Identification and management of mental health distress in Moroccan patients with cancer: Strategies adopted by oncology nurses and barriers to practice

Abstract Background Adressing mental distress among cancer patients presents a substantial challenge in the delivery of oncology care. Aims This present study aims to explore the nursing strategies for identifying and managing distress in cancer patients as well as the concomitant barriers that prevent them from achieving this task. Methods This qualitative study is based on a semi‐structured interview with 25 practicing nurses in oncology. Results Strategies used by nurses to identify mental distress in their patients include: receiving information, mobilizing interpersonal skills, and identifying causes of distress. When asked about the barriers that hinder the practice of identifying and responding to patients' distress, nurses reported facing several barriers that can be classified into three categories: health care system‐related barriers, patient‐related barriers, and nurse‐related barriers. Conclusion Oncology nurses should benefit from specific training on the systematic assessment of mental distress in cancer patients, in order to improve the overall management of oncology patients.

Among the reasons for this problem is the nonrecognition of mental health disorders in patients by oncology health professionals. 7In this sense, a study, conducted among 102 cancer patients, found that the majority of them suffered from depressive symptoms, while less than a third of these patients had a detection of mental distress. 8tection of distress is the essential step in assessment process for mental distress in oncology in order to ensure adequate management.Additionally, the role of the nurse, defined by the Canadian Association of Oncology Nurses, includes a thorough assessment of patient needs as well as facilitating continuity of care and decisionmaking for patients, nurses showed considerable uptake of distress screening results. 9Considering that cancer patients frequently experience unaddressed and unsupported mental health-related distress, and recognizing that oncology services in Morocco lack standardized screening and treatment protocols for mental health issues in cancer patients, this study is designed to investigate the strategies employed by Moroccan oncology nurses to identify and address distress in their patients, as well as the barriers they encounter in performing this role.

| Study design and participants
The present qualitative study was carried out over a period of Participants were invited by the head nurse of each oncology department, a total of 25 practicing oncology nurses were recruited and interviewed on the strategies they adopt to identify and manage mental health distress in cancer patients and the barriers that prevent them from practicing this task.

| Procedure
Ethics approval was obtained from the Moroccan Association for Research and Ethics, Research Ethics Committee, (N 06/REC/20) before the launch of the study.Then, a descriptive qualitative study was started in the oncology departments and spread over a period of 3 months.The interview, which lasted an hour on average, took place in an office within the oncology centers where each participant worked.First, the participants were informed about the study in question and they signed a consent form and accepted the audio recording of the interview.They then completed a socio-demographic data form.Subsequently, a semi-structured interview was used (Table 1), and the interviews were recorded and transcribed, with all identifiable information removed from the transcripts.Twenty-five nurses participated in the study and this sample made it possible to obtain data saturation (17 nurses).When writing the manuscript, the authors respected the guidelines of consolidated criteria for reporting qualitative research (COREQ). 10

| Data analysis
Data collection and analysis took place simultaneously and coding of the transcripts was used.The analysis was inductive with codes and categories emerging from participants' stories and not preconceived codes.As the analysis continued, the descriptive codes were further distilled to capture the main themes and sub-themes emerging from the nurses' narratives.Constant comparison was used to examine relationships within and between codes and categories, thoughts, reflections, and reactions throughout the process of collecting and analyzing data which was then used to inform the coding scheme.The research team held regular meetings to review emerging discoveries and maintain coherence in the evolving coding system throughout the data collection and analysis phases.Data collection stopped when the team determined that we were full and no new code had been created.Atlas ti 9 is the software we have been used to store and organize data This tool is qualitative data analysis (QDA) software that provides a platform for researchers to analyze and manage large volumes of text, graphics, audio, and video data.It is designed to facilitate the systematic analysis of unstructured data, including interviews, surveys, focus group transcripts, and other qualitative content.Indeed, it offers a range of tools for coding, organizing, and interpreting data, enabling researchers to uncover patterns, themes, and relationships within their datasets.

