critique of patient information resource

For the purpose of this assignment I will be critiquing a source of patient information
for people with colorectal cancer. The specific patient information I will focus on is an
information sheet on ‘Regaining Bowel Control’ by ‘Beating Bowel Cancer’ (2015)
(Beating Bowel Cancer 2015) (see appendix one). This is available to patients as a
printed information sheet or to view online in a PDF format. I have chosen this
particular resource as it is relevant to my role as a Colorectal Clinical Nurse
Specialist (CNS).
Colorectal cancer can affect any part of the colon or the rectum and is overall the
fourth most common cancer in the UK, affecting both men and women (Cancer
Research UK 2012). Surgery, radiotherapy and chemotherapy are all treatments for
colorectal cancer; however the primary treatment will vary depending on the
individual’s stage and presentation of disease.
As a Colorectal CNS I review patients on a weekly basis who have had surgery for
rectal cancer. A low anterior resection is a surgical procedure to remove the upper
section of the rectum and involves joining the colon to the lower part of the rectum,
mostly resulting in the individual requiring a temporary stoma to allow the
anastomosis time to heal (NHS choices 2014). These patients can usually have this
reversed after some time to allow them to pass faeces through the remaining rectum
and anus again. Despite this individuals will often experience a number of bowel
symptoms post-surgery and require reversal to form a permanent stoma (Landers et
al 2011). Surgery for rectal cancer is likely to result in a change of bowel habit and
can include a loss of rectal capacity (Taylor et al 2013). Often patients present i
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clinic with complaints of poor bowel function and control of defaecation. Symptoms
such as frequency, urgency and incontinence are commonly experienced (Taylor
and Bradshaw 2015).
Radiotherapy can be used in patients with rectal cancer that are not fit enough, or do
not wish, to undergo surgery. Radiotherapy is used to control symptoms and can
also be used in the neo-adjuvant setting to downsize a tumour prior to surgery.
Pieterse et al (2007) identified that patients undergoing neo-adjuvant radiotherapy
for rectal cancer have an increased likelihood of faecal incontinence postoperatively.
Irritation to the digestive system can be caused by cytotoxic drugs,
resulting in side effects such as acute diarrhoea (Cancer Research UK 2014). This
can usually be managed with medications during treatment, but patients will need to
be informed of how to manage this effectively, to avoid dehydration. It is important
patients are given appropriate information and education prior to treatment to
prepare them for a potential altered bowel function (NICE 2011).
The title of the information sheet – ‘Regaining Bowel Control’ is relevant with regards
to the aims of the content; however in this assignment I will be critiquing the quality
of the information provided under this title. This will involve reviewing whether the
information provided meets the specific needs of the patient group, if the information
written is based on the best available evidence and has the information been
produced in a form that meets national guidelines and recommendations. More
specifically I will explore how useful the information is with regards to the title and
also the clarity of the content provided. In order to evaluate these points, I will use a
variety of different sources.

