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2003 Congress Abstracts151 Severe pain is a major problem of hematopoietic stem cell transplantation
(HSCT) recipients. The major goal of this study with repeated measures
is an understanding the pain of patients undergoing HSCT. The sample consisted
of 110 adults receiving HSCT for hematologic neoplasia, malignant lymphoma,
or non-Hodgkin lymphoma at a Catholic HSCT center in Korea. 152 Cancer patients often seek medical help because of intermittent or continuous unrelieved pain. However, studies have shown that pain is often undertreated, even among cancer patients. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) calls pain “the fifth vital sign” and asserts the right of every patient to be adequately assessed and treated for pain. In view of this, M.D. Anderson Cancer Center launched a pain-management collaborative effort to improve pain assessment and management for all patients. In response to the institution’s efforts, staff of the Sarcoma Center at M.D. Anderson Cancer Center produced a two-part pain-assessment questionnaire that is filled out by each patient at each clinic visit. This questionnaire covers the description, intensity, location, and duration of the pain and alleviating and aggravating factors that may affect pain. It also asks whether the patient takes pain medications and uses alternative pain treatments. The bottom portion of the questionnaire, which is completed by the patients’ registered nurse, assesses the level of pain acceptable to the patient, the effectiveness of the patients’ current pain treatment and side effects of pain medication. Based on the patients’ responses, interventions are implemented; these may include changes in pain medication, alternative treatments, or a pain-clinic consultation for severe unrelieved pain. As a result of these assessments and interventions, pain assessment and management at Sarcoma Center have improved. According to an institutional survey conducted by the M.D. Anderson Performance Improvement Department, the percentage of Sarcoma Center patients with work limitations related to pain decreased from 35% during September 1999 to March 2001 to 24% during September 2001 to December 31, 2001. Our study showed that a simple standardized questionnaire can improve pain assessment and management and thus reduce patients’ work limitations. 153 Venlafaxine was one of the first novel antidepressants found to be effective
in reducing hot flashes. A placebo-controlled, randomized, clinical trial
established 75 mg of long acting venlafaxine as the optimally effective
dose, reducing hot flashes by 60%. Side effects of this dose of venlafaxine
included dry mouth, decreased appetite, and temporary nausea. A continuation
study of 8 weeks followed this placebo-controlled trial. Results of the
continuation study indicated that 75 mg per day continued to provide consistent
reductions in hot flashes without new tolerability issues. Nurse phone
call assessments were conducted with original participants who participated
on the continuation portion of the study at 6 months, 1 year, and 2 years.
The purpose of the follow-up was to describe long-term use of venlafaxine
as a treatment for hot flashes. Results of the 6-month follow- up shows
61% of participants were still on venlafaxine. At one year, 52% remained
on the drug, and at 2 years, 46% were still taking venlafaxine. The dose
of venlafaxine being used varied; 16% were on 37.5 mg, 38% reported taking
75 mg, and 35% were taking 150 mg. The mean frequency of hot flashes experienced
by these women was 4.6 at 6 months, 4.3 at one year, and 4.9 at 2 years.
