Running head: PROSTATE CANCER SURVIVORSHIP CARE PLANS

Quality Improvement Project
to Implement Prostate Cancer Survivorship Care Plans
Brittany R. Shirley
Arizona State University

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Abstract
There is an increasing number of cancer patients outliving their diagnosis and treatment and
requiring more support as they transition to cancer survivors. To bridge this gap, survivorship
care plans should be provided to all cancer survivors to provide post treatment plans of care,
recommendations, and resources (Commission on Cancer, 2016). A quality improvement project
was implemented in the urology practice of a National Cancer Institute-designated, academic
hospital in Phoenix, Arizona to provide survivorship care plans to prostate cancer patients with
surgical intervention as their cancer treatment. Through interprofessional collaboration, the
process change was designed and implemented with the residents and Physician Assistants of the
urology practice. There was a 93% adherence rate in delivering the survivorship care plans
during the project. The “Confidence in Survivorship Information” questionnaire was used to
measure the patients’ confidence in survivorship information prior to and after receiving a
survivorship care plan. A paired t-test showed statistical significance in improvement in
confidence in the knowledge of long-term physical effects of cancer treatment, strategies for
preventing and treating long-term physical effects, and resources available for family members
who may be at risk. Delivery of survivorship care plans will continue within the urology
practice, along with further implementation into other practices, to meet requirements for cancer
programs established by the Commission on Cancer (Commission on Cancer, 2016).
Keywords: prostate cancer, prostate cancer survivorship, survivorship care plans,
confidence and satisfaction in survivorship care

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Quality Improvement Project to Implement Prostate Cancer Survivorship Care Plans
In 2017, there were an estimated 14 million cancer survivors in the United States. “By
combining the growth in the United States’ aging population with an increased risk of cancer as
individuals age, the number of cancer survivors is projected to increase to 18 million by 2022”
(Hebdon, Abrahamson, McComb, & Sands, 2014, p. 615). Of the current 14 million survivors,
2.9 million are prostate cancer survivors (American Cancer Society, 2017). With the 5-year
survival rate of prostate cancer at almost 100% for those diagnosed with local or regional
prostate cancer, this group makes up a large portion of cancer survivors (American Society of
Clinical Oncology [ASCO], 2018). “An individual is considered a cancer survivor from the time
of cancer diagnosis through the balance of his or her life” (Institute of Medicine [IOM], 2005b,
p. 2). Cancer patients are living past their diagnosis and treatment, and they encounter a variety
of treatment-related health issues, in addition to psychological, emotional, financial, and social
challenges (National Coalition for Cancer Survivorship [NCCS], 2014). In order to describe
these issues and challenges faced by these patients, the National Coalition for Cancer
Survivorship defined the term “cancer survivorship” as “living with, through, and beyond a
cancer diagnosis” and recommends utilizing survivorship care plans to support their needs
(NCCS, 2014). There will be a great burden on the healthcare system with the increasing number
of cancer survivors, so efforts have begun to address survivorship care (Hebdon et al., 2014).
Background and Significance
The Institute of Medicine’s From Cancer Patient to Cancer Survivor: Lost in Transition
was the first to highlight as cancer patients complete their cancer treatment, they are not provided
with the essential information or support as they transition to being a cancer survivor (IOM,
2005a). The recommendations from the IOM report included an overview of the need for these

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patients to receive survivorship care plans, inclusive of their diagnosis, treatment, surveillance
schedule, recommendations and resources (IOM, 2005a, p.1). A survivorship care plan would
“allow for a comprehensive review of treatment with ongoing goals” (Rasper & Terlecki, 2016).
Other organizations, including the Centers for Disease Control and Prevention (CDC), Lance
Armstrong Foundation (Livestrong), Commission on Cancer (CoC), and National
Comprehensive Cancer Network (NCCN), have also addressed the need for survivorship care
and care coordination through post-treatment summaries or survivorship care plans (Hebdon et
al., 2014).
In 2016, the CoC released new standards for CoC-accredited cancer programs.
Specifically, Standard 3.3 requires all patients who have completed their cancer treatment be
provided with a survivorship care plan (Commission on Cancer, 2016). To meet this
requirement, the survivorship care plan must detail the treatment summary and follow-up care
plan for the patient (Commission on Cancer, 2016). It must also be delivered to patients within
one year of diagnosis and no later than six months after completion of treatment (Commission on
Cancer, 2016). Additionally, a verbal discussion about the survivorship care plan between the
patient and healthcare provider is required to meet the standard. By 2018, 75% of all eligible
cancer survivors who have completed treatment should receive a survivorship care plan
(Commission on Cancer, 2016).
Rasper and Terlecki (2016) reported prostate cancer as the most common malignancy
among male cancer survivors in the United States. This population makes up 44% of the 7
million male survivors, and therefore, survivorship care plans for these patients should be a
priority for both cancer centers and urology practices (Rasper & Terlecki, 2016). Although
patients with treatment for localized prostate cancer experience favorable outcomes, they can

