PICOT: African-American Women with Breast Cancer

Cancer is among the most potent and dreaded chronic modern conditions in human society. This is true because while there are new methods and approaches to treating the condition, such as immunotherapy, hormone therapy, and targeted therapy, it remains largely a terminal illness with a mortality rate of 159 per 100,000 people (NCI, 2020). Therefore, it is a kind of condition that, when diagnosed, can cause anxiety, stress, and depression not only for the patient but also for the family. According to Niedzwiedz et al. (2019), a cancer diagnosis substantially impacts patients' mental health outcomes, including those who did not have an underlying mental health problem(s) at the time of diagnosis. Anxiety, stress, and depression impede treatment, recovery, and quality of life. Therefore, there is an increasing need for cancer treatment and management approaches that consider the mental health aspect of cancer conditions in patients. Given the emergence of patient-centered healthcare and evidence-based practice, a clinical approach that is culturally sensitive has far more promising outcomes compared to standard nursing care. Therefore, the goal of the current paper is to investigate this potential based on the PICOT Question in the next section.

Problem Statement

            Research suggests that the distribution of anxiety, stress and depression (ASD) is not equal among the American population (Watson et al., 2012). In other words, some sections of the American population face more high-risk factors and more negative mental health outcomes compared to others. For instance, in terms of gender, women are more likely to suffer from the conditions than men. Even among women, there are disparities. According to Watson, Roberts, and Saunders (2012), African American Women are more likely to experience any of the ASDs compared to their White Women counterparts. Watson and Hunter (2015) posited that the Strong Black Woman race-gender schema contributes to this problem by inhibiting members of this population from seeking mental health services. However, on a broader scale, issues such as racism (Williams, 2018) and poverty (Knifton & Inglis, 2020) shape the significant risk factors. Across both factors, and in conditions like breast cancer, women of color are the most exposed to anxiety, stress, and depression causative risk factors based on education, household income, and neighborhood of residence.

            Considering these issues and coupling them with cancer prevalence among African American women results in a population with a significant potential to suffer from ASD conditions. Cancer, therefore, either burdens the existing coping mechanism against ASD or worsens the existing mental health connection. Going by Niedzwiedz et al.'s (2019) argument that cancer impedes treatment and management of cancer patients, African American women have the worst cancer-related health outcomes. Thus, reducing this burden requires a review of contemporary and emerging approaches to treatment in health care. In recent years, patient-centered approaches that incorporate evidence have shown positive outcomes and are increasingly adopted across the United States. A core area of this approach to treatment is that it is culturally sensitive. In other words, it considers the needs of the patient based on their cultural and religious beliefs, backgrounds, and perceptions.             Therefore, the problem in the current paper is that there is a possibility that culturally sensitive approaches to treatment and management can reduce ASD conditions among African American women patients. In this regard, the paper answers the following PICOT question: In African-American women with breast cancer (P), does provide culturally sensitive, nurse-led psychoeducation (I) in comparison to standard nursing care (C) reduce cancer-related anxiety, distress, and depression (O) from diagnosis to post-treatment (T)? In other words, how effective is culturally sensitive nurse-led psychoeducation compared to standard nursing in reducing ASD conditions in the mentioned population of patients? 

Organizational Culture and Readiness

            The outcomes of the current study are supposed to shape quality improvement plans for cancer treatment among African American women. It is anticipated that relying on culturally sensitive, nurse-led psychoeducation is more effective than the standing nursing care for cancer. If this is the case, then the current organization must implement these aspects. However, his cannot be achieved unless the organization's current state is determined. Table 1 below summarizes the SWOTT analysis of the health organization: The Johns Hopkins Hospital.

The hospital was chosen because of its stature in innovation and its location. In terms of innovation, JHH is not only a hospital but a biomedical research facility where some of the most important innovations in modern medicine have originated (JHH, 2021). Therefore, the organization would be open to new approaches to quality improvement. In terms of location, JHH is located in the geographical area of interest of the current study. The current study focuses on is Baltimore, Maryland. Out of the 1.8 million individuals living here, 31.1% are African American implying a significant number of African American women facing breast cancer risks. According to the American Science Society, Maryland experiences between 195 and 270 breast cancer cases per 100,000 population. However, for African American women, the figure stands at 255 per 100,000 population compared to a national average of 108 per 100,000 populations (ACA, 2021). Thus, the organization has a higher incentive to leverage new treatment techniques for cancer. Table 1: SWOT Analysis Summary

