Healthcare providers’ priorities for cancer care: A Delphi study in Greece

ARTICLE IN PRESS European Journal of Oncology Nursing (2007) 11, 141–150

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Healthcare providers’ priorities for cancer care: A Delphi study in Greece Nikolaos Efstathioua,, Jamal Ameenb, Anne-Marie Collc a

Senior Lecturer, Faculty of Health, Department of Health Professions, UCE Birmingham, England, UK Reader in Applied Statistics, University of Glamorgan, Wales, UK c Senior Lecturer, School of Care Sciences, University of Glamorgan, Wales, UK b

KEYWORDS Cancer; Greece; Delphi technique; Priorities; Healthcare providers; Palliative care; National cancer registry

Summary Cancer is a major problem globally and effective cancer care services are needed to lessen its burden on the community. In Greece, oncology health services provision is not located efficiently, resulting in few patients receiving high-quality care. Furthermore, shortages of health professionals and underdeveloped services such as primary care, home care and palliative care have aggravated the problem. The absence of a national cancer registry means that the extent of cancer incidence cannot be evaluated effectively. Dissatisfaction with the Greek NHS is well established, despite the reforms proposed by consecutive Greek governments. It remains that limited research exists in the area of cancer services and cancer care. The aim of this study was to identify the key areas of cancer care and services that needed to be developed or improved in Greece and their prioritisation within the Greek healthcare system. A Delphi technique was used to collect data from a sample of 30 healthcare providers, in three rounds. The response rate for each round was over 77%. The priorities for healthcare providers were focused on staff shortages, working conditions, pain management, home care, day units and communication. Based on the priorities provided by the participants and supporting literature, it is suggested that a national cancer registry, the employment of nurses to develop primary care, home care, day care and palliative care services need to be established. Furthermore, education in communication skills and the redistribution of the bio-medical technology are needed in order to provide more effective cancer services in Greece. More research is needed to validate the actual level of cancer services provided in Greece. & 2006 Elsevier Ltd. All rights reserved. Zusammenfassung Krebs ist ein schwer wiegendes, globales Problem, dessen Belastungen fu ¨r die Gesellschaft durch effektive Krebsinstitutionen verringert werden mu ¨ssen. In Griechenland sind onkologische Gesundheitseinrichtungen nicht effizient lokalisiert, was zur Folge hat, dass wenigen Patienten eine qualitativ hochwertige Versorgung zuteil wird. Des Weiteren haben Mangel an medizinischem Fachpersonal und unzureichend entwickelte Dienstleistungen, wie Prima ¨rversorgung, ha ¨usliche Betreuung und palliative Versorgung die Problematik zusa ¨tzlich versta ¨rkt. Das Fehlen eines nationalen Krebsregisters bedeutet, dass das Ausmaß der Krebsinzidenz nicht effektiv bewertet werden kann. Die Unzufriedenheit mit

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E-mail address: [email protected] (N. Efstathiou). 1462-3889/$ - see front matter & 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2006.06.005

ARTICLE IN PRESS 142

N. Efstathiou et al. dem griechischen nationalen Gesundheitssystem ist weit verbreitet, trotz der Reformvorschla ¨ge nachfolgender Regierungen. Die Tatsache bleibt bestehen, dass die existierende Forschung im Bereich Dienstleistungen der Versorgung und Betreuung von Krebspatienten beschra ¨nkt ist. Ziel dieser Studie war die Identifizierung von Dienstleistungskernbereichen in der Versorgung und Betreuung von Krebspatienten, die in Griechenland entwickelt oder verbessert werden mu ¨ssen sowie deren Prioritisierung im griechischen Gesundheitssystem. Eine Delphi-Technik wurde eingesetzt, um Daten von 30 ausgewa ¨hlten Gesundheitsdienstleistern in drei Runden zu erheben. Die Ru ¨ckmelderate fu ¨r jede Runde betrug 77%. Die Priorita ¨ten der Gesundheitsdienstleister konzentrierten sich auf Personalmangel, Arbeitsbedingungen, Schmerzbehandlung, ha ¨usliche Betreuung, Tagesbetreuungseinrichtungen und Kommunikation. Auf der Grundlage der von den Teilnehmern gelieferten Priorita ¨ten und erga ¨nzender Literatur kommt die Studie zu dem Schluss, dass die Einrichtung eines nationales Krebsregisters, die Einstellung von Pflegepersonal zur Entwicklung von Dienstleistungen in den Bereichen Prima ¨rversorgung, ha ¨usliche Betreuung, Tagesbetreuung und palliative Versorgung notwendig sind. Des Weiteren sind Fortbildung im Hinblick auf Kommunikationsfa ¨higkeiten und eine Neuverteilung bio-medizinischer Technologie erforderlich, um eine effektivere onkologische Versorgung in Griechenland zu gewa ¨hrleisten. Es bedarf weiterer Untersuchungen, um den aktuellen Stand der onkologischen Versorgung in Griechenland zu bewerten & 2006 Elsevier Ltd. All rights reserved.