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endure both functional and quality-of-life impairments (Gilbert et al., 2014). “For example, men
treated surgically (prostatectomy) face a 10%-15% risk of problematic urinary incontinence and
greater than 50% risk of erectile dysfunction” (Gilbert et al., 2014, p. 1484). These survivorship
care plans set the framework for important conversations between patients and their healthcare
providers and can facilitate efficient and effective communication about post-treatment care
(Rasper & Terlecki, 2016).
Internal Evidence
In 2017, the need for survivorship care plans for cancer patients was identified at a
National Cancer Institute-designated, academic hospital in Phoenix, Arizona. In previous years,
the hospital was able to meet the CoC requirement because it was evaluated as part of the
hospital system as a whole instead of as an individual site. The CoC evaluators recommended
that each site be evaluated on an individual basis moving forward; therefore, the hospital in
Phoenix, Arizona would no longer meet the requirements simply by falling under the enterprise
umbrella and would need to implement survivorship care plans into their practice. It was
determined the target areas for implementation of survivorship care plans would be the
organization’s three largest cancer patient populations. This included prostate, breast, and colon
cancer patients. In 2015, the urology practice of the organization provided first course treatment
to 415 patients diagnosed with prostate cancer (Mayo Clinic Cancer Registry Database, personal
communication, September 2017). There were 215 patients whose cancer was treated with
surgical intervention only, while the remaining patients were treated with various combination
therapies (Mayo Clinic Cancer Registry Database, personal communication, September 2017).
These patients with surgical intervention as their treatment course for cancer encompass a large

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portion of the organization’s cancer patients and survivors, so were identified as the initial group
for survivorship care plan implementation.
Problem Statement
The organization identified the need to meet CoC requirements by providing survivorship
care plans to patients completing cancer treatments. For the purposes of this DNP project, the
urology prostate cancer population was identified. This inquiry has led to the clinically relevant
PICO(T) question, “In adult male patients who have completed their treatment for prostate
cancer with surgical intervention (P), how does providing a Survivorship Care Plan (I) compared
to standard practice (C) affect their confidence and satisfaction in survivorship information and
health promotion (O)?
Search Strategy
To address this clinical question, an exhaustive search of the literature was completed.
The search was completed in three databases, Cumulative Index of Nursing and Allied Health
Literature (CINAHL), PubMed, and Academic Search Premier. The search terms that were used
included: prostate cancer, prostate cancer survivorship, survivorship care plan, prostate cancer
survivorship care plans, cancer survivorship care, confidence in survivorship care, satisfaction
in survivorship care, and confidence and satisfaction in cancer survivors. The searches were
restricted to peer-reviewed journals, English language, and published between 2010 and 2017.
The Boolean connector “AND” was also used to combine some of the search terms in order to
further specify the search results. In addition to the search of the databases, the reference lists of
the literature found were reviewed to help identify further useful studies.
The search of CINAHL (Appendix A, Figure A1) with the limits applied and searching
the general term “prostate cancer” yielded 3,574 article results. The search of the term “prostate

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cancer survivorship” yielded 22 results. The term “survivorship care plan” yielded 87 results,
while the specific term “prostate cancer survivorship care plans” yielded two results. A search
was also completed using the Boolean connector “AND” to combine the terms “prostate cancer”
and “survivorship care plan” which yielded two results. During a subsequent search (Appendix
A, Figure A2) the terms “confidence in survivorship care” yielded seven results, “satisfaction in
survivorship care” yielded nine results, and “confidence and satisfaction in cancer survivors”
yielded two results.
The search of PubMed (Appendix B, Figure B1) with the limits applied for the term
“prostate cancer” yielded 63,685 article results. The term “prostate cancer survivorship” yielded
295 results, and the term “survivorship care plan” yielded 238 results. Again, the Boolean
connector “AND” was utilized for the terms “prostate cancer” and “survivorship care plan” for
which 11 results were yielded. The search of the term “cancer survivorship care” yielded 2,178
results, and the term “prostate cancer survivorship care plan” yielded 11. Search results for the
terms “confidence in survivorship care”, “satisfaction in survivorship care”, and “confidence and
satisfaction in cancer survivors” yielded 179, 172, and 30 articles, respectively (Appendix B,
Figure B2).
A search was conducted in Academic Search Premier (Appendix C, Figure C1) with the
limits applied and for the same terms, “prostate cancer”, “prostate cancer survivorship”,
“survivorship care plan”, and “cancer survivorship care”, which yielded 11,202, 26, 78, and 293
results respectively. Using the Boolean connecter, “prostate cancer” AND “survivorship care
plan” yielded five results, and “prostate cancer survivorship care plan” yielded four results.
Again, a subsequent search of Academic Search Premier (Appendix C, Figure C2) was