A glance at table 1 above indicates that JHH is ready for such changes as part of quality improvement that focuses on positive health outcomes. For instance, the organization has an innovative culture that spans decades in terms of strengths. Some of the critical innovations include penis and scrotum transplant (2018), single blood test screening for eight common cancer types (2018), and a safer way to access skull-base tumors (2010) (JHH, 2021). In other words, the organization has a culture that embraces change improvement proposals and innovations. These innovations have helped the organization earn an international reputation, which is critical in attracting funds and support for quality improvement innovations and strategies and enables the hospital to have the necessary resources for research, innovation, and quality care. Therefore, a combination of resources, reputation, and an innovative culture are the key strengths of JHH.

Further, in terms of opportunities, policies like the Affordable Care Act (ACA) have increased the number of people with insurance, especially minority groups and low-income earners (Blumenthal et al., 2020). The implication is that more African American women with breast cancer will seek JHH's services. To offer quality services, JHH can embrace change that limits the impact of ASD conditions on cancer treatment among patients. Another legislation that provides an opportunity in this aspect is the Marijuana Research Act which avails quality and quantity marijuana for research purposes geared towards improving healthcare.  According to Daris et al. (2019), cannabinoids have primarily been utilized in palliative care to relieve nausea, stimulate appetite, and alleviate pain among cancer patients. In terms of ASD conditions, Cuttler et al. (2018) established that marijuana use reduces self-reported levels of anxiety, stress, and depression. As a teaching hospital and bioresearch facility, JHH stands a chance to lead on this front which, in turn, will improve treatments and management of breast cancer patients. More importantly, using marijuana as a reliever of stress and anxiety contributes to the current study.  

The strengths and opportunities indicate that JHH is ready to improve the treatment and management of breast cancer among African American women through culturally sensitive, nurse-led psychoeducation. However, this can only be achieved if the problems of high nurse turnover rates are not solved. A high nurse turnover rate and nurse burnout are among the critical weakness at JHH. Further, JHH must reduce the number of lawsuits it is facing. Since 2012, JHH has been sued 42 and 41 times for medical malpractice and torts claims, respectively. These lawsuits may impede JHH's reputation and public trust and may lead to fines that would be spent on improving care delivery. Overall, however, the organization's innovative culture, resources, and critical opportunities make JHH ready to shift from standard nursing care to culturally sensitive approaches.

