you? Because you
don’t know their life you don’t know their children you don’t know their
circumstances, you don’t you know. For us, we tell them they have got a
cancer diagnosis and support them through the process and if they flag up that
they want some involvement with the child then we will facilitate that; but we
don’t constantly ask or you know we rely on them feeding us that information.
You know, obviously if there was a concern for the safety of a child then that
is a different matter altogether but in terms of information we are very much
guided by the parent really. We give books we give information about how to
talk to the schools and things like that. [FG1-4]
The ‘we don’t constantly ask’ suggests that children are a private domain something
that can only be discussed if it is brought up by the parent. There is doubt about
whether the children’s needs are assessed routinely as the role is described as
supporting the person with a cancer diagnosis
The necessity of parents identifying needs for support is also described by another
participant:
It has got to come from them if they need it, if they need support and
guidance. [FG1-7]
11
Other participants described how parents want to be protective of their children so
that the family can keep a sense of normality in their lives:
So they wanted to deal with it as a family they didn’t want us intervening with
it, they wanted it kept with them managing it. [FG2-5]
Participants described protective strategies that are shared by both nurses and parents
so that the needs of the children remain to some extent unspoken and relatively
invisible.
HELPING PATIENTS TO HELP CHILDREN
Participants described the support of children mainly as the parents’ responsibility and
so leave the psychological welfare of the children ‘with the parents in their capable
hands’ [FG2 – 4]; with parents perceived to know best about their children. It may be
that nurses are trying to help patients keep up as ‘normal’ a family life and routine as
possible, by staying positive about the children as a strategy to help nurses and
patients cope with the demands of care and treatment for cancer.
Participants report being asked direct questions regarding how to communicate with
children:
Well sometimes they ask ‘should I tell the children? What should I tell the
children?... It’s never my place to tell them to tell the children I think. It’s
about them assessing how much information their child needs. [FG1-1]
12
The participant above described being asked directly for support from the parent
regarding what to tell the children. In response the nurse identified a strategy of not
taking over and telling the parent what to say to the child. However, she continued to
use distancing language such as ‘they’, ‘them’, ‘their’. The nurse emphasized that it
is the parent’s role to assess what their child needs, which is a protective and
avoidance strategy used by the nurse. The nurse does not appear adequately prepared
or comfortable to give support to the parent in relation to the challenging question
about what to tell the children.
NEEDS OF NURSES
Participants suggested that supporting families should take into account the busy
hospital environment, including ‘the time factor’ [FG1–3]. They suggested that
routine screening of children’s needs would not be helpful as: ‘you do it instinctively’
(FG1-4), implying that using intuition is how to assess the family situation.
Participants also felt that needs other than those of a psychosocial nature should be
prioritized. This confirms the observation by other researchers that a medicalised
approach is evident and there is a distancing from the emotional and psychosocial
needs of the family regarding children1.
Participants discussed existing support and resources available to them when
supporting families and children. Given the varying needs of patients/children,
participants report a need for easily accessible information:
All I would need to know is to know where to get information from.
[FG1– 4]
13
The participant above seemed unsure about where to locate information and also
appeared to see her role as one related to the flow of information to parents.
Nurses felt that there was a need for more preparation and guidance in relation to the
well-being of children:
And I suppose guidance about how much to tell the children, what to tell
them depending on their age and things because I suppose half the time we
are blagging it aren’t’ we? What we think that we should tell them and, you
know. [FG1-5]
The nurse above felt unprepared to confront the issues surrounding children such as
how much to tell them and age appropriate information in particular. The use of ‘we’
suggests she sees other nurses in the same situation as herself.
Given the complicated context of providing care and support for patients and their
children, a participant suggested that regularly sharing experiences with colleagues in
a supervised and safe environment would be helpful:
I think it is important to just come and talk about experiences and perhaps
learn like we have done this morning really… I think that everyone’s
experiences we would all do the same sort of thing. I think if we sat here and
thought I never thought of doing that then that might create alarm bells might
it, but it sounds like we are all doing the same sort of thing anyway which is
14
reassuring isn’t it? [FG1-5]
Sharing with colleagues and learning from their experience is identified as a way to
support nurses and enabled them to balance their needs (confirming that they are
doing the right thing) and the needs of their patients.