Hot flash scores (frequency x severity) were 9 at 6 months, 7.5 at one
year, and 9.4 at 2 years. Long term toxicities that women reported and
subjectively attributed to the venlafaxine included persistent nausea
(N = 6), increased BP (N = 3), fatigue (N = 2), mild constipation (N =
1), decreased libido (N = 1), and increase in headaches (N = 1). 154 A major focus for oncology nurses is assessment and management of symptoms related to cancer and its treatment. Complete assessments help ensure appropriate treatment of patients’ side effects and make chemotherapy regimens manageable. Traditionally, it is the nurse who questions the patients and makes observations while completing their daily assessments. This can be a challenge, as patients often have difficulty accurately describing symptoms. They may not consider the symptom important or may be reluctant to express concerns, fearing that symptoms indicate a worsening condition. On a 16-bed hematology-oncology unit, one method to involve patients in their assessments using Side Effects Clipboards and Aware Pads (Amgen) is being explored. The Clipboards list symptoms such as anemia, neutropenia, mucositis, pain, depression, and alopecia. There are pullout tabs that define related terms and list ways to manage and/or prevent the symptoms. They provide valuable educational information on side effects for cancer patients receiving chemotherapy. The Pads, attached to the Clipboards, describe the symptoms, numerically grading them from 0–10. Patients use this scale to quantify their symptoms, record them, and communicate them to their nurses. Examples include bruising/bleeding, chills, mouth sores, numbness/tingling, changes in energy/sleeping pattern, and anxiety. In this way, symptom changes and acuity can be followed over time to evaluate the effectiveness of interventions and treatments. There is a Clipboard and Pad in every patient room and patients are instructed upon admission to record symptoms daily and share them with their nurses. The use of materials and the communication of symptoms between patients and nurses are monitored. Over time, expected benefits include timely, accurate, and quantifiable assessments, better resolution of symptoms, improved patient education, and increased participation in care. 155 Ibritumomab tiuxetan (Zevalin), a radiolabeled monoclonal antibody, was approved by the U.S. Food and Drug Administration in February 2002 for the treatment of patients with low-grade or follicular non-Hodgkin lymphoma who have relapsed or refractory disease. Zevalin radioimmunotherapy (RIT) consists of the administration of a preinfusion of rituximab followed by an imaging dose of indium-111 Zevalin and, one week later, a second rituximab preinfusion followed by a therapeutic dose of yttrium-90 Zevalin. Treatment of patients with RIT presents challenges for oncology nurses, who play a key role in managing patient coordination, safety, and follow-up. Because Y-90 is a pure beta emitter and poses minimal risk of radiation exposure, Zevalin is routinely administered in an outpatient setting. Most nurses working in ambulatory infusion areas are familiar with the management of rituximab therapy; the majority of acute non-hematologic side effects observed with Zevalin RIT may be attributed to the rituximab portion of the therapy. The radiation component of the therapy with Y-90 Zevalin results in a delayed myelosuppression, which is the dose-limiting toxicity observed with RIT. In Zevalin clinical trials, the incidence and severity of myelosuppression correlated closely with the pretreatment extent of bone marrow involvement by lymphoma. Zevalin is therefore contraindicated in patients with => 25% lymphoma marrow involvement or other factors indicative of impaired bone marrow reserve. With Zevalin, blood count nadirs typically occur 7–9 weeks after treatment and last 3–4 weeks. In most patients, blood counts return to normal without intervention, but a percentage of patients may require growth factor support or transfusions. Since most patients will have previously received chemotherapy, they will need to be educated about the difference between the myelosuppression with Zevalin versus that with chemotherapy. As the primary point of continuity of care for these patients, oncology nurses need to develop procedures for effective post-treatment management. While blood counts should be monitored weekly for 12 weeks and toxicity checks should be performed on a regular basis, patients treated with Zevalin do not usually require regular weekly examinations. Strategies for nursing management of these patients will include the use of diaries, calendars, appointment systems, and electronic communication. 156 Thorough assessment and management of chemotherapy side effects is an
important aspect of the oncology nursing role. Side effects can be distressing
and are a major reason why patients discontinue or delay necessary treatments.
