While much of the research foundation is from the UK, Australian research has contributed to understandings of breast nursing and its outcomes more recently. The research results, in combination, have formulated the highest level of evidence recommending BNs involvement in the care of women with breast cancer in
Australia. Although systemic reviews have been inconclusive, there is a substantial amount of research supporting the benefits of BN interventions and potential outcomes.
The seminal research on breast nursing originated in the UK, and the majority of evidence substantiating the benefits of breast nursing comes from the UK context. Research on the effects of nurse counselling for breast cancer patients laid
important foundations for the role (Maguire et al., 1983; Maguire et al., 1980; Watson, 1988). This was followed by McArdle et al’s (1996) randomised control study assessing psychological morbidity of women consulting a BN as compared to other care options. These provided demonstration of reduced psychological morbidity for women linked with specific nursing interventions.
Scientific literature about the BN has emerged from Australia in the last 20 years, and more recently from Scandinavia. While UK breast nursing research tends to focus on the time of diagnosis and earlier care, the Scandinavian research has centred on follow-up care. The most comprehensive research undertaken in the Australian context is the NBCC’s multicentre implementation study, the SBN Demonstration Project (Liebert, et al., 2003).
Australian clinical practice guidelines recommending women’s access to SBNs primarily rely on level I and level II evidence (NBCC and NCCI, 2003; NHMRC NBCC,
37 1999). Five randomized control trials demonstrated that SBNs could improve
women’s understanding, recall, satisfaction with care and continuity of care (Clacey, et al., 1988; Maguire, et al., 1983; Maguire, et al., 1980; McArdle, et al., 1996; Watson, 1988). Breast nursing can reduce psychological morbidity and anxiety as well as increase the identification of women with depression (Redman, et al., 2003). Also, the beneficial effects of psycho-educational care have been established with a strong research base (Devine & Westlake, 1995), and this care has been effectively provided by BNs to women with breast cancer.
2.3.1.1. Systemic Reviews of Breast Nursing
Rigid evidence for the effectiveness of breast nursing has been inconclusive.
Systemic reviews of evaluations of the effectiveness of BNs have been hampered by the challenges in comparing different roles (Eicher, et al., 2006). Two systematic reviews found unclear results of the efficacy of BNs, primarily related to a lack of consistent role definitions and practice, as well as weaknesses in research
methodologies (Cruickshank, et al., 2008; Eicher, et al., 2006). However, the use of traditional evaluation techniques such as the randomised controlled trials are not a good fit for the assessment of a developing model of care due to the model’s iterative nature (Davidson, et al., 2006). Nonetheless, strong early evidence of positive outcomes laid the foundation for key breast nursing interventions.
The first systemic review indicated specialised nurses in breast care may contribute to improvements in physical and psychosocial well-being (Eicher, et al., 2006). The review included 10 studies which described and analysed specialist nursing for women with breast cancer and found in the scientific literature between 1980 and 2006. The diversity of definitions constituting a BN, along with the variety of models of care, competence and educational levels, work domains, and levels of autonomy limited the generalisability and comparability of the results, as did their restricted search method (e.g. limited to comparative designs). Nevertheless, Eicher and colleagues classified outcomes in six dimensions (Eicher, et al., 2006, p.3124). While improvement of physical impairment reflected varied results, the
38 review found specialist nurses generally demonstrated positive effects on
improvement in psychosocial problems, decision making processes, patient
satisfaction, and collaboration in multi-professional teams. No differences in costs of care were identified.
A Cochrane Review assessing BN interventions effectiveness on quality of life outcomes was limited to randomised controlled trials (Cruickshank, et al., 2008). Five studies met the inclusion criteria. The review included psychosocial and supportive care interventions, along with nurse-led follow-up interventions, and encompassed interventions covering various treatment phases in the disease trajectory (namely, diagnosis, early treatment, radiotherapy, and follow-up)
(Koinberg, et al., 2004; Maguire, et al., 1980; McArdle, et al., 1996; Ritz et al., 2000; Wengström et al., 2001). The review found BN interventions could impact quality of life indicators such as anxiety and perceived distress, while other differences in indicators such as coping skills, mood, and social and functional aspects of the disease trajectory were either inconclusive or unchanged by BN interventions. The conclusions of the Cochrane Review, based on the findings of five randomised controlled trials, were that limited evidence was available to identify the particular BN interventions that impact on quality of life, and that more research is needed. However, the Review did find that the nature of BN work within a cancer care team “serves to complement the team as a whole rather than highlighting the impact of the BCN alone” (Cruickshank, et al., 2008, p.9). This emphasises the need for breast nursing to fit within the local context, and whatever constitutes ‘the healthcare team’ in that context. Yet, there are weaknesses in relying on randomised
controlled trials as they “focus on the presumed active component of interventions, often discounting synergistic effects, and assess how efficacious the intervention is under ideal experimental conditions rather than real world conditions in which cancer care occurs” (Verhoef, et al., 2007, p.906).
Nevertheless, extensive research, including randomised controlled trials and descriptive studies, has demonstrated the potential benefits of breast nursing. BN
39 interventions have led to benefits for women, and for the healthcare team. “A significant body of evidence demonstrates that the provision of information and psychological care improves functional health, emotional adjustment and satisfaction with care in cancer patients” (NHMRC NBCC, 1999, p.47).
The below sections summarise the research by describing the interventions BNs and other health care providers could use which have demonstrated positive results for women, followed by the beneficial outcomes resulting from these interventions.