Another nurse described how she sought and received peer support from colleagues
regarding a situation with a patient, which had left her reassured that she had managed
the situation well:
It was difficult for me as well, I did check with the breast nurse as I know
they deal with young families quite often and they felt I had really gone down
the right paths with it … so it was reassuring for me as well when colleagues
have been through something it’s nice to pick up on what they have picked up
on. [FG2 – 5]
The breast care nurse has a specialist role in supporting women with breast cancer
throughout the different stages of the illness including metastatic breast cancer15. The
breast care nurse was acknowledged as a source of guidance and reassured FG2-5 that
she had handled the situation well. Although expertise does exist, the importance of
support by peers was highly valued by nurses. Participants felt comfortable
discussing challenging emotional situations regarding children with their peer group.
They described feeling safe and supported to disclose experiences and concerns and to
seek advice about courses of action from their own peer group.
15
Discussion
Nurses were concerned that families continued with a normal family life and wanted
to support them in this regard. Mothers wished to safeguard familiar routines where
possible. Fisher et al found a preference by mothers with breast cancer to carry on as
usual as much as possible16. In this study nurses described their ability to assess
family needs through intuition and appeared resistant to any form of screening of
families as they felt that this is a situation that they recognize immediately especially
when they are also mothers. Generally, they described a reactive form of assessment
mostly taking their cue from patients regarding the needs of their children. According
to Rauch et al, parents may not receive guidance on how to minimize the impact of
cancer on their children or to identify a child who requires extra support17.
Nurses used protective and avoidance strategies to bracket themselves from the
emotional impact of working in such a sensitive and emotionally draining area of
care, which is understandable in the circumstances. Nurses described how they can
identify with their patients (as a parent themselves) and this adds to the emotionally
charged context of care and to the emotional burden experienced by nurses. Nurses
appeared to want to distance themselves from the issue of children because of a lack
of confidence in how to help with these matters. A proactive approach to the needs of
dependent children within the family appears to be low on the list of priorities for
nurses and where possible avoided.
In this research there was evidence that some of the participants felt they do not have
the skills to explore sensitive issues relevant to patient’s children. However, at times
16
nurses found themselves being called on to talk to teenage children that left them
feeling daunted and out of their depth. Nurses also used terms such as: ‘leave it like
that with the parent’ and ‘totally left to the parents’; this suggests the nurses may be
using avoidance as a coping strategy what Maguire et al refer to as blocking
behaviour, which may limit the extent to which patients feel free to express concerns
about sensitive matters regarding dependents and children and the wider needs of
family members18. Avoidance is understandable, as to confront the needs of family
and children calls for emotional labour that triggers hard to manage emotions in
nurses and their patients and requires good support for nurses as well as patients.
Waiting for parents’ identification of children’s needs is a protective and reactive
strategy used by nurses in the study when dealing with a highly sensitive area of care.
Therefore, nurses report utilising a cautious approach by avoiding potentially
upsetting questions for both the parent and the nurse related to dependent children.
Dependent children are largely identified as the private domain of the parent and a
highly sensitive and emotive area of care for the nurses in the study.
Much research points to the needs of mothers in particular for support at all stages of
the cancer illness regarding worry about their children and the need for psychosocial
support regarding these worries19. Working with the uncertainties associated with
cancer and the chronic nature of some cancers means that patients’ needs will be
variable over time and nurses will need the skills to respond to those needs over
longer and shorter timescales as the acute and chronic cancer illness experience
overlap and are extended. It is important that the needs of children have been assessed
and a system of team collaboration developed with wraparound services for
children20.
17
Findings demonstrated that nurses did not normally engage directly with children and
that the mainstay of support reported by nurses was vicarious support in that they
offered a way to support the parents and in doing so to support the children. It was
mainly left to parents to initiate/request support as nurses engaged in a reactive way
with issues regarding children. Participants described how parents were reluctant to
involve their children in their illness, through parental avoidance, because of a wish to
maintain hope which can mean that discussions about potentially negative
consequences of a cancer illness within the family are avoided. It can be conflicting
for nurses to help patients maintain hope and at the same time convey to patients and
their families the seriousness of the situation. Hope can in this sense compromise
acceptance of a serious illness and may lead to withholding of information and
support for families; and nurses need to strike a careful balance. However, even quite
young children can understand when something is wrong, such as serious illness in a
parent, and it is essential that families receive support to enable them to communicate
effectively and support their children21. In the US a pilot intervention for parents on
the effects of their illness on their children was reported to be well received7.