A frequently prescribed treatment for breast and lung cancer involves
the use of intravenous taxotere. One distressing side effect of taxotere
treatment is nail changes. As many as 30% of patients report nail changes
and 2.3% of patients experience severe nail changes following taxotere
treatments. Common nail changes following taxotere therapy include discoloration,
brittle nails, lines in the nail plate, softness, tenderness or pain in
nail beds, slowed growth, and total nail loss. 158 Although much research has focused on understanding the symptoms of lung cancer, there has been little attention focused on understanding the symptoms of patients with malignant pleural mesothelioma (MPM). MPM is a rare, aggressive tumor that is associated with exposure to asbestos and SV40 virus. The incidence is rising steadily with 2,000–3,000 new cases diagnosed annually in the United States. Initial symptoms at presentation include dyspnea, cough and chest pain, fatigue, weight loss, and fever. The thoracic oncology service at this NCI-designated comprehensive cancer center sought an objective measure of presentation symptoms in this patient population. It was perceived that patients with MPM present with greater frequency and severity of symptoms than those patients with other thoracic malignancies. The Lung Cancer Symptom Scale (LCSS) was identified as a possible tool for measuring disease specific symptoms of MPM. The LCSS is a disease specific instrument that measures the physical and functional dimensions of quality of life (Hollen 1993). It has been found to be feasible, reliable, and valid in patients with non-small and small cell lung cancers and thought to be reasonable for use in this population of patients. As part of a phase II trial testing a new chemotherapy agent in patients with MPM, patients are given the LCSS prior to treatment with any chemotherapy and then monthly while on treatment. To date, 10 patients have been entered on the trial with a total accrual goal of 37 patients. This abstract will present an overview of MPM, our experience using the LCSS, and report the frequency and severity of symptoms seen in patients with MPM. As we present the symptom profile of MPM patients, we will describe the role of the oncology nurse providing symptom-focused interventions in a nursing care plan format. 159 Zevalin (ibritumomab tiuxetan), the first commercially available radioimmunotherapy, consists of a murine monoclonal antibody and a linker chelator that attaches Indium 111 for imaging and Yttrium 90 for therapy. The Zevalin regimen consists of rituximab 250 mg/m2 followed by the imaging dose of In-111 Zevalin 5 mCi on day 1. Upon imaging confirmation of the expected biodistribution, treatment continues on day 7, 8, or 9 when rituximab 250 mg/m2 is again given, followed by the therapeutic dose of Y-90 Zevalin: 0.4 mCi/kg (0.3 mCi/kg in patients with platelet counts of 100,000–149,000/mL), to a maximum of 32 mCi. Patients with platelet counts < 100,000/ìL should not be treated. The first rituximab infusion is started at 50 mg/h and, if tolerated, escalated in 50 mg/h increments every 30 minutes, to a maximum 400 mg/h. Subsequent infusions may be initiated at 100 mg/h (if the initial infusion was well tolerated) and escalated in 100-mg/h increments every 30 minutes, to a maximum 400 mg/h, as tolerated. If an infusion reaction occurs, the infusion is slowed or interrupted and then continued at 50% of the pre-reaction rate after the symptoms have improved. The Y-90 Zevalin is administered by a physician or technologist licensed to handle radiopharmaceuticals, ideally within 4 hours of the second rituximab infusion. A 0.22 mm filter is placed between the infusion port and the 10 mL syringe containing the Zevalin, and the Zevalin is slowly infused through the infusion port over 10 minutes. Zevalin must not be combined with other IV solutions or medications or given as an IV bolus. When the injection is completed, the line is slowly flushed with at least 10 mL of 0.9% sodium chloride solution. Acute adverse events are related to the rituximab infusion and most are transient and respond to standard interventions. The most common reactions are fever, chills, rigors, urticaria, nausea, diarrhea, and arthralgias. Dyspnea, hypotension, and bronchospasm occur infrequently; patients may be premedicated with acetaminophen and diphenhydramine as a precaution. Zevalin handling precautions are universal precautions. Nurses are central to the safe and effective administration of radioimmunotherapy and should be familiar with the details of its administration. 160 Nurses are key in the identification, prevention, and management of palmar-plantar erythrodysesthesia or PPE, a potentially distressing side-effect of doxil and certain other chemotherapy agents. This is important for oncology nurses to know now, and to be prepared for, as Doxil, an agent with a remarkable and theoretically effective mechanism of action, becomes more widely used. The exciting kinetic feature is, through the steath liposomal technology, creation of a drug delivery system that takes advantage of the vascular leaks in tumors to preferentially deliver drug to the tumor site, together with an extended drug half-life of 54 hours. The medical literature and discussions at major oncology symposia are increasingly suggesting studies with doxil as a replacement for doxorubicin in standard therapies where cardiotoxicity may be a dose-limiting toxicity in potentially curative therapies such as Adriamycin-Cytoxan for breast cancer, or to reduce cost and complexity in therapies requiring continuous doxorubicin infusion, such as Vincristine-Adriamycin-Dexamethasone in the treatment of multiple myeloma. PPE, sometimes called “hand-foot syndrome” is characterized by erythema of the ventral surfaces of the hands and feet. With continued drug administration, this will progress to swelling, then pain, blister formation, and ultimately to cutaneous dry then moist desquamation of