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Alexander et al (2006) highlight that a sensitive and tactful approach should be used
from the moment a patient is referred to hospital, whether this is as an inpatient or
outpatient. For patients with colorectal cancer a discussion about loss of bowel
control and/or increased frequency of bowel movements may be a sensitive topic to
broach, but is a subject they will require information on. Alexander et al (2006) also
recognise that patients may not actively seek information in when they require it, due
to staff appearing busy and unavailable. A difficult task for healthcare professionals
is to provide information to individuals at the correct rate and time (Tobias and
Hochhauser 2015). Challenges can arise when communicating information to
individuals, as it requires adaptation to suit the needs of each individual (Kissane
and Bultz 2010). It’s important to produce information that is accessible for a wide
variety of individuals with different needs.
The Nursing and Midwifery Council (NMC) (2015) Code states that nurses should
‘act in partnership with those receiving care, helping them to access relevant health
and social care, information and support when they need it.’ Providing an individual
with information on a particular subject can help them gain a sense of control over
their life (Alexander et al 2006). Poor bowel control can affect both the physical and
psychological wellbeing of a patient. By providing information, healthcare
professionals can empower patients to take control. Macmillan (2012) highlight that
cancer patients that receive good information and are supported with the
consequences of their treatment, are more likely to have a positive care experience.
Furthermore, Lithner et al (2015) showed that receiving information after colorectal
cancer surgery was vital for patients in regaining control of their life.
In my area of cancer nursing we commonly use ‘Beating Bowel Cancer’ as a source
for patient information. This can be for advice pre- and post-operatively, during
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chemotherapy or radiotherapy or for long term support after treatment for bowel
cancer. We advise patients to read this particular information sheet on ‘Regaining
Bowel Control’ if they have complaints of erratic/unpredictable bowel function or
incontinence issues as a result of surgery, radiotherapy or chemotherapy. It could
be suggested that this information is given prior to surgery to prepare the patient, but
it could be argued this would be too much information for the patient at that time.
The information sheet briefly discusses how chemotherapy and radiotherapy can
cause side effects of the bowel; however it doesn’t explain these effects in detail. As
a colorectal CNS, I care for patients that may have had surgery, neo-adjuvant or
adjuvant chemotherapy and radiotherapy, or all of these. This information sheet
focuses on the anatomy of the rectum and anus and explains how treatments can
affect the nerves in these areas, often resulting in poor bowel function. The main
content of the information sheet surrounds advice on physical exercises as a way of
addressing poor bowel function. This advice may not be appropriate for all patient
groups; therefore an assessment should be made by healthcare professionals to
determine how effectively a patient can self-manage their symptoms (Taylor and
Bradshaw 2015).
Often patients are going through a difficult and stressful time when we see them in
the hospital setting, either as an inpatient or an outpatient. By keeping the patient
informed and advised along their journey my aim as a CNS is to reduce stress and
anxiety. Baker et al (2013) recognise that clinical nurse specialists play an important
role in the management and support of patients with cancer, with a key role in
supporting those who are in distress. The NHS Brand Guidelines (2010) highlight
that information is a key part of a patient’s journey and this could be in the form of
written or verbal information. The guidelines also recognise that written information in
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particular is effective where patients may be unable to retain or understand the
verbal information they are given by a healthcare professional, due to reasons such
as stress, language barriers or memory problems.
Listening to and involving patients is a key factor in producing good patient
information (Turnbull 2003). The particular piece of information I have selected is in
written form and can be accessed as a printed information sheet or via the
organisation’s webpage. The NHS brand guidelines (2010) explain that using plain
language and avoiding jargon is important when producing a piece of written
information. They also highlight the importance of writing from a patient’s point of
view when producing information. This is particularly important when using medical
terminology/jargon. NICE (2011) guidance on colorectal cancer, support that verbal
and written information should be offered that avoids the use of jargon and is clearly
understood. This information sheet from ‘Beating Bowel Cancer’ includes two
diagrams, which identify the ‘internal and external sphincters’ of the rectum. Some
patients’ may understand terminology such as ‘external sphincter’, but to many
individuals this may not be as easily understood. Barnett (2010) highlights that the
content of written information should be produced with easily understood terms. It
should be recognised that this may be difficult to achieve when targeting a variety of
individuals with different levels of knowledge. There should be a balance between
using plain English, but also avoiding childish or language that is too simple, as this
could be interpreted as patronising (NHS Brand Guidelines, 2010). For this
particular information sheet, the choice of the word ‘muscle’ may have been more
appropriate than ‘sphincter’. The information does go on to describe what
‘sphincters’ are, however, by avoiding medical jargon the amount of content in this
leaflet could have been reduc
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A readability test showed that the leaflet from ‘Beating Bowel Cancer’ (2015) had a
SMOG (Simple Measure of Gobbledygook) score of 10 (Online Uitility no date). This
can be interpreted as a reading age of 14-15 years old. Data from 2011 identifies
that 16 percent of adults in the UK would not pass a GCSE English exam and have
literacy levels at or below those expected of an 11 year old National Literacy Trust
(2011). This suggests that this leaflet may not be user friendly to all colorectal cancer
patients and may deter some individuals from accessing it. It’s important to
recognise that this leaflet uses small paragraphs of text and is presented effectively
with a contrast of dark print against a light background in the form of black font on
white paper as recommended by the NHS brand guidelines (2010). There is not,
however, sufficient space between each paragraph and both A4 sheets contain lots
of words with only two small pictures, this could be overwhelming and off-putting for
the reader.
Bryant et al (2012) explains how patients’ can experience adverse symptoms of a
bowel resection for up to 15 years afterwards. Patients may put off asking questions
or seeking advice as they may not see healthcare professionals as often once
treatment has finished (Macmillan 2013). This leaflet on ‘Regaining Bowel Control’
focuses mainly on physical exercises to address poor bowel control, but for some
individuals they may find this challenging to self-manage at home. The Macmillan
(2014) website page on ‘Bowel Function After Surgery’ keeps their advice more
simplistic and this may suit some patients. The information sheet from Beating Bowel
Cancer briefly informs the reader that diet and medications can be considered too
when trying to improve bowel function, but further advice on this within the leaflet is
limited. The information is, however, effective in directing the reader to where they
can seek further advice, for example other websites.