| Characteristics of the participants
The average age of the participants was 33.76 years with a 6.5-year standard deviation (SD), the vast majority of nurses are female (60%), married (80%), and practicing nurses (84%) in different oncology units in Morocco.The average years of practice was 10.59 (6.52) and 4.35 (3.44) years of oncology practice.The majority of nurses have a professional nursing license (68%) and almost all do not have an oncology certification (80%) (Table 2).

| Strategies for identifying mental distress
When nurses were asked to discuss identifying distress in their oncology patients, they reported five main themes: All nurses interviewed confirmed that there is no longer a standardized screening and assessment protocol for mental health distress in oncology departments.However, these participants reported adopting their own distress identification strategies.Each theme is described in more detail below with supporting quotes and presented in Figure 1:

| Get information directly from the patient
When nurses were asked about their strategies for identifying mental health distress in cancer patients, they reported a theme that involved requesting directly.Regarding this, a nurse said: "I am asking her direct questions: 'How are you feeling today?'".Another claimed in the same vein: "I ask them with questions.For example, I notice the woman is absorbed with a sad look I ask her," "What is the matter?
Why are you sad?".

| Look for the causes of distress
One nurse said she relied on a patient interview to research the sources and likely causes of patient distress.With this in mind, she reported: "The sources of the distress let me know if the patient has a tendency to be depressed… when the woman has just had her divorce letter after a hysterectomy… when a woman moves from a companion very far from the hospital and she does not have the means and leaves her children… here we are talking about the sources or the causes of mental distress."

| Strategies for managing mental distress
Some participants reported that after identifying the distress, they used a number of strategies to deal with their patients' distress.The data coding allowed us to group the ratings into five themes: (a) Provide psycho-social support; (b) Adopt a religious approach; (c) Adopt a scientific approach; (d) Group therapy/Focus group; (e) Integration of family members.The results are summarized in Figure 2 and each theme is explained in more detail below.

| Provide psycho-social support
Nurses and social workers reported that one way they helped manage the patient's mental health distress was to try to build a supportive and compassionate relationship with their patients based on affective empathy, the act of soothing, relieving and reassuring the patient, giving him hope, encouraging him, strengthening him, and making him smile.Additionally, creating a climate of humor and trivializing the disease were also mentioned as strategies adopted by some participants.
Other participants indicated that they kept their kindness and supported the character of their patients.In this regard, a social worker explained: "As a strategy, I push the patient to express herself, and support her even if she speaks and tells things far from her therapeutic course, I listen to her, I accept her, don't block it, i avoid severe reactions." In the same vein of psycho-social support, a head nurse said she was involved in a socio-esthetic project allowing women with cancer to benefit from esthetic care in order to reduce their distress.
From another perspective, facilitating access to care was a way of contributing to the management of mental distress.In this regard, a nurse noted: "…I try to contribute to this care by facilitating the circuit for the patient because that also stresses him…."

| Adopt a religious approach
Participants noted that they used the religious approach to help patients cope with their distress.As one nurse remarked: "I always say an expression to my patients: 'It is not the disease that kills the person', I always refer to religion, I give examples of people who have died during an accident or people who die from strokes when there are people who had metastases and they healed anyway."

| Adopt a scientific approach
In addition to the religious approach, nurses and social workers reported that they adopted a scientific approach to managing distress, mainly based on informing patients about the progress of science in terms of the treatment of distress disease and current survival rates.
F I G U R E 2 Strategies for managing mental distress.
About this, a nurse said, "First the thing I do and I see it very important is information.When I explain to the patient that science has no limits and that cancerous disease has become like other chronic diseases it is curable and the treatment is effective it relieves her.
Because the patient has information needs and emotional needs."

| Focus group
Some nurses have indicated that they rely on group therapy to provide relief to distressed patients and give them hope.In this sense, a social worker explained: "Sometimes I use group therapy… For groups, I bring them together according to certain criteria, for example women in a group and men in a group.Sometimes I form groups according to age or people who have the same problem….I take the example of a very positive person or a person who had an advanced stage but has healed, I ask him to speak to them and tell his story."