the palms of the hands and/or soles of the feet, or other areas of significant cutaneous pressure. Early clinical trials with doxil showed that dose and dosing interval were key factors, and that nurses, through patient education and close clinical assessment, played a crucial role in the early identification and prevention of progressive pain, loss of cutaneous integrity, and disability. In addition, once early PPE is identified, the nursing role in patient education, support, and symptom management is essential to effective patient self-care (or family care) and in most cases, patient’s willingness to continue this therapy. This presentation will review: 1) the pathophysiology of PPE, 2) key issues in patient and family teaching in terms of prevention, early identification, notification of the nurse, and management strategies, and 3) nursing assessment and grading of PPE, evidence-based clinical management, anecdotal management strategies, and collaborative dose or dosing related implications. 161 Thalidomide was originally developed in the 1960s as a sedative with
antiemetic effects. However, it was rapidly taken off the market when
its teratogenic effects (babies being born without limbs) were discovered,
and it was prohibited from use throughout the world. Today it is FDA approved
for use with leprosy; however, it is becoming a common treatment for patients
with multiple myeloma. At this NCI-designated comprehensive cancer center
it is being evaluated as a putatively anti-angiogenic treatment for various
types of solid tumors, including neuroendocrine tumors. For this patient
population, the dosing starts at 200 mg daily and is escalated 200 mg
every two weeks until there are any dose-limiting side effects. 162 As an advanced practice oncology nurse liaison for palliative care at
the University of Virginia Health System, it has been my observation that
general oncology patients, as well as disease-specific oncology populations,
are at higher than average risk for venous thromboembolism (VTE). After
a literature review was completed, and clinical observations correlated
with anecdotal reports from physicians, the decision was made to review
medical records on an oncology patient population that reportedly experiences
VTE most often. Retrospective medical record review was completed at our
institution and supported the literature, suggesting that a significant
number of patients evaluated with the diagnosis of lung cancer at the
University of Virginia Cancer Center, had experienced clinically evident
VTE. More extensive review was completed to assess potential for supportive
interventions that might prevent this serious complication and allow patients
opportunity for eligibility to participate in therapeutic clinical trials
for lung cancer. With no standard guidelines available, the medical oncology
lung and palliative care team decided to collaborate on a supportive care
study that might benefit this patient population by reducing incidence
of this serious and often fatal complication. The phase II trial was initiated
and designed to evaluate thromboprophylactic efficacy of low-dose Coumadin
in lung cancer patients during and after cancer treatment, including chemotherapy
and radiotherapy. The study design examines quality-of-life issues and
potential healthcare cost savings associated with prophylactic anticoagulation.
The primary endpoint remains interest in significantly diminishing incidence
of VTE in this patient population. As a co-investigator, and the healthcare
professional primarily following these patients in the clinical setting,
results of this study are expected to demonstrate the impact of the advanced
practice oncology nursing role on the end result of care in the areas
of clinical, psychosocial, and fiscal/organizational outcome. There is
potential to impact care of this (often acutely ill) patient population,
and perhaps suggest future supportive studies for other disease-specific
oncology patient populations. The results might even allow for the opportunity
to develop and publish care management guidelines at the time of diagnosis
for this patient population. This is part of a larger study to develop a protocol for hospice service
in Korea. In Korea, 60 hospice agencies are now providing various levels
of service and there is a great need to develop standards of care for
hospice patients. 164 Patients with advanced cancer experience multiple complex symptoms at the end of life. Traditionally, nursing education has not adequately prepared nurses to manage these symptoms. The purpose of this project, which was funded by the Oncology Nursing Foundation, was to determine the impact of an educational intervention on nurses’ attitudes toward and knowledge of palliative care and how that, in turn, affected their ability to manage end-of-life symptoms. Additionally, the timeliness and numbers of referrals to hospice were also evaluated. Educational content was guided by a framework of the essential nursing competencies for end-of-life care (AACN, 1997) and the End–of-Life Nursing Education Consortium (ELNEC) training program. The project used a convenience sample of 77 RNs from two in-patient divisions of a large midwestern comprehensive cancer center. The intervention consisted of an eight-month intensive nurse-nurse consultation with the oncology staff nurses and the palliative care advanced practice nurse. A palliative care seminar, covering pain and symptom management and communication skills, was presented. Nurses who indicated a desire to become “palliative care resource nurses” for their divisions participated in a two-day clinical experience with a large community-based hospice. Project methods included use of two written surveys from the City of Hope National Medical Center, “RN End-of-Life Knowledge Assessment” and “End-of-Life Attitudes Survey”; in-patient chart review of pain assessment documentation; and an analysis of the number of hospice referrals and the length of stay of these referrals, pre- and post-intervention. Data analysis is underway, consisting of descriptive statistics and comparisons (t tests) of the findings of the pre- and post-intervention knowledge and attitude surveys, hospice referral data, and frequency of pain assessment documentation. Qualitative analysis of nurse consultation notes is being done to identify common themes and further educational needs. Preliminary findings of themes include inadequate pain and symptom management, patient barriers to pain management, fears associated with hospice referral, and the challenges of integrating hospice/palliative care into an acute care oncology unit. 165 Lack of professional education has been identified as a barrier to providing