Introduction Cancer is a leading cause of premature death and disability and efforts to control it make up a great proportion of health care systems worldwide (Micheli et al., 2003). It is suggested that cancer rates could be doubled by 2020 (Eaton, 2003), as one in three people will be diagnosed with cancer during their lifetime in the European Union (Mason, 2004). In 2004 in Europe, there were an estimated 2,886,800 incident cases of cancer diagnosed and 1,711,000 cancer deaths. The most common incident forms of cancer and causes of cancer death were lung cancer, colorectal cancer and breast cancer (Boyle and Ferlay, 2005). In Greece, the estimated incidence of cancer for 2002 was 38,785 new cases with an estimated mortality rate of 24,173 for a population of almost 11,000,000 (Globocan, 2002). In the same year, the National Statistical Service of Greece (ESYE) reported 24,386 deaths due to cancer, representing 23% of all deaths, with almost 90% of the cases occurring in people over 50 yr old (ESYE, 2002). Lung cancer for men and breast cancer for women are the main sites of incidence and mortality for the Greek population (Globocan, 2002).

Background The most recent reports indicate that there is a considerable difference between the incidence and mortality rates in Greece and the rest of the European countries, with agestandardised cancer incidence and mortality rates being lower than the average European rates (Bray et al., 2002). However, due to a lack of organised national cancer registries, incidence rates for Greece have been estimated using registries from Italy and Spain (Vlachonikolis et al., 2002). Furthermore, the apparently low cancer mortality rates in Greece could be attributed to inaccuracies in completing death certificates from which mortality data are obtained (Lionis et al., 2000).

Epidemiological data for the period from 1960 to 1985 has shown a steady increase in mortality from all cancers in Greece (Katsougianni et al., 1990). More recent data revealed that there were further increases in the number of cancer deaths in both men and women in Greece up to the year 2000 (Quinn et al., 2003). Prospective data also shows that the epicentre of the pattern of incidence of tobaccorelated cancers is moving from northern Europe to southern Europe (Black et al., 1997). Furthermore, cancer incidences are more common with increasing age. It is estimated that the Greek elderly population will increase by 10% during the next 30 years. This means that one third of the population will be over 60 by the year 2020 (WHO, 1998). These statistics are anticipated to affect the Greek health services in the near future. Cancer care services offered in Greece are very complex and disorganised (Giokas, 2001). Since the establishment of the Greek National Health System (NHS) in 1983, the provision of healthcare in Greece has not evolved as well as it might have been hoped. As research on cancer care services in Greece is scarce and patchy, a comprehensive assessment of its effectiveness and cancer patients’ satisfaction of health services has yet to be established. With regards to the general views on the health care services offered in Greece, Ferrera (1993) reported on the European Commission’s finding that only 25% of the Greek population was satisfied. A Eurobarometer study, conducted by the European Commission, concluded that the percentage is even lower at only 10.7% (Eurostat, 2000). The latest research by the Ministry of Internal Affairs on the same issue revealed that only 29% of a diverse sample was satisfied with the Greek NHS, while 68.5% were less than satisfied (Komninou, 2000). By comparison, in other European countries, satisfaction with services is, in most cases, higher. For example in the United Kingdom the ‘fairly’ and ‘very satisfied’ citizens were almost 50% and in Finland 78% (Eurostat, 2000). Based on data provided by the World Health Organisation (WHO, 2002) and the dissatisfaction with the health services

