Spiritual and psychological support: the nurse-led team helping people cope with cancer

Nurse counsellors lead the pastoral care services at London’s Royal Marsden Hospital

Nurse counsellors lead the pastoral care services at the Royal Marsden Hospital

As head of pastoral care and psychological support at one of the UK’s leading cancer hospitals, Sara Lister has a lot of responsibilities.

Sara Lister: ‘When someone is having treatment they often feel they are on a mission,
but when treatment is finished they are not the same person.’

She manages the department that provides spiritual and psychological support to patients, families and staff at London’s Royal Marsden NHS Foundation Trust. She also co-edits the respected Royal Marsden Manual of Clinical Nursing Procedures, and teaches nursing students.

Her remit is broad, including the hospital’s chaplaincy service, liaison psychiatry, staff counselling and the patient advice and liaison service.

But her favourite part of the job is when for a quiet hour it is just her and a patient. ‘It’s the best bit of my week,’ she says simply. ‘It’s a very safe way of giving someone your total attention. I’m not saying it’s not harrowing at times, but it’s also very rewarding.’

Emotional impact of a cancer diagnosis

Ms Lister is unusual in her profession – a nurse who is also a trained counsellor. She brings both these skillsets to her roles as manager of a substantial department and as a counsellor for patients who are finding it difficult to cope emotionally with their diagnosis or treatment.

‘It is a real privilege to be able to come from a physical nurse training background and be able to give patients an hour of my time, developing a relationship and looking at the whole person.

‘I provide a safe place for people to discuss things that they may not want to discuss with family and friends’

Sara Lister

‘I am a nurse as well as a counsellor, which means I have a real awareness of the physical experiences that patients go through, which a psychologist would not have in the same way. Nurses have seen a stoma, for example, we have treated patients who have had constant diarrhoea as a side effect of their treatment. It does give an additional perspective.’

She is well aware of the psychological effect that cancer has on people, and one of her primary responsibilities is leading the trust’s psychological support for adult patients. This involves managing a multidisciplinary team comprising nurse counsellors, psychologists, a family therapist and an art therapist.

Tailored to each person’s needs

The majority of patients referred to the service have finished their cancer treatment, she says, and are finding it difficult to cope with the emotional impact. ‘When someone is having treatment they often feel they are on a mission, but when treatment is finished they are not the same person.’

People have different responses to cancer and treatment, she says, and counselling is tailored to each person’s needs. This usually involves up to six sessions using an integrative approach combining different techniques, such as person-centred counselling or cognitive behavioural therapy.

Some want to explore existential issues, she says. ‘They are trying to make sense of what life is about – that’s something that’s important to them. I provide a safe place for them to discuss things that they may not want to discuss with family and friends.

Spiritual questions

'For some with a religious faith, there can be spiritual questions such as "Am I being punished by God?" or "Why can’t I talk to God any more?". For some faiths there can be shame attached to a cancer diagnosis.’

Successful cancer treatment can also make people want to shake up their lives, she says – change their job, for example, or even leave a marriage. Others whose cancer or treatment has left a lasting physical impact might have to consider alternative employment because they are no longer able to do the job they had previously.

‘The chaplaincy team really get alongside people, and can be an important sounding board for patients and their families’

Sara Lister

Although the hospital does not offer stand-alone support to patients’ relatives, families can be seen with the patient. The team members also support each other, and other staff at the hospital, and the counsellors receive independent supervision to help them cope with a workload that can be emotionally gruelling.

'All faiths and none'

The trust’s chaplaincy team is for ‘all faiths and none’, Ms Lister says. ‘They really get alongside people, particularly inpatients, and can be an important sounding board for patients and their families.'

The team can draw on the help of leaders from different faiths when requested, and also has links with humanists.