quality palliative care at the end of life. Nursing textbooks provide
limited content related to end-of-life nursing care despite the growing
body of palliative care knowledge. Undergraduate nursing students commonly
report feeling worried and unprepared to be involved with patients who
are actively dying. At the same time, several patients receiving inpatient
palliative care may be dying alone, without family or friends available
to be at the bedside. In response, we have developed a palliative care
companion program to enhance services available to patients and their
families and to provide a unique educational opportunity for undergraduate
nursing students. 166 Problem and Purpose: The recent literature documenting the problems of
end-of-life (EOL) care in the United States has largely ignored the experiences
of the vulnerable populations who live at the edges of society. Most of
the literature related to socioeconomic status (SES) and cancer underscores
the greater morbidity and mortality of poor people when compared with
more affluent groups (Bradley et al. 2002, Marcella & Miller, 2001).
Untangling (unconfounding) the effect of race and poverty on cancer-related
morbidity and mortality is a challenge. No published research has been
located that examines the perspectives of poor patients with cancer regarding
EOL care; only one clinically based report has been located (Hughes, 2001).
This pilot study will explore the experiences of the urban poor living
with cancer about care at the end of life. 167 Significance: The concept of personal control is central in Western bioethics.
Control of one’s life is closely connected with the concepts of
choice and autonomy. Given society’s emphasis on personal control,
many people value the right to autonomous decision-making in issues involving
health, disease, and dying. 168 Topic: Palliative care includes comprehensive physical, psychological,
social, and spiritual support for patients and their caregivers. Providing
palliative care to underserved populations (e.g., some minorities, the
indigent) is a major challenge. The challenge to prepare and retain competent oncology nurses becomes
progressively more critical as the nursing shortage causes increased competition
among hospitals and other places of employment. Extensive recruitment
efforts must be made to attract registered nurses to this specialized
field and then the challenge continues to retain them. 170 The nursing shortage may reach crisis proportions in the next 10 years.
Unless innovative strategies are implemented immediately, the delivery
of healthcare, especially cancer care, will be compromised. A shortage
of qualified nursing staff may place patients at high risk for increased
morbidity and mortality. Patient care may suffer because the quality and
quantity of time spent at the bedside is inadequate. 171 The nursing shortage and higher nursing turnover rate can result in difficulty
maintaining morale and standards of patient care. It is imperative to
have experienced, skilled nurses who know the institution’s policies
and procedures. This is the most effective way to assure safe, quality
patient care. Nurses on busy inpatient units are increasingly stressed
and deserve our best effort to provide an environment that contributes
to nurse retention. About two years ago, our hematological malignancies
unit experienced a high turnover rate. The staff identified areas that
nurses believed were important to them. Two of these were professional
growth and development and psychological and emotional nurturing. The
clinical nurse specialist and senior nursing staff promoted professional
development by offering educational sessions on the unit so that all nurses
could attend. Dinner lectures were developed and staff was encouraged
to attend. We supported attendance at local and national conferences,
encouraged OCN® and CCRN certifications, and membership
in professional organizations by assisting with scheduling or financial
aid. We implemented a unit specific orientation program that supported
new nurses through their steep learning curves. We sponsored events and
activities to promote unity and camaraderie for the staff. We held welcome
parties for new staff and posted banners. We celebrated special events
such as birthdays, weddings, and baby showers. Occasionally, we spontaneously
held a staff breakfast or lunch with everyone participating. We organized
“happy hours” and bowling parties. We created an “Our
Staff Family” board that showcased special occasions such as our
unit’s holiday party. The staff selected a design for a unit T-shirt
identifying us as the “heme team”; we entered and placed in
a competition for the best nursing team in a local nursing magazine. As
a result of these and other efforts, we have a cohesive team that supports
one another as we professionally grow and develop. Best of all, we have
had a dramatic decline in our turnover rate and have nurses return after
resigning and agency nurses asking to join our staff. These efforts are
well worth the investment in relation to the orientation costs saved and
the supportive unit environment. In light of the current nursing shortage, retaining a core group of experienced
oncology nurses is critical to quality patient care and positive outcomes.