ARTICLE IN PRESS Healthcare providers’ priorities for cancer care provided in Greece in general, it was expected that there would also be a level of dissatisfaction with cancer care services. In 2002, WHO (2002) provided guidelines to change ineffective practices and organise cancer care services following the example of cancer plans established in countries/counties, such as the United Kingdom (Department of Health, 2000) and Ontario (Cancer Care Ontario, 2004). It was anticipated that in order to provide satisfactory and effective cancer care services in Greece, healthcare providers’ and users’ priorities should be taken into account. However, research in this area is sparse. This paper seeks to identify healthcare providers’ priorities in order to inform and direct the policy makers’ decision-making process in cancer care.

143 suggest that Delphi technique maximises the benefits of surveys and other consultative processes while minimising their limitations. This research would not have been possible using a questionnaire survey. The challenge of critically analysing the literature, constructing and validating a questionnaire, having pilot group discussions as well as testing these ideas with experts would be time consuming and would have limited the views that could be expressed by the participants (Cormack, 2000). It was considered that focus groups could be an effective way of generating ideas and allowing the sharing of views (Krueger, 1994). However, these views would have had limited validity particularly if some respondents talked at length or said enough depending on group dynamics (Webb and Kevern, 2001).

The study Aim This study was undertaken to investigate healthcare providers’ views on cancer care services in Greece and to prioritise those areas which needed to be developed or improved. It is part of a larger project which also investigated users’ views on this area for the same purpose.

Methods A Delphi technique was used to elicit the healthcare providers’ diverse views on establishing priorities in cancer care and cancer services in Greece. The Delphi technique is a type of survey research that aims to structure group opinion and discussion. Its purpose is to generate discussion and enable a judgment on a specified topic to be made so that decisions can be taken which can claim to represent a given group’s requirements and views (Hasson et al., 2000). The Delphi technique is characterised by anonymity, questionnaires with controlled feedback, statistical analysis of the group responses and expert input (Goodman, 1987). Data are collected through repetitive surveys (usually three rounds) and the results of preceding rounds are fed back by the researcher in the form of statistical summaries, until consensus has been reached among the panel (van Zolingen and Klaassen, 2003; McKenna, 1994). The panel is usually consisting of a group of ‘experts’ who reflect current knowledge and perceptions on the subject under consideration (Jairath and Weinstein, 1994). Delphi technique has been used as a means to obtain information on topics about which little is known and in defining concepts and determining priorities (Twycross, 2001). In recent years, Delphi techniques have been used in the area of health services development by examining health professionals’ and service users’ views (Lowe et al., 1995; Beech, 1997; Cangialose et al., 2000). Despite the criticisms on Delphi technique with regards to its scientific merit and features such as anonymity and the use of ‘experts’ (Hasson et al., 2000), no other technique enables open-ended questioning, attitudinal measurement and controlled anonymous feedback, concepts embedded both in the quantitative and the qualitative paradigms (Bowles, 1999). In addition, Jairath and Weinstein (1994)