Literature Review Search Strategy            Several databases, including HAPI, Cochrane, EBSCOhost, Google Scholar, EMBASE, and CINAHL, were utilized in the literature search. These databases were chosen because they provide many peer-reviewed articles helpful to the current study. The search was conducted using keywords and key terms identified from both the PICOT question and the scope of the research. The keywords or phrases used in the search were psychoeducation, nurse-led psychoeducation, breast cancer, cancer survivors, symptom distress, African American women, anxiety, stress, and depression. Synthesis of Literature In the current study, two approaches to the treatment and management of cancer patients are under scrutiny. These are culturally sensitive, nurse-led psychoeducation, and the standard nursing procedure. Psychoeducation refers to an intervention encompassing a systematic, didactic, and structured transfer of knowledge for a medical condition and its treatment. According to Schulman-Green and Jeon (2017), the intervention integrates emotional and motivational aspects that empower patients to cope with the medical condition and adhere to treatment plans to enhance the efficacy of favorable health outcomes. In this aspect, the standard nursing care encompasses all medical procedures and processes with little or no aspect of psychoeducation led by a nurse. Several studies focusing on cancer have tried to establish the efficacy of psychoeducation. For instance, Schulman-Green and Jeon (2017) investigated the effectiveness of a psychoeducational intervention in improving self-management and reducing depression, anxiety, and uncertainty among breast cancer patients using a one-group, pre-post-test study. The study involved 100 breast cancer patients aged 21 years and above and with non-metastatic cancer. Participants underwent a seven-module psychoeducational intervention called Managing Cancer Care (MCC). The primary outcomes indicated that psychoeducation positively influenced all ASD conditions. The secondary outcome manifested in the form of improved self-management attitudes.              In a different approach on the topic, Weis et al. (2020) assessed the effect of a psychoeducation program on cancer patients. The dependent variables in the study included self-efficacy, coping processes, and fear of recurrence among breast cancer survivors. The study utilized a non-randomized trial involving 50 women with breast cancer. Participants underwent a six-session psychoeducation intervention with results revealing that the program improved self-efficacy, provided reliable coping strategies, and reduced fear of prolonged ailment or fatality. In other words, participants experienced reduced anxiety and stress levels, albeit at different rates. According to the authors, the differences in rates highlight the need for patient-centered care since not all patients have similar needs. A highlight, however, is that the study did not establish a significant change in depression levels.              Taking a similar approach, Lally et al. (2020) examined the effectiveness of a psychoeducational program on distress among newly diagnosed breast cancer patients. The study relied on a randomized controlled trial (RCT) involving 100 females diagnosed within the past three months. The intervention showed preliminary effectiveness in reducing cancer-related depressive symptoms and distress among newly diagnosed breast cancer patients. In this aspect, Lally et al. (2020) agrees with Schulman-Green and Jeon (2017) but does not agree with Weis et al. (2020) conclusions, especially on the aspect of depression.            In a similar study, albeit through a different approach, Bernstein et al. (2018) employed a prospective study to investigate the impact of a single psychoeducational intervention on cancer-related cognitive dysfunction. In the study, 100 female breast cancer survivors underwent a single individualized psychoeducational session. Results suggest that intervention improved cancer-related cognitive dysfunction and self-efficacy and reduced distress symptoms. Participants reported an increased understanding of their condition and the dangers involved with the treatment and management procedures. Dissemination of such information by nurses through psychoeducation provided a basis for the patients to accept the problem they were facing and maintain a positive attitude. The authors concluded that a positive attitude is vital in adhering to treatment plans, reducing distress over possible recurrence, and preparing family members for potential outcomes. Thus, there is a significantly positive relationship between psychoeducation and ASD conditions outcomes because psychoeducation prepares the patients mentally for their condition.            The articles mentioned talk of psychoeducation so far, but cultural sensitivity is often left. One study that captures this aspect was Chan et al. (2017). In the study, an RCT was utilized to assess the effectiveness of a culturally sensitive psychoeducation group program in managing distress among breast cancer survivors. Culturally sensitive implies that the professionals involved observed, acknowledged, and took into consideration the cultural background of patients, an essential element in patient-centered healthcare intervention. The study had premised that cultural sensitivity allows each patient to be treated or managed differently based on their unique needs. In the study by Chan et al. (2017), seventy-two Asian breast cancer survivors were assigned to a three-session psychoeducation program. The results revealed that the intervention reduced cancer-related fatigue and physical symptom distress, proving the viability of culturally sensitive approaches.            Further, the articles mentioned so far focus on psychoeducation intervention, with Chan et al. (2017) incorporating the aspect of cultural sensitivity. However, none of the articles highlight the role of nurses in the process. Nurses are vital primary healthcare providers that interact with more patients, within and without an organization, at a higher frequency compared to other medical professionals. Hence, they are best placed to provide psychoeducation for cancer patients receiving chemotherapy treatment. Wu et al. (2018) introduce this aspect. Their study used an RCT to investigate the effect of a psychoeducational intervention (provided by nurses) on anxiety, depression, resilience, self-efficacy, cancer-specific care knowledge, and the quality of life among breast cancer patients receiving chemotherapy. Forty adult breast cancer patients were assigned to a six-session psychoeducational program to achieve this. The results showed that the intervention significantly reduced depression and anxiety and improved resilience, cancer-specific knowledge, and quality of life.            In a similar study, Nguyen et al. (2018) utilized a quasi-experimental trial to investigate the effect of a psychoeducational intervention on cluster symptoms outcomes. Like Wu et al. (2018). Nguyen et al. (2018) also introduced the aspect of nurses leading the intervention because of their high frequency of interaction with cancer patients. Following the participation of 120 patients, the intervention was found to significantly reduce the severity of cancer-related fatigue, sleep disturbance, anxiety, and depression. Unlike the already mentioned studies, this study provides another dimension to the importance of psychoeducation, reducing sleep disturbance.            Lastly, Park et al. (2018) employed a quasi-experimental trial to explore the impact of an integrated psychoeducational program in managing distress among newly diagnosed breast cancer patients. In this study, both cultural sensitivity and the involvement of nurses were highli...