| Integration of family members
Nurses said they were integrating the patient's relatives to address his broad-spectrum distress.This integration is based on correcting rumors related to the disease, educating the family in its role of support and accompaniment, sex education and therapeutic education.
As a head nurse explained during nurse consultation: "I bring the patients together after the first medical consultation, the patients come depressed, do not even know the trajectory of their care or their treatment.So, I gather the women in a room of 50 to 60 people, this number includes the patients and their companions such as the son or the husband of the wife, but I especially insist on the presence of the husband so that he understands and inform him on the intimate side… that his wife needs to be surrounded… that he be kinder and more attentive to her….The woman too, must understand that she can continue her life and fight to be able to live.That there is progress in the therapeutic care… I give him feeding advice and correct bad rumors for the woman and for the family… I insist on the importance of the family support, it is necessary not to stigmatize the cancer woman.So it is important that the primary caregiver listens to us and understands either the son, the daughter or the partner to continue the normal life and understand that cancer is not a contagious disease and to continue the intimate relationship with the woman and c is very important for the woman to feel that she is supported …."

| Barriers to the assessment and management of mental distress
When the nurses were asked to discuss barriers to identifying distress and managing it, they stated three main themes: (a) Barriers related to the health system; (b) Barriers related to the patient; (c) Barriers related to the nurse (Figure 3).

| Barriers related to the health system
Lack of evaluation and management protocol for mental health distress Some nurses said that the lack of tools to screen for distress, the absence of a protocol for the assessment and management of mental health problems in oncology services could be a barrier to developing.
"carry out a systematic assessment of the distress as well as hamper its management.

Lack of specific training in psycho-oncology
Oncology nurses indicated that they had not received any training in assessing mental health distress.In their view, the lack of knowledge and skill in psycho-oncology was a significant barrier in helping their patients.Only two nurses who received continuing education in oncology care had the opportunity to have a psychology module during this training.Indeed, their knowledge on the subject was based on their personal experiences.
F I G U R E 3 Barriers to the assessment and management of mental distress.

Work overload: Time challenges and the number of patients
Nurses reported that a major barrier to identifying mental health distress was a lack of time to sit down and listen to patients.Then faced with a huge number of patients with a shortage of human resources, they also reported being so overburdened with practical care responsibilities that they rarely had time to talk to patients about their psychological state.

| Patient-related barriers
Reluctance: Asked about the barriers to dealing with mental distress, other nurses reported obstacles related to patients such as the refusal to share their suffering and the refusal of help offered by nurses or by the attending physician.As one nurse remarked: "When the patient is used to sharing her suffering, it allows me to talk to her and support her but when she is withdrawn and she no longer wants help it also blocks me… Sometimes I feel that the patient does not want to share her suffering and hides her vulnerability."

Dialect challenges
In connection with the challenge identified above, nurses reported that the dialect was a barrier to identifying and managing distress.On this subject, a nurse claimed: "For example, I work in Tangier, I welcome many patients of 'Rifi' origin, I do not speak the dialect of their region, I already find it difficult to approach subjects with patients… I only speak with relatives who understand the Arabic dialect… the latter constitutes a barrier, so I cannot discuss with these kind of patients the state of their mental health, their feelings… especially since in this case the patient remains silent and his loved one answers in his place so I cannot know the patient's anxieties."

Emotional projection
Other nurses have reported that their emotional projection of patients may act as a barrier to assessing mental health distress in these patients.On this problem, a nurse remarked: "… I do the projection in each patient I see a mom, I see a sister, a dad… Sometimes it blocks me, I avoid feeling what they have.if not, I will cry with them…." Faced with these barriers as well as the absence of psychiatrists and psychologists within certain oncology services, the nurses expressed their wish to have favorable conditions in order to be able to carry out a systematic assessment of distress linked to mental health with their cancer patients.