Sampling A combination of purposive and network/snowball sampling was used to recruit the sample. Purposive sampling is often used when a researcher wants a sample of experts, as in the case of Delphi surveys (Polit and Hungler, 1999). With regards to network/snowball sampling, it is likely to be used when the research population consists of people who might be difficult to identify (Polit and Hungler, 1999). However, in the current study, the advantage of using network/snowball sampling was that experts in cancer care proposed potential participants who were acknowledged for their expertise in the area of oncology, reducing the possible bias of the researcher in identifying the participants. For the expert group in this study, doctors, nurses, social workers and members of patient support groups in different cancer care settings were invited to participate. Key participants were selected in order that the responses would reflect national priorities rather than local issues (Goodman, 1987). The final panel consisted of 30 participants (who will be called healthcare providers) categorised under three groups: nurses, doctors and others. Ethical considerations Although university ethical approval was obtained to conduct this study, due to a lack of ethical approval committees at a central level within the Greek NHS, approval was granted by the individual healthcare settings where the participants were based. The participants were approached directly by the researcher and asked if they wanted to participate in the study. After their agreement to participate, letters were sent to participants with more information about the study, a leaflet giving information about Delphi technique and the question of the first round. In the accompanying letter it was stated that the return of the questionnaire implied their consent to participate. Participants were assured that their identities would remain anonymous and that they could withdraw from the study at any time. The three round iterative Delphi process Data collection on the healthcare providers’ views consisted of three rounds. The purpose of the initial questionnaire was to identify the areas of cancer care and the cancer services that needed to be developed or improved in Greece.

ARTICLE IN PRESS 144

N. Efstathiou et al. First round The first round questionnaire asked the participants to suggest the areas of cancer care and cancer services which needed to be developed or improved in Greece. This was piloted on a small sample of nurses (n ¼ 8) who cared for cancer patients and did not form part of the panel. The pilot showed that it was eliciting the anticipated responses. The analysis of the first round included the transcription of the responses into a data handling software program (Approach by Lotus Smart Suite). A panel of seven experts in research and qualitative data analysis at the university collapsed the data into thematic groups. The statements unedited within the thematic groups formed the questionnaire for the second round.

Responses for the first questionnaire were analysed and a second questionnaire was developed from these initial responses to rate the priority of each of the issues raised in round one. These ratings were collated and the consensual highest-rated responses were then fed back to the panel via a third questionnaire which asked respondents to rank them (Fig. 1). Trustworthiness of the Delphi technique was based on the formulation of the initial question, transcribing individual responses and documenting response rates over successive rounds (Crisp et al., 1997). Reliability was maximised by using three rounds of data collection to obtain a consensus from the panel of experts. Validity of the results was achieved by obtaining good response rates at every round (Lopez, 2003).

Analysis of 1st round A panel created themes and the suggestions were grouped under these themes 3 nd

Preparation of 2 round questionnaire

1st ROUND

2nd ROUND

"In your opinion, which cancer services and which areas in cancer care need to be developed or improved in Greece"

2 4

EXPERT PANEL 1

30 Healthcare providers

The panel was asked to rate all the suggestions on a 7 point Likert-type scale of 1=very low priority to 7=very high priority

5

7

2nd round analysis Criteria for inclusion in 3rd round Preparation of 3rd round questionnaire 6

rd

3 ROUND 8

The panel was asked to rank in order the suggestions within thematic groups

3rd round analysis

9

FINAL RESULTS CONSENSUS ON THE HIGHEST RANKED STATEMENTS

Fig. 1 The flow chart of the healthcare providers’ Delphi study.

ARTICLE IN PRESS Healthcare providers’ priorities for cancer care Second round The second round questionnaire was posted to the same 30 healthcare providers asking them to rate each statement on a seven Likert-type scale from 1 ‘very low priority’ to 7 ‘very high priority’. The data from round two were analysed using the Statistical Package for Social Sciences (SPSS Version 10). The means and standard deviations were calculated for item scores (Greatorex and Dexter, 2000; Norwood 2000). Correlation coefficients were computed for the mean ratings between the groups of healthcare providers in order to examine the association between the ratings. Achieving consensus Although consensus is a fundamental component of Delphi studies, it is poorly explained (Hardy et al., 2004). Consensus is usually determined through measuring the range in ratings for each statement. Less range is understood to mean greater consensus (Rowe and Wright, 1999). In this study, the data received from the second round showed that more than half of the statements had a high mean score and the range of rating was small suggesting that there was agreement among the panel for a number of statements. At this stage criteria were set for consensus for the highly prioritised statements. Statements with a mean rating score of at least six, with no individual scores below four (neither low nor high priority) on the seven-point Likert-type scale were considered consensual. Third round Usually, during the third round of Delphi techniques, participants are asked to re-consider their ratings based on the summary feedback from the second round. However, there was little scope for re-consideration in this study, as already there was consensus on a large number of statements. It was anticipated that a further round of reconsidering the ratings based on statistical feedback would make the experts conform to the group without changing their opinions (Munier and Ronde´, 2001). For this reason, the consensual statements from round two were kept and the participants were asked to rank them in the third round questionnaire. As 39 (30%) statements had met the consensus criteria set in round two, it was anticipated that participants would have to make considerable comparisons to rank them in order. For this reason, the 39 statements were placed again in groups of three to six statements under specific thematic groups based on the analysis of the first round data. The ranking in order of consensual statements among Delphi panelists is not a new approach and it has also been used in Pelletier et al.’s (1997) Delphi study on the cardiac nurse’s role. The third round questionnaire asked the 30 healthcare providers to rank the statements in order within each of the thematic groups. In round three, the sum of all ranks assigned to an item was computed within each thematic group using SPSS Version 10. The Kruskal–Wallis test was used to investigate if there were any significant differences between the three groups of the participants. The Kendall coefficient of concordance (Kendall’s W) was also used to investigate if there was any significant agreement on the rankings among