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completed for the terms “confidence in survivorship care”, “satisfaction in survivorship care”,
and “confidence and satisfaction in cancer survivors” yielding five, nine, and two articles.
The articles yielded from the searches were a combination of both qualitative and
quantitative. After extensive review of the literature, ten articles were selected for their
examination of prostate cancer survivorship, survivorship care plans, and cancer survivorship
care.
Evidence Synthesis
Both qualitative and quantitative articles were found regarding implementation of
survivorship care plans into practice. A majority of the articles found were systematic reviews of
qualitative studies, Level V evidence (Melnyk & Fineout-Overholt, 2011). The articles reviewed
examined: implementing survivorship care plans into practice; effectiveness in post-treatment
care; and the effect of the model of care delivery used. No model of care delivery was more
beneficial than another, for example, which healthcare provider delivers the survivorship care
plan (i.e. physician or nurse) or in what setting (i.e. primary care clinic or survivorship care
clinic) (Hebdon et al., 2014). A Level IV evidence cohort study was reviewed that looked at the
prevalence and barriers of survivorship care plans in practice, which showed most organizations
had adopted survivorship care plans, however less than a quarter of the providers had reported
using them (Birken, Mayer, & Weiner, 2013). Some of the contributing factors for why the
providers did not use the care plans were lack of organizational resources such as time, funding,
staff, training, and lack of a referral system to a survivorship nurse (Birken, Mayer, & Weiner,
2013). Another study found the time it took to develop and deliver the care plan, an average of
49 minutes and 16 minutes respectively, was a barrier for the care team members and contributed
to the compliance of delivery (Mayer, Gerstel, Walton, Triglianos, Sadiq,…Davies, 2014).

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Additionally, a Level I evidence Randomized Controlled Trial supported an increase in
confidence in survivorship information following the implementation of survivorship care plans
(Mayer et al., 2016).
The evidence confirmed inconsistencies in the delivery of survivorship care plans to
patients due to time and available organizational resources. Further studies are needed to
examine and support a specific model of care delivery for survivorship care, either through
physicians, Physician Assistants (PAs), Nurse Practitioners (NPs), or nurses. Additionally, a
majority of the literature came to the same conclusion that further studies are needed to support
the effects of survivorship care plans on cancer survivors’ quality of life.
Purpose and Rationale
The purpose of providing survivorship care recommendations and resources to cancer
survivors is to improve their quality of life following treatment. By increasing communication
and collaboration between the care team and the patient, and increasing the patient’s awareness
of the surveillance plan, follow-up care, cancer survivor resources and wellness promotion, it is
hoped patients will become active and knowledgeable participants in their own care. The aim of
the project is to give prostate cancer survivors confidence to navigate their care after completing
their cancer treatment.
Contribution of Theory and Models
Watson’s Theory of Human Caring
Jean Watson’s Theory of Human Caring was the theoretical framework used to guide the
implementation of survivorship care plans for prostate cancer survivors to increase their
knowledge and self-care following their cancer treatment. The core concepts of this theory are
understanding the patient’s health needs, caring that is inclusive and circular, care for the patients

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and their families, and focusing on health promotion (Watson Caring Science Institute, 2010).
Watson’s “10 Caritas Processes” are the guidelines for putting the theory into action, and six of
these specifically were utilized to guide the project (Watson Caring Science Institute, 2010, p.2):
Be sensitive to self and others by nurturing individual beliefs, personal growth, and practices;
Develop helping-trusting caring relationships; Promote and accept positive and negative feelings
by authentically listening to another’s story; Share teaching and learning that addresses the
individual needs, readiness, and learning styles; Create a healing environment for the physical
and spiritual self that respects human dignity; Assist with basic physical, emotional, and spiritual
human needs. This theory supports the principal objectives of survivorship care plans, which are
to provide essential information to cancer patients as they transition to cancer survivors, to
educate them on health promotion, and to provide support for their physical, psychological, and
emotional well-being following their treatment.
Interprofessional Collaborative Practice Model
“Interprofessional collaborative practice has been defined as a process which includes
communication and decision-making, enabling a synergistic influence of grouped knowledge and
skills” (Bridges, Davidson, Odegard, Maki, & Tomkowiak, 2011, p.1). Due to the complex
health needs of patients and the complexity of healthcare organizations, more than one discipline
is required to address issues (Bridges et al., 2011). Through collaboration, coordination, and
communication, these interprofessional teams bring their individual professional cultures and
knowledge together to work on common goals to improve the quality of patient care (Mangold,
Denke, Gorombei, Ostroski, & Root, 2014). Time, distance, lack of respect, and poor
communication can create challenges in interprofessional collaboration (Mangold et al., 2014).
To promote strong relationships and provide quality outputs, it is vital to anticipate these