A proactive approach utilized by the nursing department of Fox Chase Cancer
Center, was aimed at identifying the “nursing stars” and providing
a structured opportunity for them to articulate the factors that attracted
and retained them to the facility. The nursing career specialist, a member
of the professional development and recognition committee and a member
of the retention and recruitment committee designed and implemented a
recognition dinner event that was supported by nursing administration
theoretically, financially, and educationally. Consultants from nursing
research provided guidance in formatting the event as a focus group to
facilitate lively discussion in a controlled atmosphere. 173 The current nursing shortage, coupled with the challenge of recruiting
and retaining skilled oncology nurses, makes maintaining staff satisfaction
a priority for the nurse leader when developing staffing plans. An innovative
ambulatory care model was designed to address these issues and simultaneously
sustain high quality patient care. At this comprehensive cancer center,
attending oncologists and registered nurses work collaboratively, providing
care to a shared caseload of patients five days/week. The nurse is responsible
for assuring continuity of care to patients across the continuum and for
documenting the care provided. In 2001, the gastrointestinal (GI) medical
oncology service had 22,322 ambulatory patient visits, an increase of
approximately ten percent from the prior year. The increased volume and
acuity lead to the following concerns: (1) an increase in nursing care
hours and difficulty in complying with documentation standards, (2) inability
to recruit and retain staff to the service, and (3) dissatisfaction of
the nursing and physician staff with the current workload, nursing support,
and coverage. In response to these concerns, the nurse leader proposed
a flexible four-day workweek in the GI service. The new care delivery
model involved partnering two nurses in a collaborative relationship with
two physicians to ensure coverage and continuity of care using a four-day
workweek. The model was presented to nursing and hospital administration
to establish an implementation plan. The pilot commenced January 2002
and ended June 2002. It included 11 attending oncologists, 12 office practice
nurses, and three research nurses. Three data points were used to evaluate
the model pre- and post-implementation: nursing documentation, turnover
rate, and satisfaction surveys completed by physicians, nurses, and patients.
The evaluation demonstrated marked improvement in all areas. This new
model was well received by the nursing division, administration, and physicians.
This presentation will illustrate the process of the development, application,
and evaluation of a plan that was piloted and adapted in a busy medical
oncology ambulatory setting. Due to the success of this new care delivery
model, future plans are to implement flexible scheduling options to the
other services within our institution. Nursing’s tight labor market within the global healthcare workforce shortage mandates institutional vigilance about recruitment and retention efforts. With crippling nurse vacancies across the nation, escalation in nurse turnover rates, and a widely anticipated increase in nurse retirement, retention issues have evolved in importance to rival cost and quality imperatives. Model long-term solutions to counter turnover are the focus of innovation. The inpatient blood & marrow transplant unit at our large comprehensive cancer center successfully reduced registered nurse turnover by nearly 10%. In collaboration with a shared-governance council structure, a unit-based task force developed strategies to address this issue. Staff nurses, nurse managers, assistant nurse managers, clinical nurse specialists, the clinical instructor, and clinical administrative director created mechanisms to minimize the three highest drivers of staff turnover: 1) strengthen new hire education and support, 2) reconfigure scheduling and workload intensity and address compensation, and 3) evaluate staff satisfaction with nurse manager performance. These interventions will be discussed in detail. Designing a successful recruitment and retention plan and sustaining these improvement efforts can facilitate change in staffing patterns, which support longevity in specialty clinical practice. 175 After approximately one year of employment in the ambulatory clinic of
a large Midwestern NCI-designated national cancer center, both the clinical
nurse specialist and unit manager noted that there was a lack of communication
and teamwork among staff. They also noted that nurses felt their role
had limited impact and value on the patients they served. They collaborated
on a program designed to increase teamwork, morale, communication, and
self-awareness. Staff was assigned to groups based upon personality traits,