145 the participants from each of the groups of doctors, nurses and others.

Results All the recruited sample members responded in round one, thus giving a response rate of 100%. Participants were appointed under three groups; nurses 43.3%, doctors 33.4% and others 23.3%. It was not surprising to find that women represented 73.3% of the panel due to the large number of women in the caring professions. Twenty of the participants were hospital based and 10 were working in the community. Nine of the participants combined more than one role and three were also involved in research and policy development. Although 25 members of the panel were from the greater geographical area of Athens where most of the expertise is concentrated, five members were from other areas of Greece. The average age of the panel was 39.2 yr (SD ¼ 8.05) and the respondents’ average length of experience in cancer care was 11.5 (SD ¼ 7.1) years. The participants were asked to provide a maximum of five statements for the question of the first round. This generated a total of 130 statements by the participants. The average number of statements provided by the members of the panel was 4.3. Nurses, the largest group in the panel, provided 69 statements (53%), doctors provided 31 statements (24%) and the rest of the health professionals provided 30 (23%). After the external panel analysis of the first round, 29 themes were identified. Forty percent of the statements were themed as ‘home care’, ‘education/training’, ‘public health/health promotion’ and ‘psychological support’. ‘Home care’ as a theme incorporated the highest number of statements. Surprisingly, doctors did not provide any statement suggesting development or improvement in the area of ‘education/training’. Other themes that were identified were ‘pain management’, ‘financial resources’, ‘staff shortages’, ‘hospices’, ‘research’, ‘communication’ and ‘information’. For the second round, 23 (77% response rate) questionnaires were returned by the participants after rating the statements generated in the first round. All three groups of health professionals were represented in this round. Surprisingly, from the 130 statements, only 27 had a mean score lower than six (high priority). Seventy nine percent of the statements had a mean score of six and above (high to very high priority). All the participants rated the statement ‘‘Home care should be developed for oncology patients not only during treatment but for terminally ill patients’’ as ‘very high priority’. The main areas prioritised by the healthcare providers were the development of ‘home care’, the problem of ‘staff shortages’ and ‘pain management’. Other issues rated highly by the participants were ‘psychological support’, provision of ‘day units’ and ‘communication’. Table 1 presents the 10 statements that were rated the highest by the participants listed by their mean score. A small but significant positive correlation (r ¼ 0:28, Po0.01) was found between the ratings of doctors, nurses and others indicating agreement among the panel. Not surprisingly, a significant moderate relationship was displayed for the doctors’ and

ARTICLE IN PRESS 146

Table 1

N. Efstathiou et al.

The 10 highest rated statements by the healthcare providers (Round 2)