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challenges and work to prevent or minimize them. These groups also require strong leadership to
ensure productivity, and communication that is both timely and meaningful.
Evidence-Based Practice Model
The Mayo Clinic Nursing Evidence-Based Practice Model was chosen to guide the
survivorship care plan implementation for prostate cancer survivors. The Mayo Clinic Nursing
Evidence-Based Practice Model (Appendix D) is a cyclical model that drives the evidence-based
process through seven steps (Mayo Clinic, personal communication, September 2017):
Formulate a question; Search the evidence; Appraise the evidence; Compare and contrast the
evidence; Decision options; Evaluate; Disseminate. Decision options include confirming the
current practice reflects the best available evidence, identifying if there is a discrepancy between
the current practice and evidence that supports a practice change, or validating the evidence is
inconclusive. Decision options and practice strategies are based on the best available evidence
including clinical expertise, patient values, and literature review (Mayo Clinic, personal
communication, 2017). Through the use of this evidence-based practice model, the
implementation of survivorship care plans into practice can be evaluated with meaningful
outcomes, and these outcomes can be disseminated.
Project Methods
A team was assembled to design and implement the Prostate Cancer Survivorship Care
Plan Quality Improvement Project. This interprofessional team collaboration included the DNP
student leader, a Project Manager from the organization, the Manager of Nursing Research, a
Clinical Informatics nurse, and a physician recognized as the physician sponsor for the project.
To move forward with the project, the DNP student leader submitted for approval from
the Institutional Review Board of the organization. The project was deemed exempt from further

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IRB review (Appendix E). The DNP student leader also submitted the project description,
questionnaire, and phone script for the follow-up calls to the Arizona State University (ASU)
Institutional Review Board (Appendix F). No consents were submitted as the project was
regarded as a quality improvement project through the organization. The project was approved
by the ASU Institutional Review Board as Study #00007269 (Appendix F).
Participants
The participants identified for the project were patients diagnosed with prostate cancer
who had surgical intervention as their primary cancer treatment. Based on CoC requirements, the
inclusion criteria included: Adult males with a diagnosis of prostate cancer stages I, II, and III,
ages 18 and older that were treated with curative intent for an initial cancer occurrence, who
have completed their active therapy at the identified National Cancer Institute-designated,
academic hospital in Phoenix, Arizona (Commission on Cancer, 2016). Patients with stage 0, IV,
or with metastatic disease and that have been treated without curative intent, patients who are
pathologically staged but never treated or seen for follow up, and patients receiving radiation,
chemotherapy, or hormone therapy were excluded from the project. Participants were not
required to consent as this was a quality improvement project for the organization.
Instrumentation
With permission from the University of Pennsylvania, the “Confidence in Survivorship
Information” Questionnaire (Appendix G) was identified as the tool for the project to measure
the patients’ confidence in their survivorship care prior to and after receiving a care plan. The
reported reliability of the tool was “two subscales: 1) confidence in knowledge of past cancer
diagnostic and treatment details (3 items; Cronbach's alpha = 0.77) and 2) confidence in
knowledge about prevention and treatment of long-term and late-effects of disease and treatment,

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prevention of future disease, access to resources, and familial risk of cancer (10 items;
Cronbach's alpha = 0.95)” (Palmer, Jacobs, Mao, & Stricker, 2012, p.1). Three additional
organization-specific questions on satisfaction were also added to the questionnaire. The first 13
questions measured confidence and utilized a three-point Likert scale. One being “not at all
confident” and three being “very confident”. The three organizational-specific demographic
questions regarding satisfaction utilized a five-point Likert scale. One being “very dissatisfied”
and five being “very satisfied”.
Patients were provided the questionnaire upon check-in to their follow-up appointment
and asked to complete it prior to meeting with their provider. One to three months following this
appointment, the patients who completed the pre-intervention questionnaire were called to
complete a post-intervention questionnaire.
Implementation Strategy
The interprofessional team was concerned about the amount of time it would take to
develop and deliver a survivorship care plan. A technology-enabled care plan tool was identified
to reduce this time. The tool enables a care plan to be created using patient specific data entered
by the provider. The care plan is also populated with health promotion recommendations based
on the standard NCCN guidelines (NCCN, 2018). There is an option for the practice to
customize the tool with practice preferences. The DNP student leader and the Clinical
Informatics nurse reviewed and tested the prostate cancer compendium with the organization’s
practice preferences to ensure the correct information was generated into the care plans when a
trigger was met with the patient-specific data.
Initially, the team met with the Nurse Manager and Nurse Administrator of the outpatient
urology practice to determine if the nurses could provide the survivorship care plans to the