witnessed behavioral interactions, and leadership skills. 176 There has been much discussion on the recruitment and retention of nurses, particularly in the inpatient setting. However, retention is a primary concern in all nursing settings due to the intensity and expense of orientation necessary for positions, as well as the need to provide ongoing quality service. In a defined sub-specialty such as oncology research nursing, the need for retention is crucial because specialized training is necessary. In the years 1997 to 1999, the clinical trials office (CTO) of a national cancer institute comprehensive cancer center experienced an annual turnover of 20 percent with an average of 36 employees per year. Magnification of the need for retention becomes clear when focusing on the elements of quality documentation and safety, along with goals for accrual. With clinical trials being an integral piece of a comprehensive cancer center, the need for a stable, professionally focused nucleus of employees to conduct research is clearly evident. To attain this, the staff and management of the CTO developed a committee to address employee concerns and promote empowerment in an effort to improve retention. All areas of the CTO were represented: nursing, data management, IRB, computer support, and management. A committee spokesperson was established and goals were developed, as well as objectives and a mission statement. The acronym G.L.U.E, Greater Loyalty Utilizing Empowerment, was adopted. A manager was present at each meeting as an ex-officio member of the committee allowing group empowerment. Committee meetings were held bimonthly during lunchtime for one hour and the staff was updated at regularly scheduled staff meetings regarding G.L.U.E activities. Encouragement to communicate with committee members resulted in ideas felt to make retention a high priority. Implemented employee surge boosters included a variety of interventions from flex scheduling to ergonomic evaluation of workstations. The communication gap between management and staff was narrowed by a variety of G.L.U.E activities. Evaluation of G.L.U.E after one year finds the number of employees at 56 and turnover rate at 4 percent since program implementation. Empowerment through this approach does boost morale and aid in employee retention. 177 Faced with inpatient oncology units where 6 out of 10 staff nurses leave within 24 months, the oncology leadership team of an urban comprehensive cancer program performed an assessment to identify key issues facing staff nurses. The assessment included staff interviews, patient focus groups, and individual interviews with physicians and other key interdisciplinary team members. Findings indicated that patient acuity was high, but staffing on the unit was adequate. Oncology nurses, however, were faced with an array of systems and process issues in addition to the emotional toll, hard, physical labor, and complex mental processes inherent in cancer care, with the most common issue cited as “work intensity.” The mission of the leadership team was to break the cycle of turnover by creating an environment of support and development; one that retained our skilled, motivated, and intelligent care providers in and beyond the 24-month period. To develop and retain a more hardy and resilient staff, competency building needed to include skills related to their own psychosocial wellness. A pilot series of retreats, the first phase of a staff psychosocial wellness initiative called the Circle of Care Program, was delivered to over 150 members of the interdisciplinary patient care team. Survey data collected from 58 RN retreat participants revealed significant burnout and frustration, feelings of being “used up” at the end of the workday, and often facing the workday already feeling fatigued. Paradoxically, many characterized their work as worthwhile, even “exhilarating,” and reported that they were positively impacting patient’s lives. Addressing these diverse issues, the skill-building retreats included discussions of professional boundaries and loss, and featured instruction in positive coping strategies and constructive self-care behaviors, as well as introduction to the FISH philosophy, a management strategy designed to energize and improve commitment and morale in the workplace. Many short- and long-term retention strategies were devised as a result of participant feedback including annual retreats, regular bereavement sessions, rituals to help work through loss, etc. Underway is a follow-up study of the workforce relative to the issues of burnout, team effectiveness, and the resultant patient/family satisfaction. 178 Cultural competence is a critical skill needed by oncology nurses to
provide quality cancer care to patients and families. Cultural competence
is defined as the ability of individuals and systems to respond respectfully
and effectively to people of all cultures, classes, races, ethnic backgrounds,
and religions in a manner that recognizes, affirms, and values the cultural
differences and similarities and protects and preserves the dignity of
each. The cancer experience, in itself, is a significant event in their
lives, with culture playing a major role in how patients and families
respond to this experience. The importance of developing one’s cultural
competence is only reinforced, as the population we, as nurses, serve
becomes more diverse. The demographics of Canada are constantly changing
not only as a result of immigration, but also population increases among
racial, ethnic, linguistic, and culturally diverse groups. The purpose
of this presentation is to help oncology nurses understand key concepts
and skills that are vital in providing culturally competent care to patients.