| DISCUSSION
Mental distress, such as anxiety and depression, is a common issue in cancer patients. 12Several studies have demonstrated that psychosocial distress ranks among the primary concerns for individuals facing cancer, leading to difficulties in adhering to treatment and causing them to withdraw from family and social support systems. 13,14though it has been recommended that nurses take on the role of assessing distress due to their privileged position within oncology services compared to other health professionals, as well as the positive impact of this task on nursing practice, little is known about how nurses assess distress, respond to patients' needs, and the challenges they encounter in their practice. 15,16e primary objectives of the present study were to investigate how oncology nurses identify distress in their patients, examine the strategies they employ to respond to their patients' distress, and explore the challenges they face when addressing the mental distress needs of their patients.Nurses employ various strategies to identify mental distress in their patients, which encompass information gathering, utilization of interpersonal skills, and identifying the underlying causes of distress.In responding to patients' needs, nurses reported providing psychosocial support, incorporating religious and scientific approaches, conducting focus groups, and involving the patient's family.Nurses also identified three categories of barriers that impede the identification and response to their patients' distress.These barriers encompass issues related to the healthcare system, such as the absence of standardized assessment and distress treatment protocols in oncology, the high workload due to the number of patients and time constraints, and the lack of specific training in psycho-oncology.
Additionally, barriers stemming from patient-related factors include patient reluctance, while barriers linked to the nurses themselves involve emotional projection and challenges in communication.
In the same perspective of our results, a study by Granek et al indicated that nurses in oncology departments relied on questioning patient to assess distress, while the lack of training in mental health and time constraints are the main obstacles to this assessment. 17tient reluctance to ask the nurse's questions has been mentioned as a barrier to helping patients, other studies have reported that the use of random assessment strategies can lead to misdiagnoses. 18In this sense, a study showed that nurses trained in interpersonal skills were better able to assess distress in cancer patients than those who were not trained. 19erall, the nurses in our study were not trained to screen for and respond to mental distress in patients and they confirmed that there was no protocol for assessing and managing the distress within their departments.Nonetheless, they reported the frequency of distress in their patients and mentioned the strategies they adopt to identify and cope with it.These data are encouraging insofar as nurses, despite the obstacles, have recognized the importance of managing distress and have sought solutions to alleviate it.However, these results remain worrying, because the evaluation remains nonstandardized and not systematic, each nurse is based on his own knowledge and his own skills to know how to assess the distress and how to meet the patient's needs. 20 previously discussed, it is imperative to conduct mental distress screening for cancer patients as an integral component of their comprehensive care. 21Screening enables the referral of patients to psycho-oncology specialists, ensuring the effective management of cancer-related emotional challenges.Beyond its potential to enhance patient well-being and quality of life, there is substantial evidence suggesting that unaddressed distress in patients can result in adverse outcomes, such as non-compliance with treatment regimens, 22 compromised anti-cancer care, 23 reduced satisfaction with healthcare, 24 prolonged hospital stays, 25 increased healthcare visits, 26 and elevated cancer-related mortality. 4Consequently, mental distress screening carries not only personal but also economic and systemic implications, profoundly impacting patients and their healthcare providers.To promote the routine adoption of evidence-based mental health screening, it is imperative to educate stakeholders about the significance and rationale underlying the identification of distress. 20 enhance the accuracy of mental health disorder diagnosis, clinical approaches should encompass the systematic utilization of reliable tools tailored to the Moroccan context for distress screening.These tools may include the Hospital Anxiety and Depression Scale (HADS), 27 a 14-item self-report questionnaire assessing anxiety and depression symptoms experienced by patients in the past week.A HADS total score exceeding 15 has demonstrated good sensitivity and specificity for identifying anxiety and depressive disorders in cancer patients. 28other widely employed tool is the Distress Thermometer, 29 a straightforward self-report measure represented as a scale ranging from 0 to 10, anchored at 0 with "No Distress" and at 10 with "Extreme Distress."Patients are asked to indicate their level of distress on this scale for the past week.A score of 4 or higher signifies the need for intervention.This measure has been extensively employed in cancer patient research and is recommended for clinical use. 30Patients can self-administer this screening, optimizing the utilization of limited treatment time.Only patients scoring above the cutoff should be flagged, enabling healthcare professionals to engage in focused discussions with them.

| Study limitations
Our study has certain limitations.While our in-depth qualitative methodology provided valuable insights into the identification and management of mental distress in cancer patients by oncology nurses, it did not allow us to determine the actual frequency of clinical distress assessments or the number of patients referred for psychosocial care.
Despite our efforts to gather this information, no objective data in the form of health records were available to ascertain the exact number of patients who received psychosocial care.

| Clinical implications
Systematic assessment of mental distress in oncology may have several benefits and improve clinical implications for oncology nurses.