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patients. In the outpatient urology practice, the nurses perform more procedural roles than
clinical support roles therefore it was agreed this was not the best option for this practice. The
DNP student leader and the physician sponsor met with the attending physicians of the urology
practice to gain key stakeholder buy-in, and to collaborate and determine responsibility to create
and deliver the survivorship care plans to the patients. During this meeting, the urology residents
and PAs were identified as the care providers who would be trained to implement the care plans
into practice.
An overview of survivorship care plans was communicated to the residents and PAs to
gain buy-in and develop a process for the delivery of the survivorship care plans (Appendix H).
Through team discussion and collaboration, it was determined that the 1-week follow-up visit
after surgery would be the best time to deliver the survivorship care plans as pathology would
have been reviewed with the patients. Another potential issue considered was patients not
returning for their follow-up visits at the 3-month mark. To facilitate recognition of the need to
provide the care plan during the appointment, the providers were encouraged to enter a comment
stating “Survivorship Care Plan Visit” into the Post-Operative Visit (POV) order. This triggered
action by the scheduling department to place a reminder on the providers’ calendar. This also
functioned as a reminder prompt for the front desk staff to be aware that the patient should be
given the survivorship questionnaire.
The DNP student leader led 1:1 education sessions with the residents and PAs prior to the
scheduled start date. During the education sessions, the use of the technology-enabled care plan
tool was demonstrated. The subsequent steps to be completed to meet the CoC requirements
(Appendix H) were reviewed and return demonstration by the provider was completed.

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The implementation start date was December 11, 2017. During the first week, the patients were
manually identified from the surgical schedule. A more sustainable and less manual process was
needed for patient identification; therefore, a report was developed. By searching the surgery
dates, the report identified the patients and their POV appointment dates. Subsequent parts were
added to the report, such as links to the dictated note and the care plan in the patient’s electronic
health record (EHR), to use it as an auditing tool for process measures.
Outcomes/Project Results/Impact
Prior to the implementation of the project, survivorship care plans were not developed
and given to prostate cancer patients. During the implementation period, 71 eligible patients
were identified. Of these 71 patients, 66 of these patients received a survivorship care plan
resulting in a 93% adherence rate to the implemented process change. The correct version of the
survivorship care plan was sent to the patient’s EHR 74% of the time (Appendix I). A dictated
note detailing the delivery and review of the survivorship care plan was completed 80% of the
time (Appendix I).
Of these 66 patients who received a survivorship care plan, 16 completed the preintervention questionnaire, a 26% response rate. The patient sample had a mean age of 64.31
years (SD 7.068), ranging from 52 to 74 years old. Follow-up phone calls were made to the
patients who completed the pre-intervention questionnaire at one to three months following their
POV appointment. Six patients provided responses for the post-intervention questionnaire.
A paired samples t-test was conducted for each question to compare the confidence and
satisfaction in survivorship information prior to and then after receiving a survivorship care plan.
There were four questions that showed statistical significance when the paired t-test was
performed (p<0.05), while there was no statistical significance in the other 12 questions

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(Appendix J). There was a significant difference in the scores for Question 5 pre-intervention
(M=2.00, SD=0.62) and Question 5 post-intervention (M=2.83, SD=0.41); t(5)=-5.00, p=.004.
This result suggests there was an increase in confidence in knowledge about the long-term
physical effects of cancer treatment associated to the survivorship care plan. Next, there was a
significant difference in the scores for Question 6 pre-intervention (M=2.00, SD=0.632) and
Question 6 post-intervention (M=3.00, SD=.000); t(5)= -3.87, p=0.012. This result suggests there
was an increase in confidence in knowledge about strategies for preventing long-term physical
effects of cancer treatment due to the survivorship care plan. There was also a significant
difference in the scores for Question 7 pre-intervention (M= 2.00, SD= 0.632) and Question 7
post-intervention (M= 2.67, SD= 0.516); t(5)=-3.162, p=0.025. This result suggests there was an
increase in confidence in knowledge about strategies for treating long-term physical effects of
cancer treatment related to the survivorship care plan. Finally, there was a significant difference
in the scores for Question 13 pre-intervention (M=2.00, SD= .632) and Question 13 postintervention (M= 2.67, SD= .516); t(5)=-3.162, p=0.025. This result suggests there was an
increase in confidence in knowledge about how to get information for family members and their
risk for cancer related to the survivorship care plan. A Wilcoxon Sign-Ranked test was further
completed on the four questions that showed statistical significance in the paired t-test. These
same four questions, Questions 5, 6, 7, and 13, were again statistically significant.
Although there was not statistical significance on all questions for confidence and
satisfaction in survivorship information, all questions showed an increase in mean scores in
confidence from the pre-intervention questionnaire to post-intervention questionnaire with the
exception of Question 4 (Appendix K). There was no increase in mean scores for any of the three
satisfaction questions (Appendix K). Survivors confidence in their knowledge of the potential

