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Correcting Critical Imbalance

Kagan, Sarah H. PhD, RN

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doi: 10.1097/NCC.0b013e31826c7cd1
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The conversations about healthcare I hear today revolve ever more around outcomes. The relative paucity of substantive discussions about process worries me. In cancer care, perhaps more than in some other specialties, process is essential. Our extant research in cancer experience—from diagnosis through survivorship and death—underscores process. An imbalance in valuing and evaluating process and outcomes, as fundamental tenets of quality, is a critical concern for cancer care.1,2

Recently, I attended 2 rather small and intensely focused meetings in England, one addressing the fundamentals of care, and the other human appearance. These meetings defied that trend to emphasize outcomes by reveling in exploration of process, although outcomes were by no means missing in the dialogue. I came away from these meetings with renewed concern that we lack sufficient investigation into process in cancer nursing and therefore in cancer care.

Our nursing traditions emphasize, to a remarkable degree, the importance of process. This emphasis generally attends to education for practice and not to research as means to improve practice. Our educational discourse is replete with references to the nurse-patient relationship, communication, nursing process, and patient-centeredness. Yet, I increasingly hear concerns about whether we are teaching these classic elements of our professional practice well enough. I am simultaneously relieved and engaged, as a nurse educator and clinician, as I participate in these discussions. They are strong platforms from which to pose questions, direct analysis, and derive plans to renew our focus on process in education.

In my roles as a cancer researcher and clinical nurse specialist, I am ever more troubled by the dissonance I observe between expectations of care and metrics for healthcare outcomes. I read Changrong Yuan’s guest editorial in the July/August issue of Cancer Nursing entitled “How Cancer Patients Think: Addressing the Gap Between ‘Where They Are’ and ‘Where We Are’”3 with interest. People diagnosed with cancer expect processes of care in which their personhood is preserved and respected, among other attributes. Those expectations are often lost in care, research, and even education that is blatantly not patient-centered. Yuan’s insights added to my contemplation of the imbalance between process and outcomes. She eloquently illustrates how wrong care can go when processes of communication and relationship are neglected. Yuan is indeed correct as in outlining this important gap. In fact, I believe distances—between where patients, where clinicians, and where researchers sit in the realm of cancer—are growing larger, obscured by a focus on metrics that reflect outcomes of processes and not the quality of the processes themselves.

A brief scan of the literature, even in relation to current initiatives such as patient- and family-centered care now popular in many countries, reveals little evidence to actually guide processes such as communication and the nurse-patient relationship in cancer. Some of you might argue that research in patient education, tailored behavioral intervention, and patient satisfaction is all about process. And, in one sense, you are correct—these are process topics. Nonetheless, my concern persists. Even in investigating process, we tend to measure outcomes and not the process itself. We most often do not describe, delimit, interpret, and evaluate the processes themselves. The underlying assumption is that if the outcome is good, then the process or processes that generated the outcome were good as well. Many patients, like those to whom Yuan3 introduces us, argue just the opposite. Poor processes can easily be part of acceptable or even good outcomes.

Cancer care gains strength almost daily with new therapeutic options that obliterate the cancer or, at the very least, control it for extended periods. Many people around the world benefit as innovations in anticancer therapies are disseminated throughout many countries. The outcomes of cure and control, of education for self-care, and of satisfaction with care are absolutely essential to evaluating the quality of cancer care. Nevertheless, achieving them does not negate that those outcomes are only attained by individuals, families, and even communities through often complex processes that involve many people and a vast array of technologies. Although the outcomes of cancer therapy are increasingly better understood and can thus be improved even more, the processes of cancer care are less well studied, lagging then in quality. Many health disciplines—medicine among the leaders—lay claim to good therapeutic outcomes. But who will shepherd process in cancer care?

Nursing values process highly. Let those of us in nursing who study the myriad aspects of cancer then lay claim to process. It is time to move beyond teaching processes like communication and relationship to investigating process itself in order to generate evidence necessary to improve both practice and education—and, as a result, patient care. If we don’t stake out this domain of process as one that is meaningful to patients and powerful in healthcare, who will?


1. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966; 44 (3): 166–206.
2. Donabedian A. The quality of care: how can it be assessed? JAMA. 1988; 260 (12): 1743–1748.
3. Yuan C. How cancer patients think: addressing the gap between “where they are” and “where we are”. Cancer Nurs. 2012; 35 (4): 247–248.
© 2012 Lippincott Williams & Wilkins, Inc.