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The NHS brand guidelines (2010) advise producers to always signpost to other
sources of information and support. This is an important role of the CNS when
advising patients and addressing their needs. This could, however, cause some
individuals to be deterred from seeking further advice as they may want to avoid
reading further information. Costa et al (2015) support this with recognising how the
amount of cancer information given to individuals could result in them disengaging
from sources of information that may be beneficial. The availability of this information
sheet as an online format could however encourage patients to access the advice or
support they require, whilst also prompting them to look at other sources of
recommended information too, as links are included. For example the information
leaflet on ‘Regaining Bowel Control’ advises patients they can find more information
at ‘Bladder and Bowel Foundation’ and they have included a link to their webpage. It
is important to recognise that using internet sources can result in receiving false or
misleading information if accessed incorrectly, which can then affect individuals’
health outcomes (Rawlings and Tieman 2015). According to the ‘NHS
Communication Principles’, materials should be ‘accessible’ and ‘easily obtainable’
(NHS Brand Guidelines 2010). This should aim to reduce the risk of individuals
accessing incorrect information.
Exploring further into the quality of this information sheet, it’s important to recognise
that the organisation ‘Beating Bowel Cancer’ is a certified member of ‘The
Information Standard’ (NHS England 2014). This is to certify the information they
are providing as an organisation has been checked and is accurate, up to date, clear
and based on the best available evidence. For individuals accessing information,
support and advice this is of great importance as they can be reassured the
information has been approved before productio
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One thing identified on review of this leaflet is that it doesn’t clearly state whether the
information can be accessed in a different language to English or whether it is
available in braille for those that are visually impaired. Healthcare professionals’ may
be asked this by patients or relatives and it’s important for them to know how to
access this. Barnett (2010) support this by recognising information should be
produced to suit the communication needs of all individuals. A positive aspect of the
information sheet is that it does provide clear contact details within it, which may help
healthcare professionals, patients and family members/carers find out further
information such as the availability of the information in another language or form.
On review of this information sheet, a suggestion could be made that it should be
more generic, rather than mainly focusing on pelvic floor exercises, as this is not
appropriate for everyone. It may be more appropriate to include within the leaflet that
there are professional pelvic floor teams/specialist nurses available and to inform
individuals of how they can access these services. Wyatt and Hulbert-Williams
(2015) recognise there are key behaviours when giving information. This includes
ensuring the provider has checked the individual’s perception and concerns. It would
be advisable for healthcare professionals to only give this current information leaflet
to those that can manage exercises and self-management at home. The concern
would be that those who can’t self-manage their symptoms at home do not seek
further support when needed. The information should be selected and given based
upon individual needs.
This assignment has highlighted that good quality patient information is important
when addressing individual needs. The design of the information will often effect how
an individual will respond to it (Maat and Lentz 2010). It could be recommended that
the use of jargon in this leaflet should be reduced to make it more accessible
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those with lower reading abilities. Information often has to be tailored to different
individuals for their ongoing management and the Clinical Nurse Specialist’s role is
to assist this (Palmieri et al 2013). When providing patients with written information
such as this leaflet on ‘Regaining Bowel Control’ it’s important for healthcare
professionals to make the individual aware of how they can seek further advice or
management. Written information in the format of a leaflet is useful for individuals to
refer to outside of the hospital setting, but signposting an individual to where they
can obtain further advice where needed is important.
In conclusion, there are aspects of this information sheet on ‘Regaining Bowel
Control’ from Beating Bowel Cancer that could be improved as identified within this
assignment. The evidence presented within this assignment emphasises the
importance of producing easily understood information that suit’s a variety of
individuals during their cancer journey. Patients with colorectal cancer can face an
uncertain future whilst also having to deal with side effects, such as bowel urgency
and frequency (Spalding et al 2013). By providing quality information, healthcare
professionals can support these individuals to manage their needs and any
symptoms they may have.
(Word count: 2,
References
Alexander MF, Fawcett JN and Runciman PJ (2006) Nursing Practice Hospital and
Home (3rd edition). London: Churchill Livingstone.
Baker J, Kearins O, O’Sullivan E, and Casey M (2013) Patient satisfaction with
clinical nurse specialists’ practice. Nursing Standard. 27 (37), 41-47.
Barnett M (2010) A guide to producing quality written information for patients.
Journal of community nursing. 24 (2), 4-8.
Be
Maat H and Lentz (2010) Improving the usability of patient information leaflets.
Patient Education and Counselling. 80, 113-119. Available at http://ac.elscdn.com.oxfordbrookes.idm.oclc.org/S0738399109004467/1-s2.0-
S0738399109004467-main.pdf?_tid=9aba9108-95da-11e5-b213-
00000aab0f01&acdnat=1448720363_8c8a038bccc02e23f734f0707ca097c6
(accessed 14
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Macmillan (2012) Improving cancer patient experience. Available at
http://www.macmillan.org.uk/Documents/AboutUs/Commissioners/Patientexperience