Nurses reported that they needed more knowledge and support to engage with
children’s needs and their developmental stages. They were interested in how to
adapt information and support to children’s developmental stages and described a lack
of informative resources available to themselves and parents. Additionally, nurses
described a need to balance respect for individual family differences and the
avoidance of imposing on parents’ ways of communicating with children and this is
an area where they lacked confidence.
18
IMPLICATIONS FOR PRACTICE
Nurses were very positive about the support they received from their peer group.
They felt that more use could be made of peer support by having regular opportunities
to meet with their peer group and to reflect on issues regarding families and children.
Peer support is therefore the most beneficial support strategy identified and was the
nurses preferred method of support. In addition, some educational needs and access
to resources were identified concerning children’s developmental stages and how to
communicate about cancer with children of different ages. Other methods of support
that nurses could benefit from include group and individual clinical supervision with a
focus on supporting parents and children. Following the study workshops have been
organized to support nurses and to develop their confidence in relating to parents
about their children. In the UK NICE Guidelines (2004) recommend the availability
of psychosocial and emotional support for patients and families of those with cancer.
Therefore, there should be clear guidelines and care pathways about how families and
children access further support services including social work and mental health
services22. Support from an interdisciplinary team is essential to minimize the impact
of parental cancer on children but also to signpost families to further support services
should they be necessary.
FURTHER RESEARCH
It is interesting to note that participants brought up more issues in the focus groups
related to mothers than fathers as patients. This could be a reflection of the sample
19
being made up of mostly female nurses who were identifying with female patients.
However, it could also reflect the fact that there is a distinct lack of knowledge about
the needs of fathers with cancer who have dependent children22. In future research it
would be important to examine the gender role assumptions of nurses and other health
care practitioners to enquire into how they respond to fathers with cancer in contrast
to mothers.
Limitations
Participants were recruited from one National Health Service trust only; therefore, the
findings may not represent the views or confidence of nurses from other acute
services in the UK or indeed those of nurses from an international perspective.
However, the study provided an opportunity to gain an understanding of this
previously under researched area.
Conclusions
Research participants were oncology and palliative care nurses and although they are
specialists in their field they felt they needed more support in order to provide
effective care for parents with children. Participants identified the importance of peer
support and regular opportunities to reflect on practice with colleagues where they can
share experiences. They also reported needing access to updated information sources.
Supporting families can awaken emotions of a personal nature in cancer and palliative
care nurses, which can affect practice positively or negatively. Although it may be
emotionally draining for nurses to identify closely with patients and draw from their
own experience it may also be a helpful and empathic strategy and one that can
reduce the feeling of emotional burden. Nurses felt they lacked confidence and knowledge
20
in supporting parents with cancer regarding their children and many reported using distancing
strategies to protect themselves emotionally from helping parents support children. Peer
support strategies, were the methods of support that nurses felt comfortable with.
Nurses require good psycho social support and clinical supervision in order to engage
with issues related to patient’s children.
References
1. Fearnley R. Death of a parent and the children's experience: don't ignore the
elephant in the room. Journal of Interprofessional Care. 2010;24(4): 450-459.
2. Lewis FM. Parental cancer and dependent children: selected issues for future
research. Psycho-Oncology. 2007;16:97–98.
3. Kennedy C, McIntyre R, Worth A, Hogg R. Supporting children and families
facing the death of a parent: part 1. International Journal of Palliative Nursing. 2008;
14(4):162-168.
4. Turner J, Clavarino A, Yates P, Hargraves M, Connors V, Hausmann S. Oncology
nurses’ perceptions of their supportive care for parents with advanced cancer:
challenges and educational needs. Psycho-Oncology. 2007;16:149-157.