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long-term physical effects from their cancer treatment, strategies for preventing and treating
long-term effects, resources for their family’s risk for cancer, and available community resources
were the areas most improved following the delivery of the survivorship care plan.
Discussion
With the small sample size (n=6) of patients completing both the pre-intervention and
post-intervention questionnaires, it is difficult to know the overall effectiveness of survivorship
care plans on cancer survivors’ confidence and satisfaction. However, the results of this quality
improvement project show a positive trend in the effects of the survivorship care plan. By
collecting data of a larger sample size, this could help to confirm the results found in this smaller
sample size.
Although the process change was created through collaboration with the urology practice,
greater adherence to the process change might have occurred with greater buy-in and deeper
knowledge of the importance of survivorship care plans, their purpose, and the positive effect on
communication between healthcare providers and patients. The specific requirements to meet the
CoC standard should be reviewed again with the providers to improve their practice and further
adherence to the process. Also, an initial meeting should occur with the key stakeholders as it
did; however, it would be more beneficial to include all stakeholders when a process change is
planned. This would encourage open communication and consensus by those who will deliver
the care plans. With this buy-in and acknowledgement of roles and responsibilities, the
successful transition of the project to the practice and its continued sustainability would be more
likely.
Strengths
There were a few strengths noted throughout the project and during the evaluation.

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The first strength was the interprofessional collaboration noted throughout the entire process.
This was truly necessary to develop the project design and for successful implementation of
survivorship care plans into the urology practice. Another asset to the project was the use of the
technology-enabled care plan tool. Through the literature review, the interprofessional team
identified the potential barrier the time it takes for providers to create care plans. To proactively
address this issue, the team leveraged the technology-enabled care plan tool to help decrease the
time it would take for the providers to produce the care plans. Another strength of the project
was the 94% adherence rate for providers delivering survivorship care plans to the patients. This
was a great start towards the CoC requirement of percentage of patients to receive a care plan by
the end of 2018.
Barriers
Questionnaire responses from patients was a challenge for the project. Only 16 out of 71
patients completed a pre-intervention questionnaire. Although a workflow was identified to
create reminder prompts, this was dependent on the providers placing a comment in the POV
order. This comment was not consistently added to the POV orders as noted in audits completed.
Post-intervention responses were also difficult to obtain. Patients were called at home, and either
did not answer or asked to be called back at another time. During call reattempts, the patients did
not answer. In the future, response rates might improve if the questionnaire could be sent
electronically through the patient portal both pre- and post-intervention.
The flow and pace of the outpatient urology clinic was also determined to be a barrier in
successfully delivering the care plans to all eligible patients. Since the clinic is so busy, the
providers do not have adequate time to discuss in depth the survivorship care plans. This

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demanding clinic schedule also affects the ability for the providers to send the correct version of
the care plans to the patients’ EHR and timely dictate a note to meet the CoC standard.
Another obstacle to the project and its sustainability in the urology group is the residents’
perception of their responsibility to create and deliver the survivorship care plans. Due to the
more procedural role the nurses have in the outpatient urology clinic, the residents and PAs were
identified to be the best group to create and deliver the care plans to the patients. This differs
from the process design in other practices within the organization that have implemented
survivorship care plans. Other specialties have Nurse Practitioners or Nurse Navigators to create
and deliver the survivorship care plans. The residents were aware that other departments were
utilizing non-physician team members to complete and deliver the survivorship care plans. This
might have affected their willingness to complete the survivorship care plans. It also creates a
barrier to the value of the survivorship care plan and the interaction between the patient and the
provider. The residents may not have realized the importance of the survivorship care plans and
the additional opportunity to understand and address concerns affecting the patient’s posttreatment quality of life.
Sustainment Plan
Since survivorship care plans are a requirement from the CoC to retain cancer program
accreditation, the survivorship care plans will continue to be given to the prostate cancer patients.
Feedback regarding the technology-enabled care plan tool was received, and it was examined by
the team whether or not to renew the contract for the product or to build care plans another way.
A new EHR will be implemented into the organization in the fall of 2018. The new EHR product
does not have a survivorship care plan solution developed yet. Therefore, the team agreed to
renew the current contract for the technology-enabled care plan tool for another year while a