When to refer a patient with cancer for psychological support

Although she stresses that each patient should be treated as an individual, Sara Lister says there are three points to consider when deciding whether someone needs extra support:

  • Cancer and treatment for cancer are emotionally distressing, and so it is expected that patients may be upset. Most will benefit from help from friends and family and in time come to terms with their diagnosis and its implications, and do not need to be referred on
  • For some patients, the distress can have a significant impact on their day-to-day ability to function. If they are experiencing continual high levels of anxiety or feeling very low, they should be offered psychological support. This may be from the hospital’s psychological and spiritual support service if it has one, the patient’s GP, or services such as Maggie’s support centres. Maggie's also offers online services, so can be particularly helpful for people in rural areas who might be some distance from a face-to-face service
  • If the level of distress is so great that a patient is talking about harming themselves or wanting to end their life, they should receive a mental health assessment. This can be via their GP or, if they are a hospital inpatient, through the psychiatric liaison service. If neither of these are available and the risk is considered high, the patient should be referred to an emergency department with a mental health service. Such situations should always be taken seriously, as cancer patients are at increased risk of taking their own lives.

It can be difficult for nurses in general to support patients with the ‘big’ spiritual issues, she concedes, so working with the chaplaincy is a valuable experience for nursing staff as well as patients and families.

Ms Lister believes that nurse counsellors have a big contribution to make in looking after patients’ emotional and spiritual needs. ‘It’s a significant role,’ she says, adding that there is currently a vacancy on her team for a nurse with formal counselling qualifications.

Dual role

For Royal Marsden team member Beverley Henderson, working as an intensive care nurse inspired her to train as a counsellor. ‘My work in the intensive care unit was one-to-one and involved a lot of support for relatives – I found it very satisfying,’ Ms Henderson says.

Although her background was not in cancer nursing, she recognised that the Royal Marsden nurse counsellor post was perfect for her interests and skills.

‘It’s about being a counsellor, but also having that nursing understanding,’ she says. ‘When you’re working with patients therapeutically, we also understand what’s going on physically, and that helps.’

Ms Henderson offers counselling by telephone, which is particularly appreciated by patients who live some distance away from the hospital – as a tertiary unit, it covers a large geographical area.

It is also helpful for people who find travelling difficult as a result of their cancer or treatment. ‘People are triaged and asked if they want face-to-face or telephone counselling, so in a way it is self-selecting,’ Ms Henderson says.

‘I always start by talking to people about how important it is to feel connected, but in my experience, some people find it easier to say things on the telephone than when they are sitting looking at someone.

‘It’s a bit like the psychiatrist’s couch – there’s no eye contact, and sometimes that helps.’

Self-care for the counsellor

She offers six sessions, although some people need fewer and others more, she says. The patient profile tends to be similar to those who have face-to-face counselling; that is, people at the point of diagnosis, having a change in treatment, at the end of treatment, or those dealing with bad news.

‘People who are particularly unwell or near end stage often appreciate not having to make the trip to the hospital,’ Ms Henderson adds.

She is acutely aware that the job of counselling people to help them through tough times can have an impact on the counsellor too. ‘I have reduced my hours because it was beginning to affect me,’ she says. ‘I have supervision and I know my triggers – I’m pretty careful with self-care.

‘People think it must be depressing, but it’s anything but. It’s uplifting and it’s a privilege to be able to do it’

Beverley Henderson, Royal Marsden pastoral care team nurse and counsellor

‘But it’s a very rewarding job – it’s meaningful and I love it. People think it must be depressing, but it’s anything but. It’s uplifting and it’s a privilege to be able to do it.’

What might be broadly termed spirituality is an important part of the counselling support. ‘It’s about finding meaning. For everybody, the meaning of life is affected by a cancer diagnosis. It makes people feel differently about things, about what is important to them.’

Cost is a barrier

This aspect of her work has had an impact on her own attitude, she admits. ‘I live a very full life; I seize the moment,’ she says.

She believes that nurse counsellors make a valuable contribution to the care and support of patients and would like to see the role adopted more widely.

She is not convinced that it will be, however, with cost being a major barrier. ‘We all paid for our own training and therapy, which is a requirement of the course. It’s quite a specialist role.’

Ms Lister accepts that nurses who have not trained formally as psychotherapists often undertake counselling in their day-to-day job. ‘This is especially the case with a clinical nurse specialist role, which involves advanced communication skills.’ But, she adds: ‘Being someone’s therapist is different to being someone’s nurse, and we shouldn’t forget that.’

Jennifer Trueland is a health journalist

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