Combined consent/evaluation form

Patients who agree to have a foot reflexology treatment session are given a combined consent/evaluation form which provides evidence of consent and is used as a data collection tool. Patients fill out a new consent/evaluation form for each reflexology treatment as their symptoms often change throughout their cancer treatment.

The consent part of the form states that by completing the form patients are consenting to their information being stored and used for research purposes, staff training and service development. To ensure anonymity, patients are asked to initial rather than sign the form and neither their NHS number nor hospital number is recorded.

The evaluation part of the form is adapted from the Measure Yourself Concerns and Wellbeing (MYCaW) tool (Paterson et al 2007). Patients fill out the evaluation section of the form before and after each reflexology treatment and the data are entered at a later point onto a software spreadsheet by one of the reflexologists. The data are used in annual reports that are prepared for the funding charity, the DCHFT chief executive, cancer service management and staff to inform them about service quality, service uptake and patient satisfaction and to provide evidence of value for money.

Foot reflexology treatment method

The ethos of foot reflexology is to encourage a deep sense of relaxation. The length of each treatment is adjusted to meet individual patients’ needs, but usually the maximum time per session is 20 minutes. Footwear is removed and the patient’s feet are refreshed with disposable wet wipes. Grapeseed oil is then applied to the patient’s feet to facilitate smooth delivery of the reflexology treatment.

An adapted sequence of reflexology massage movements is carried out, starting with the right foot then moving on to the left. The adapted sequence follows the Federation of Holistic Therapists Vocational Training Charitable Trust Reflexology Manual level 3 guidelines (Cressy 2006). Due to the complexities and frailty of some patients in this condition-specific group, a more even pressure is applied over the feet rather than organ-specific pressure. The sequence was standardised by the reflexologists to ensure continuity of treatment delivery for all patients across all sites.

Data collection tool

DCHFT guidance on the foot reflexology service states that all patients should be able to measure symptom improvement following reflexology based on a comparison of level of concern scores before and after treatment. As previously mentioned, the form used to obtain consent and capture evaluation data relating to the reflexology treatment is an adapted version of the MYCaW tool. The MYCaW tool was originally developed by Paterson et al (2007) as an individualised method of evaluating outcomes in cancer support care, including complementary therapies. It is a validated and reliable patient-centred questionnaire that allows patients with cancer to identify and quantify the severity of their ‘concerns’ and ‘well-being’ (Paterson et al 2007, Jolliffe et al 2015).

The combined consent/evaluation form used by the DCHFT foot reflexology service has undergone a number of revisions since initial implementation of the service, based on patient feedback. The version of the form used during this service evaluation period provided space for consent (patient and reflexologist initials) and identification of the delivery site (Fortuneswell ward, chemotherapy unit, radiotherapy outpatient department).

On the reverse side of the form patients are requested to indicate their age and gender and whether they would recommend the service to others. They are also asked to identify their concern(s) (symptoms), physiological or psychological or both, and to rate their level of concern on a ten-point scale, ranging from one (low) to ten (high), before and after their reflexology treatment. If a patient enters more than one concern, the first concern and its score is recorded on the software spreadsheet. Additional space is provided for comments about the patient’s experience of the reflexology service, the beneficial effects of the reflexology treatment on symptoms and the overall therapeutic effect of the treatment.

Patient-reported concerns

Patients reported a range of concerns. The most frequently cited was anxiety, followed by pain and swelling (see Figure 1).

Figure 1.

Patient-reported concerns

Patient-reported level of concern before and after reflexology treatment

Figure 2 illustrates patient-reported level of concern before and after reflexology treatment sessions. The findings show that before the reflexology treatment, levels of concern were rated at the higher end of the scale (6-10) (1,543 [74%] forms) and that after the reflexology treatment levels of concern were rated towards the lower end of the scale (1-5) (1,923 [93%] forms). Only 155 (7%) consent/evaluation forms contained post-treatment levels of concern rated between six and ten. These findings suggest that patients’ level of concern reduced following a foot reflexology treatment session.

Figure 2.

Patient-reported level of concern before and after reflexology treatment session

Patient experience

A total of 1,839 (88%) of the 2,078 consent/evaluation forms contained patient comments, of which 638 (35%) were about patients’ experience of the foot reflexology service (Figure 3), 247 (13%) were about the beneficial effects of the reflexology treatment on their symptoms (Figure 4) and 954 (52%) were about the therapeutic effect of the reflexology treatment (Figure 5).

Figure 3.

Patient comments on the foot reflexology service

Figure 4.

Patient comments on the beneficial effects of foot reflexology treatment on symptoms

Figure 5.

Patient comments on therapeutic effect of the foot reflexology treatment

Effectiveness of the combined consent/evaluation form

The combined consent/evaluation form was considered by the first author to be an effective method of collecting data, based on the number of completed forms available for review (2,078). However, the number of forms does not correlate with the total number of treatments delivered during the review period, as some forms were incomplete or unreadable and could not therefore be used in this service evaluation.

In the first author’s experience, some patients can find it challenging to complete the consent/evaluation form due to physical issues, such as suboptimal eyesight or grip or cannulation, therefore rendering the form unreadable, while others can find the terminology confusing, particularly the word ‘optional’ applied to physiological or psychological concerns and the terms ‘high/low’ in relation to the level of concern scale.

Designated therapeutic space

Fortuneswell cancer ward comprises 17 beds, three isolation rooms and two specialist rooms for patients with neutropenia. Reflexology is delivered to patients who are confined to bed and to those who are able to sit out of bed, but there are few options for providing these patients with a private space for this treatment.

The outpatient chemotherapy unit consists of one large room with eight recliner chairs and two small rooms with three recliner chairs, one room with a bed for patients who are unable to sit and one room with a bed and recliner chair for clinical tasks such as wound dressing. Although a large chemotherapy room can provide patients with companionship and an opportunity to share experiences, some people prefer a more private space for reflexology treatment. At the time of writing, the chemotherapy outpatient unit was about to undergo remodelling which may include space for a complementary therapy room or a shared consultation room.

Meeting demand for appointments

Meeting demand for reflexology appointments is challenging, due in part to the limited funded hours and the number of reflexologists.

It may be possible for oncology staff to prioritise patients for referral to the reflexologists; for example, patients on Fortuneswell cancer ward who are in acute pain or who are receiving end of life care, or patients attending outpatients who may have a needle phobia or acute symptoms related to chemotherapy or radiotherapy treatment.

Consent/evaluation form

It is important to use a validated data collection tool when conducting a service evaluation but such tools must also meet the needs of the intended patient group. In the first author’s experience, patients who receive foot reflexology treatment at DCHFT are often extremely unwell or extremely fatigued, therefore the data collection tool must be short, easy to understand and simple and quick to complete. Consequently, the combined consent/evaluation form has undergone numerous revisions based on patient feedback since the foot reflexology service was first implemented.

Based on the first author’s experience of the process of reviewing the consent/evaluation forms for this service evaluation, suggested improvements include simplifying the level of concern scale by using the words ‘better/worse’ rather than ‘low/high’ and removing the word ‘optional’ in relation to physiological or psychological concerns. Additionally, the reflexologist could write patients’ verbal scoring and comments on the form on their behalf and add their initials to acknowledge this. These changes could result in fewer incomplete forms and therefore provide a larger amount of data to inform future funding applications and potentially increase funded treatment hours.