One of the advantages of working in a research-intensive environment is the opportunity to work with international scholars. When we form a collaboration with a visiting scholar, he/she becomes a regular member of our research team and works on our currently funded projects. Several years ago, a nurse from China joined us as a visiting scholar and became a vital team member of our distress screening training grant, through which we trained 180 multidisciplinary professionals throughout the United States to implement distress screening programs and evaluated the training's impact on implementation.1 While studying with us, this nurse developed a proposal to implement distress screening in her institution. She carried out that proposal, and returned to Yale to analyze the data.

Initially in reviewing the data, we concluded that the patients who reported psychosocial distress warranted further evaluation and referral to appropriate services to manage their distress. However, we soon learned that most of the distressed patients were from rural regions. They represented a vulnerable population who were unemployed, experienced high physical symptoms, and were diagnosed with stage IV cancer. We also became aware of healthcare disparities based on where they lived. The government-funded insurance available to them as rural dwellers covers less and has higher out-of-pocket costs as compared with the government-funded insurance available to urban dwellers. Hospitalization in the area's cancer hospital, located in the provincial capital and some distance from rural regions, was a major source of rural patients' financial distress. As well, patients in rural regions did not have access to ongoing cancer treatment or symptom management at nearby community hospitals. Many delayed seeking symptom relief because of the need to travel great distances to the cancer hospital and the added financial burden it presented to their families.

After careful review of these findings, we now conclude that it was premature to recommend universal distress screening of patients who do not have access to resources that could manage their distress. Distress screening guidelines were developed 20-plus years ago in the United States by the National Comprehensive Cancer Network's. Today's National Comprehensive Cancer Network standard states that "all patients should be screened for distress at their initial visit, and at appropriate intervals, as clinically indicated."2 In 2004, the Canadian Strategy for Cancer Control made distress the sixth vital sign in cancer care. Just as with temperature, pulse, respiration, blood pressure, and pain, cancer care professionals in Canada routinely screen for distress.3 In 2009, the International Psycho-Oncology Society set measuring distress as the sixth vital sign as an international standard of quality cancer care.4 Many international organizations have endorsed the International Psycho-Oncology Society standard.5

However, even with evidence-based benefits,6,7 the challenge is how to move distress screening into clinical practice in low-resource settings. Given our experience, we have learned that distress screening must be a 5-step comprehensive process that includes a rapid screen, evaluation of that screen, referral to psychosocial services if needed, follow-up with the patient and the primary oncology team to ensure the patient's psychosocial needs have been met, and quality assurance. These steps should be in place before screening is started.8 In addition, we have learned that there must be key-stakeholder buy-in; resources identified and allocated; a referral network for psychosocial services that covers the hospital's service area; a psychosocial committee to provide oversight; a system-wide policy, with a detailed screening protocol; and trained staff.1 It is easy to recommend that distress screening include this comprehensive process, with the necessary complex infrastructure, in settings where resources are available and healthcare insurance covers associated patient costs.

We found that patients were willing to report their distress and confide in their nurses its source, but there was little that could be done to relieve it. Their frankness demonstrated that the problems are deeply rooted in the lack of accessible services for patients who live in rural regions. It is essential that healthcare systems are structured to provide needed services that include appropriately trained professionals, established infrastructures, and adequate insurance coverage. Patients who live in rural regions experience disparities: there are no local services to manage their cancer and symptoms, and their insurance provides inadequate coverage. The same most likely is true in low-resource settings around the world. It may also be true in rural regions in high-resource settings.

Therefore, we must conclude that, when resources are inadequate or inaccessible, patients' physical needs must be addressed before their psychosocial problems are identified. It is not just about taking care of their physical needs first. Rather, it is that we may be creating distress by not doing so.

Our best to you,

Ruth McCorkle, PhD, RN, FAAN+

The Florence Wald Professor of Nursing

Yale University School of Nursing

West Haven, Connecticut

Mark Lazenby, PhD, APRN, FAAN

Professor of Nursing and Philosophy Associate Dean

for Faculty and Student Affairs, School of Nursing

University of Connecticut

References