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solution for survivorship care plans within the new EHR is created and released. The new EHR
could potentially create other challenges in the current process regarding documentation, and
when a new solution is created, the process design will need to be reexamined.
The Physician Assistant Team Lead of the urology practice was identified as the lead for
the continuation of the project within the practice. The DNP student leader met with this PA to
review the requirements and the auditing tool. Questions were answered about the frequency and
need for audits moving forward. After receiving the feedback from the residents, the team has
scheduled another meeting with the urology practice to determine further needs for the
sustainment of the project in the practice.
Conclusion
Although a requirement set forth by the CoC, survivorship care plans have yet to be
implemented consistently throughout many organizations including this National Cancer
Institute-designated, academic hospital in Phoenix, Arizona. Survivorship care plans will
continue to be delivered to prostate cancer survivors within the organization. This quality
improvement project provided valued results to support sustaining delivery of survivorship care
plans within the practice. Additionally, it highlighted the importance of interprofessional
collaboration during process change and further sustainment of the change. There are many more
opportunities for further development of evidence to support the use of survivorship care plans,
the best process for implementation, and the effect of their use on cancer survivors’ confidence
in their post treatment care.

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21

References
American Cancer Society (2017). Key statistics for prostate cancer. Retrieved from
https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html
American Society of Clinical Oncology (ASCO) (2018). Prostate cancer: Statistics. Retrieved
from https://www.cancer.net/cancer-types/prostate-cancer/statistics
Birken, S.A., Mayer, D.K., Weiner, B.J. (2013). Survivorship care plans: Prevalence and barriers
to use. Journal of Cancer Education, 28, 290-296.
Bridges, D.R, Davidson, R.A., Odegard, P.S., Maki, I.V., & Tomkowiak, J. (2011).
Interprofessional collaboration: Three best practice models of interprofessional
education. Medical Education Online, 15. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081249/pdf/MEO-16-6035.pdf
Commission on Cancer (2016). Cancer program standards: Ensuring patient-centered care.
Retrieved from
https://www.facs.org/~/media/files/quality%20programs/cancer/coc/2016%20coc%20sta
ndards%20manual_interactive%20pdf.ashx
Gilbert, S.M., Dunn, R.L., Wittmann, D., Montgomery, J.S., Hollingsworth, J.M., Miller,
D.C.,… Montie, J.E. (2014). Quality of life and satisfaction among prostate cancer
patients followed in a dedicated survivorship clinic. Cancer, 1484-1491.
Hebdon, M., Abrahamson, K., McComb, S., & Sands, L. (2014). Transitioning patients to
survivorship care: A systematic review. Oncology Nursing Forum, 41(6), 615-625.
Institute of Medicine of the National Academies (IOM) (2005a). Cancer Survivorship Care
Planning. Fact Sheet, 1-2. Retrieved from

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http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2005/FromCancer-Patient-to-Cancer-Survivor-Lost-in-Transition/factsheetcareplanning.pdf
Institute of Medicine of the National Academies (IOM) (2005b). Glossary of common cancer
terms. Fact Sheet, 1-2. Retrieved from
http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2005/FromCancer-Patient-to-Cancer-Survivor-Lost-in-Transition/factsheetglossary.pdf
Mangold, K., Denke, N.J., Gorombei, D., Ostroski, T.L., & Root, L. (2014). Principles of
successful partnerships. Nursing Administration Quarterly, 38(4), 340-347.
Mayer, D.K., Deal, A.M., Crane, J.M., Chen, R.C., Asher, G.N.,…Rosenstein, D.L. (2016).
Using survivorship care plans to enhance communication and cancer care coordination.
Oncology Nursing Forum, 43(5), 636-645.
Mayer, D.K., Gerstel, A., Walton, A.L., Triglianos, T., Sadiq, T.E.,…Davies, J.M. (2014).
Implementing survivorship care plans for colon cancer patients. Oncology Nursing
Forum, 41(3), 266-273.
Melnyk, B. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare
(2nd ed.). Philadelphia, PA: Wolter Kluwer Health.
National Coalition for Cancer Survivorship (NCCS) (2014). Defining cancer survivorship [web
log post]. Retrieved from https://www.canceradvocacy.org/news/defining-cancersurvivorship/
National Comprehensive Care Network (NCCN) (2018). NCCN content in health information
technologies. Retrieved from https://www.nccn.org/healthinfotech/default.aspx
Palmer, S.C., Jacobs, L.A., Mao, J.J., & Stricker, C.T. (2012). Confidence in survivorship
information. Retrieved from