Statements

Mean

SD

Home care should be developed for oncology patients not only during treatment but for terminally ill patients. Nurses should be employed by the Greek state in order to overcome the problem of shortage of staff in home car services. Services like home care should be developed for terminally ill cancer patients, for better quality of life at the last stages of life. Greater attention should be given to the management of pain. Health professionals should be informed and educated in pain management. Pain clinics. Day units should be increased in Oncology hospitals in order to serve more cancer patients (day units, out patients’ radiotherapy), so that patients stay more at their home environment. Screening services in hospitals should be operating for more hours, so that waiting lists get shorter (waiting period for a mammography may take 4 months). The number of nursing staff should be increased in Oncology hospitals. Psychological support should be provided to cancer patients and their families through all the stages of the disease. Pain management services should be developed by pain clinics, offering pain management not only during treatment but also when at home, through all the stages of the disease. The system connecting the health centres with the hospitals should be improved.

7.00

0.00

6.95

0.22

6.86

0.35

6.86

0.47

6.86

0.47

6.83

0.65

6.82 6.78

0.39 0.52

6.77

0.53

6.77

0.61

nurses’ ratings (r ¼ 0.56, Po0.01) as doctors and nurses tend to work together and share the same experiences. The third round questionnaire was sent to all 30 participants and 26 questionnaires were completed and returned by the panel (a response rate of 86.7%). All health professionals were represented again in this round from various healthcare settings. After the completion of the third round data analysis, the highest ranked statements suggested the development or improvement of services in order to provide effective cancer care, from prevention to terminal care, either at the patients’ home or close to where they live. Other highest ranked statements suggested the recruitment of more nurses, improvement in all levels of education and psychological support for cancer patients. Table 2 presents the highest ranked statements for healthcare providers within each of the third round’s nine thematic groups. The Kruskal–Wallis test did not identify any significant differences among the raters for the highest ranked statements. On the contrary, there was a significant agreement within the three groups’ rankings. The Kendall coefficient of concordance (Kendall’s W) revealed a significant level of correlation between:

 The nurses’ rankings (w2 ¼ 141.351, d.f. ¼ 38, Po0:001) Kendall’s W ¼ 0:338;

 The doctor’s rankings (w2 ¼ 107.609, d.f. ¼ 38, Po0:001) Kendall’s W ¼ 0:354;

 The remaining of health professionals’ rankings (w2 ¼ 99.459, d.f. ¼ 38, Po0:001) Kendall’s W ¼ 0:374.

Discussion In this study, the application of the Delphi technique enabled participants to generate statements about the

development or improvement of cancer care and services in Greece and agree on their prioritisation. Following this approach, consensus was achieved within the responses and this enhances the validity of conclusions drawn from the data (Marsden et al., 2003). Concerns were raised over the prioritisation of a large number of statements in the second round; however that was resolved in the third round by modifying the Delphi technique and requiring by the participants to rank the consensual statements. Although the panel was not randomly selected and was not representative of the whole population of healthcare providers in Greece, it has agreed and ranked the highest nine suggestions that may provide a coherent and comprehensive perspective of the issues associated with the provision of cancer care in Greece. One of the issues mentioned in the final round of the Delphi technique was the limited resources available for cancer care. Human and financial resources are limited in Greece for the healthcare sector (Petridou et al., 1999). In this study, human resources were focused on nursing personnel shortages. This is not surprising as the problem of nursing shortages in Greece has been well documented. Plati et al. (1998) have reported that the number of nursing personnel was 35,715 in 1993 while the estimated needs were 62,000. Polyzos and Yfantopoulos (2000) have also reported on the shortages of the nursing personnel in their paper adding that before or after graduation, 50% of nurses leave the profession due to unacceptable working conditions. In addition, a recent study among 800 health professionals and administrative staff working in public hospitals suggested that for 25% of the nurses in the sample, the shortage of nursing personnel was a major problem for the Greek NHS (Komninou, 2000). It is expected that the Greek government will soon consider a plan for gradually increasing and retaining the number of nurses employed in order to reverse the lowest nurse patient ratio in Europe (Nikolentzos, 2005).