5. Niemelä M, Paananen R, Hakko H, Merikukka M, Gissler M, Räsänen S. The
prevalence of children affected by parental cancer and their use of specialized
psychiatric services: The 1987 Finnish Birth Cohort study. International Journal of
Cancer. 2012;131:2117-2125.
6. Christ GH. Healing children’s grief: surviving parent’s death from cancer.
Oxford, Oxford University Press; 2000.
7. Turner J, Clavarino A, Yates P, Hargraves M, Connors V, Hausmann S.
Development of a resource for parents with advanced cancer: what do parents want?
Palliative and Supportive Care. 2007;5:135-145.
21
8. Rauch P K, Muriel A C, Cassem N H. Parents with cancer: Who's looking after the
children? J Clin Oncol. 2003;21(9):117-121.
9. Semple C J, McCaughan E. Family life when a parent is diagnosed with cancer:
impact of a psychosocial intervention for young children. Eur J Cancer Care. 2013;
(22):219–231.
10. Kennedy C, McIntyre R, Worth A, Hogg R. Supporting children and families
facing the death of a parent: part 2. International Journal of Nursing Studies.
2008;14.230-237
11 RCN Factsheet: Specialist nursing in the UK (2014)
https://www2.rcn.org.uk/__data/assets/pdf_file/0018/501921/4.13_RCN_Factsheet_o
n_Specialist_nursing_in_UK_-_2013.pdf (last accessed 3rd May 2016).
12. Millward L. Focus Groups. In Breakwell GM, Hammond MS, Fife-Schaw CR,
eds. Research Methods in Psychology. London: SAGE Publications; 2000: 305.
13. QSR International available from
http://www.qsrinternational.com/products/productoverview/product_overview.htm.
Accessed May 5, 2016.
14. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research
in Psychology. 2006;3:77-101.
15. Reed E, Scanlon K, Fenlon D A survey of provision of breast care nursing for
patients with metastatic breast cancer-implication for the role. Eur J Cancer Care.
2010;(19):575–580.
16. Fisher C, O'Connor M. ‘Motherhood' in the Context of Living with Breast
Cancer. Cancer Nurs.2012;34(2):157-163.
17. Rauch P, Moore C. A population-based estimate of cancer survivors residing with
minor children. Cancer. 2010; 116(18):4218-4220.
18. Maguire P, Pitceathly C. Key communication skills and how to acquire them.
22
BMJ. 2002;325:697-700.
19. Stinesen-Kollberg K, Thorsteinsdottir T, Wilderäng U, Steineck G. Worry about
one's own children, psychological well-being, and interest in psychosocial
intervention. Psycho-Oncology. 2013;22:2117-2123.
20. Niemela M, Vaisanen L, Marshall C, Hakko H, Rasanen A, The experiences of
mental health professionals using structured family-centred interventions to support
children of cancer patients. Cancer Nurs. 2010;33, 6.
21. Forrest G, Plumb C, Ziebland S, Stein A. Breast cancer in the family-children's
perceptions of their mother's cancer and its initial treatment: qualitative study. BMJ.
2006;332:998.
22.National Institute Clinical Excellence. Guidance on Cancer Services: Improving
supportive and palliative care for adults with cancer. http://www.nice.org.uk
Accessed September 10, 2016.
23. Visser A, Huizinga GA, Hoekstra HJ, van der Graaf WTA, Klip EC, Pras E,
Hoekstra-Weebers J EHM. Emotional and behavioural functioning of children of a
parent diagnosed with cancer: a cross-informant perspective. Psycho-Oncology.
2005;14:746-758.
23
Table 1: Participants in the Study
FG1-1 Breast care nurse
FG1-2 Chemotherapy clinical nurse specialist
FG1-3 Breast care nurse
FG1-4 Breast care nurse
FG1-5 Haematology Day Unit Manager & Chemotherapy nurse
FG1-6 Lung Cancer Clinical Nurse specialist
FG1-7 Lung Cancer and Palliative Care Clinical Nurse Specialist
FG2-1 Haematology Clinical Nurse Specialist
FG2-2 End of Life Care Clinical Nurse Specialist
FG2-3 Palliative Care Clinical Nurse Specialist
FG2-4 Head and Neck Clinical Nurse Specialist
FG2-5 Gynaecology Clinical Nurse Specialist
24