Guidance on critiquing a patient information resource
Most patients with cancer want to learn about their disease and treatment, but a lack of understanding and misconceptions about their disease can result in poorer treatment outcomes (Chelf et al., 2001). Written patient information materials can be valuable communication tools for teaching and reinforcing the verbal message, especially in the present climate of today’s health service where patients are in hospital for such short periods of time.

However, many patient information resources contain incomplete information about treatments; are biased towards benefits of treatment over risks of that treatment; often have a health literacy level beyond that of the patient/ carer; and some contain inaccurate or out-of-date information. In addition, historically patients were rarely involved in designing and writing the information resource, so they have often been paternalistic and not addressed relevant patient information needs. It is, therefore, an important part or your role in supporting people affected by cancer to ensure that the information you provide, or recommend, is appropriate for their information needs: thus learning to critique such information is an essential skill in cancer care.

When critiquing a patient information resource you may find it helpful to consider the following questions, although in the context of your assignment you won’t be able to address them all:

• What type of patient information resource is it and why have you chosen to
critique it?
• What’s it called?
• Is its title appropriate for the content of the information resource?
• Who authored the resource?
• Why was it developed?
• Was it needed to address a specific patient information need?
• Is the content relevant for the patients/carers that use the information?
• Is sponsorship disclosed?
• Who funded the production of the resource? What was their incentive for
doing so?
• Are sources of evidence clearly stated?
• What evidence is there about the content of the patient information resource
that demonstrates best current practice?
• Does the resource reflect or reference that evidence base?
• Has the information resource been produced in response to, or in line with, national guidelines, recommendations, or policies?
• Is the information contained within the resource accurate?
• Could any of the information be easily misinterpreted?
• Is the information paternalistic?
• Is the information consistent with, and supportive of, information patients receive from other sources e.g. verbally, or does it contradict other information patients/carers are given?
• How user-friendly is the resource?
• Is the information clearly presented and communicated?
• Is appropriate language used?
• How readable is the information, e.g. what is its Standard Measurement of Gobbledegook (SMOG) score (McLaughlin, 1969)?
• Does the resource contain acronyms or abbreviations?
• Is the resource available in languages other than English?
• Does the language exclude its readership, e.g. is it for children, but written for adults?
• Are the font and graphics clear enough to understand?
• Are visual graphics used to explain concepts, and if so, are they easy to understand?
• Do you consider someone with a disability would be able to use the resource as it was intended? If not, is there an alternative resource that would address this need?
• How easy is it for patients and their family/carer to access?
• Do you or your colleagues use the resource, if so do you/they find it useful?
• Do you recommend it to your patients/ carers? Do they find it helpful?
• Is there any evidence that the patient information resource was or has been evaluated or audited following its introduction?
• Are there other resources that provide similar information? If so, what are they? Which resource is better, and why?
• Would you recommend the resource to other health professionals?
• If you were to improve the information resource, what would you change and why?
• In conducting your critique what have you learnt about producing information resources for patients with cancer and their families/carers?
It is important to remember that a critique is not simply your evaluation of the information resource. Your work needs to demonstrate underpinning knowledge and understanding, and your discussion should be supported by appropriate references using the Harvard Referencing System.

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