ARTICLE IN PRESS Healthcare providers’ priorities for cancer care

Table 2

147

The highest ranked priorities by the healthcare providers (Round 3)

1. Manpower resources 2. Organisational issues 3. Public health/Health promotion/ Prevention 4. Services development 5. Equity in access of healthcare 6. Education/Training 7. Psychological support 8. Communication

9. Palliative care/Pain management

The shortage of specialised nursing staff requires the immediate initiation and application of a plan for the recruitment and retaining of nurses in the profession. Oncology hospitals must become independent, functional, efficient, nonbureaucratic. The environment of oncology hospitals should not seem impersonal. Media should inform people about cancer prevention Day units should be developed as well as special intensive care units, physiotherapy units and home care services in all the oncology hospitals Cancer hospitals should be built in the greater area of Greece so that cancer patients will not have to travel far for special treatment Education (basic, post basic and continuing) must be improved for all health professionals (doctors, nurses, psychologists, social workers). Psychological support groups must be created in oncology hospitals, consisting of psychiatrist, nurses, psychologist and social workers. All health professionals who come in contact with cancer patients should receive special training in communication skills (How to tell the diagnosis, bad news regarding the treatment etc.). Development of terminal care for patients either at home or in special hospitals and institutions

In this study, education and training for health professionals was not rated very highly. None of the statements under this category appeared in the highest 10 rated items in the second round. It is possible that education and continuing training were not amongst the highest priorities for participants as they may assume that healthcare professionals already have a reasonable level of education and it should therefore not be highly prioritised. However, the importance of training in oncology was addressed in a study among 256 Greek medical students, acknowledging that the level of oncology education was average (46%), requiring further improvements (Andrikopoulos et al., 1999). On the third round, healthcare providers agreed that all levels of education for all healthcare professionals should be improved. Another issue, which can be linked with education, was that of training in communication skills. In the third round, under the ‘communication’ thematic group, 65.4% of the healthcare providers ranked the need for special training in communication skills as first. Participants from the panel suggested that the breaking of bad news should be communicated sensitively and there should be appropriate training provided for healthcare professionals for this purpose. In Mystakidou et al.’s (1996) study of 228 Greek oncologists, radiotherapists and palliative care specialists, it was revealed that 39% of the sample felt that they were not adequately trained in communication skills. Furthermore, Georgaki et al. (2002) have revealed that 66% of 178 Greek nurses had difficulties in communicating with cancer patients due to insufficient education in communication skills. It is suggested that training on breaking bad news and communication with cancer patients should be prioritised in order to provide adequate information to patients to support them to make the right decisions and cope with the stress and anxiety that a cancer diagnosis brings (Wells et al., 2001; Mystakidou et al., 2005). With regards to cancer care services, prevention is seen as imperative which offers the greatest public health

potential and the most cost effective long-term cancer control (WHO, 2002). In the second round, one of the highest rated statements within the ‘prevention’ thematic group suggested well-organised screening programmes for the population, such as Papanikolaou (PAP) test or mammography which is currently sporadic. However, this statement did not meet the consensus criteria. The statement that did meet the consensus criteria and ranked first among the three statements of the thematic group ‘prevention’ in the third round indicated the involvement of ‘media’ in health promotion. It has to be considered that the entire health system in Greece is treatment orientated and health promotion has not been emphasised (Petridou et al., 1999). It is of great importance to investigate ways to develop effective prevention strategies even within a treatmentorientated health care system. Another area of cancer care provision that has received great attention is palliative care. This is an approach that aims to improve the quality of life of patients and their families who face the problems associated with a lifethreatening illness (WHO, 2002). The statement that suggested the development of palliative care either at home or in special institutions under the thematic group ‘palliative care/pain management’, was ranked first by 46.2% of the participants in the third round. According to Mystakidou et al. (2003) there is an increasing need to develop hospices and expand palliative care and home-care services across Greece. However, further research is required to explore the need for palliative care services in Greece and their effectiveness where they exist. Cancer causes considerable psychological distress in patients. White and MacLeod (2002) suggest that psychological problems are common among cancer patients which may include unpleasant symptoms such as pain, nausea, and fatigue; family worries; existential and spiritual doubts. These issues were acknowledged by the panel in this study who rated statements under the thematic group of ‘psychological support’ highly. The highest ranked consensual