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https://smhs.gwu.edu/cancercontroltap/sites/cancercontroltap/files/CSI%20description.pd
f?src=TAPResource
Rasper, A.M. & Terlecki, R.P. (2016). Prostate cancer survivorship: Implementation of
survivorship care plans to meet the mandate and enhance urologic practice through
collaborative care. Reviews in Urology, 18(4), 214-220.
Watson Caring Science Institute (2010). Core concepts of Jean Watson’s theory of human
caring/caring science. Retrieved from
https://www.watsoncaringscience.org/files/Cohort%206/watsons-theory-of-humancaring-core-concepts-and-evolution-to-caritas-processes-handout.pdf

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix A
Figure A1: CINAHL Search Strategy

Figure A2: CINAHL Search Strategy

24

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix B
Figure B1: PubMed Search Strategy

Figure B2: PubMed Search Strategy

25

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix C
Figure C1: Academic Search Premier Search Strategy

Figure C2: Academic Search Premier Search Strategy

26

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix D
The Mayo Clinic Nursing Evidence-Based Practice Model
IMAGE REMOVED PER MAYO’S REQUEST

27

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix E
Mayo IRB Letter

Date:

Thursday, October 26, 2017

From:

Mayo Clinic Institutional Review Board

Re:

Quality Improvement Project to Implement Prostate Cancer Survivorship Care Plans)

To:

Noël Arring, DNP, RN, OCN and Brittany Shirley, MSN, RN)

The Mayo Clinic Institutional Review Board (IRB) acknowledges that based on the responses
submitted for this new activity through the Mayo Clinic IRBe Human Subjects Research Wizard
tool, and in accordance with the Code of Federal Regulations, 45 CFR 46.102, the above noted
activity does not require IRB review.
Other Federal, State and local laws and/or regulations may apply to the activity. This study must be
reconsidered for submission to the IRB if any changes are made.
The Principal Investigator is responsible for the accuracy and reliability of the information submitted
through the Human Subjects Research Wizard tool, for following all applicable Federal, State and
local laws and/or regulations, and is also responsible for submitting research studies to the IRB when
required.

28

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix F
Arizona State University IRB Approval Letter

29

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30

Appendix G
Confidence in Survivorship Information Questionnaire

Add Patient Label Here

Confidence in Survivorship Information Questionnaire*
How confident are you about your knowledge of each of the following aspects of your cancer and cancerrelated follow up care?
Please select only one box per question.

The type of cancer you have/ had?
The stage of cancer you have/ had?
The treatments you received/are receiving for cancer?
Things you can do to help prevent your cancer from recurring?
The long-term physical effects you may experience from cancer and
its treatment?
Strategies for preventing long-term physical effects of cancer
treatment?
Strategies for treating long-term physical effects of cancer treatment?
The long-term emotional effects you may experience from cancer and
its treatments?
Strategies for preventing long-term emotional effects of cancer
treatment?
Strategies for treating long-term emotional effects of cancer
treatment?
Community resources available to help you deal with long-term
effects of cancer and its treatments?
Whether your family members are at increased risk for cancer?
How your family members can get information on their risk for
cancer?

Not at all
Confident

Somewhat
Confident

Very
Confident

□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□
□
□

How satisfied are you with the survivorship care you received at Mayo Clinic?
Very Satisfied
Satisfied
Neutral
Dissatisfied
How your healthcare provider addressed ways to improve wellness?
Very Satisfied
Satisfied
Neutral
Dissatisfied
How your healthcare provider addressed ways to promote your health?
Very Satisfied
Satisfied
Neutral
Dissatisfied

Very Dissatisfied
Very Dissatisfied
Very Dissatisfied

*Used with permission from University of Pennsylvania.

Please return to your provider upon completion.
Send to Noel Arring PX SS 01 AHED

Do Not Scan

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix H
Prostate Cancer Survivorship Workflow-Surgery Only

31

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32

Appendix I

December 2017- March 2018 Prostate SCP Dashboard
Provider
1
2
3
4
5
6
Total

#SCP Identified # SCP Delivered
22
11
7
11
16
4
71

19
11
6
10
16
4
66

SCP %*
86%
100%
86%
91%
100%
100%
94%

*Number of patients given an SCP/Number of patients identified needing an SCP
†Number of correct SCP sent to HIMS/Number of delivered SCPs
††Number of dictated notes/Number of delivered SCPs

Correct SCP
Note
Sent to HIMS† Completed††
47%
100%
100%
80%
44%
75%
74%

52%
73%
83%
90%
81%
100%
80%

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix J
Table 1

33

PROSTATE CANCER SURVIVORSHIP CARE PLANS
Appendix K
Table 1

34