3
months (March 1, 2022 to June 1, 2022), at the level of four oncology centers in Morocco (Hematology and Oncology Center of the University Hospital of Marrakech, Oncology Department of the Ibn Rochd University Hospital Center Casablanca, Oncology Center of the Hassan II University Hospital (Fez) and Oncology Center Beni Mellal).
(a) Get information directly from the patient; (b) Ask family members; (c) Communication and active listening; (d) Establish a trust relationship; (e) Look for the causes of distress.

Faced 3 |" 3 . 2 . 4 |
with difficulties in communicating with the patient, some nurses reported learning about the patient's mental health from family and friends.As one nurse mentioned: "When the patient seems reluctant to me, I ask his relatives about the symptoms of distress such as sleep disorders".F I G U R E 1 Strategies for identifying mental distress.T A B L E 2 Sample characteristics (n = 25).Communication and active listening Some nurses reported that communication and active listening were part of their strategies for identifying mental health distress in patients.In this regard, a nurse explained: "I do not do an assessment based on standardized or validated tools but I do it in my own way… By talking to the patient, by analyzing the non-verbal nature of patient.Establish a trust relationship Other nurses indicated that building trust was one of their strategies for assessing mental health distress in cancer patients.A nurse explained in this sense: "I always work on the bond of trust, the stronger this bond, the more I can know the patient's condition and his psychological suffering."

First, the systematic
assessment of mental distress allows early identification of patients who may have mental health needs.This allows oncology nurses to quickly identify patients who may require further assessment and psychosocial intervention.Early detection can help prevent a deterioration in the patient's mental state and allow earlier and more effective intervention.Then, the individualization of care, by systematically evaluating the mental distress of cancer patients, nurses can better understand their needs and adapt care accordingly.The assessment of mental distress takes into account the psychosocial, emotional, and cognitive factors that can influence the overall health of the patient.This allows for the provision of individualized care that meets the specific needs of the patient, including appropriate psychosocial and supportive interventions.Then, the systematic assessment of mental distress helps to recognize and treat psychological symptoms such as anxiety, depression, fear, or hopelessness in cancer patients.Oncology nurses may work collaboratively with a multidisciplinary care team to implement distress management strategies, such as psychological support interventions, referrals to mental health specialists, or stress management programs.This helps to improve the psychological well-being of patients and promote a better quality of life.Additionally, systematic assessment of mental distress can facilitate communication between oncology nurses and patients.By asking questions about mental distress, nurses open the door to deeper discussions about patients' emotions, concerns, and needs.This can strengthen the therapeutic relationship, foster empathy and trust, and enable nurses to provide emotional support and attentive listening to patients.Also, this systematic evaluation of mental distress makes it possible to measure the results of the psychosocial interventions implemented for patients.Nurses can regularly assess patients' mental distress to monitor the effectiveness of interventions and adjust care accordingly.This allows patients' progress in their mental health to be tracked and necessary changes to be made to optimize their well-being.The systematic assessment of mental distress in oncology enables oncology nurses to detect mental health needs early, individualize care, manage psychological symptoms, improve communication with patients, and follow up the effectiveness of interventions.This contributes to improved clinical implications by providing holistic support to cancer patients.5 | CONCLUSIONS In conclusion, this study underscores the crucial importance of early identification of mental distress in cancer patients.While current strategies employed by oncology nurses, such as gathering information and utilizing interpersonal skills, show promise, additional efforts are required.Targeted training, aimed at enhancing communication skills and recognizing treatable disorders like anxiety and depression, is indispensable.Furthermore, proactively directing at-risk patients to specialized mental health care, including psychotherapy and psychopharmacology, can narrow treatment gaps.Investing in the ongoing education of oncology nurses and promoting referrals to specialized care will significantly contribute to enhancing the overall care of oncology patients, thereby addressing current gaps in the provision of psychosocial support. 11 Interview schedule.
T A B L E 1