ARTICLE IN PRESS 148 statement under this thematic group suggested the provision of psychological support at the hospital by a multi disciplinary team. It is suggested that routinely screening for emotional distress should be conducted to identify cancer patients with psychosocial problems as healthcare providers often fail to correctly identify them (Berard et al., 1998). Further research is required in this area in Greece to identify the impact of a cancer diagnosis on patients and their family. Well-established assessment tools have been translated in Greek and validated, such as the Hospital Anxiety and Distress scale for terminally ill cancer patients (Mystakidou et al., 2004), which could be used routinely as an effective tool to identify emotionally distressed cancer patients and initiate the appropriate support. All participants in round two gave one statement suggesting the development of home care for cancer patients during treatment and at the end of life very high priority. Home care is very limited in Greece, whereas in the rest of the world there has been a shift towards its development (Kerkstra and Hutten, 1996). Although a systematic review on the effectiveness of home care services for cancer patients had inconclusive results (Smeenk et al., 1998), these services are preferred by patients as they are considered to be user orientated (Sitzia and Wood, 1997). The limited available studies in the area of home care in Greece have revealed some cost effectiveness of the services (Tsitoura, 1997) and the satisfaction of the patients (Christopoulou, 1990). Further investigation is required to identify the effectiveness of these services in Greece and the satisfaction of the patients receiving these services. Another issue that healthcare providers agreed on was in prioritising the organisation of cancer hospitals. The statement emphasising the independence and the efficiency of cancer hospitals, was ranked first by more than 60% of the panel in the third round under the ‘organisation’ thematic group. The organisation of oncology hospitals has also been an issue in other Greek studies. A study, involving 800 health professionals’ and administrative staffs’ views about the Greek NHS, revealed that for 40% of the doctors in the sample the bureaucracy existing in Greek hospitals is a major problem while only 8.9% of nurses in the sample shared the same view (Komninou, 2000). An earlier study by Kyriopoulos et al. (1994) reported that 21.2% of 194 doctors suggested changes in the way hospitals were operating in order to become more efficient. However, according to Nikolentzos (2005), the medical profession and its trade union usually resist the efforts of Greek governments to change the health care system. In order to bring changes, there needs to be a high level of consensus or at least the ability to compromise among the groups/interests whose support is necessary to implement reforms. Unfortunately, no consensus was ever achieved in 1983 and there has been none since in favour of significant health sector reform (Nikolentzos, 2005).

Conclusion A Delphi technique aimed to identify the problematic areas in cancer care and cancer services in Greece and prioritised them with the use of a carefully selected panel of

N. Efstathiou et al. healthcare providers. The large number of statements prioritised in the second round of this study may indicate that there are several areas of cancer care provision that need to be developed or improved in Greece. This study has contributed to the view that the Greek NHS has not evolved as it might have been hoped and cancer care provision is inevitably affected as it is offered within the same system. The changes required to improve or develop cancer care and cancer services proposed by the healthcare professionals in this study are in accordance with those identified in the literature with regards to the Greek NHS. It is acknowledged that some of the proposed priorities would require extra financial resources, which are limited in Greece. However, the Greek authorities should seriously consider the shortage of nurses, as a great number of healthcare services could be organised and run by nurses. In addition, the existing cancer care services should be evaluated in order to identify their efficiency and effectiveness. This could be achieved by developing a national cancer registry to identify the true incidence, mortality and survival rates for the different types of cancer. The culture of central organisation within the Greek NHS tends to lead to fragmentation in planning and the views of healthcare providers are not usually taken into account when developing or improving healthcare services. However, in order to create effective services, healthcare providers’ views should be acknowledged as they are closely involved and have valuable experience of working in the NHS.

Acknowledgements The project was partly funded by the European Oncology Nursing Society (EONS/Roche grant). The first author received the ‘Novice Researcher’ award (1999) for this study. We would like to thank Professor Laurie Moseley and Professor Donna Mead for their advice and supervision during the initial stages of the study and for their involvement in the study conception.

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