Challenges faced by oncology nurses in clinical practice are shared, along
with strategies to help nurses develop their cultural competence. Cultural
competence is portrayed as a journey, rather than a destination; a process,
rather than event; a state of “becoming,” not “being.”
179 The critical nursing shortage, as well as the aging of the nursing workforce,
has had a tremendous impact on the delivery of nursing care nationally.
To respond to this challenge, this NCI-designated comprehensive cancer
center reframed its primary nursing model to partner with certified nursing
assistants with oncology-specific skills. Goals of the nursing assistant
development program were to expand utilization of nursing assistants throughout
the institution, and to provide educational programs designed to ensure
that nursing assistants have appropriate skills to function effectively
as members of the oncology nursing team. 180 Cancer can affect patients’ sexuality either temporarily or permanently. Sexuality is not simply sexual function but an ever-changing experience in how one views one’s body and one’s self. Sexual dysfunction can affect an individual’s sense of well-being and therefore affects quality of life. Barriers to discussing sexuality include cultural issues, discomfort about the topic, lack of educational preparation, a presumption that issues of survival override issues of sexuality, and an assumption that the elderly lose interest in sexuality. However, expressions of sexuality are an intimate form of communication that can relieve suffering. The information nurses give patients about cancer’s effect on sexuality is often inaccurate or complete. Cancer threatens sexual functioning as well as body image (disfigurement, alopecia), infertility, fatigue, and pain. Sexual concerns may increase after treatment is complete and its side effects become apparent. A sexual assessment with each visit addresses sexual dysfunction. To deal effectively with patients’ sexual issues, healthcare providers must know what to ask and how to ask it, and they must understand patients’ expectations, premorbid lifestyles, attitudes towards sex and relationships, and relationships with current sexual partners. Screening for unexpressed anxiety, guilt, and anger is important. An environment that supports expression of concerns and fears provides a sense of confidence that feelings can be addressed. This poster will inform nurses on how to address sexuality and cancer BETTER. This acronym was created to help nurses conduct sexual assessments more effectively. BETTER stands for: BRING up the topic so patients know they can discuss sexuality and cancer. EXPLAIN that you are concerned with all aspects of patients’ lives affected by cancer. TELL patients sexual dysfunction can happen and that you will find appropriate resources to address their concerns. TIMING is important to address sexuality with each visit to let patients know they can ask for information at any time. EDUCATE patients about the side effects of their treatments and that side effects may be temporary, and RECORD your assessments and interventions in patients’ medical records. Integrating information about sexuality into clinical practice can validate patients’ experiences and enhance their quality of life. 181 Encouraging nurses to grow professionally, and providing the manpower
and resources to support this growth is a challenge for nursing leadership.
At this NCI-designated cancer center, the professional development task
force (PDTF) was created to provide direction, education, and support
for nurses preparing abstracts/posters for presentation, professional
speaking, writing for publication, and mentoring activities. In 1999,
several members of the Ambulatory Advanced Practice Council (AAPC) took
the initiative to coordinate an abstract preparation program for the division
of nursing. These nurses conducted several workshops that provided written
educational materials, a review of abstract/poster submission criteria,
and a critique of abstracts previously presented. Informal discussion
was encouraged to explore the potential author’s plan and mentoring
needs. To date, 130 nurses attended the workshops, and 112 have submitted
abstracts. Based on the success of the abstract program, several of the
advanced practice nurses (APNs) recognized a need to develop similar programs
for other professional activities such as presentations and writing for
publication. The abstract program provided a model for a more comprehensive
program and the PDTF provided the structure. 182 The hallmark of a profession is formal publication. The knowledge that is shared through written communication is a powerful way to advance a profession. Nurses have knowledge and expertise in a variety of areas, some of which include clinical practice, education, research, and leadership. Nurses need to share with their peers so that the profession can grow and develop. There are many reasons why nurses should write and publish their work. Publication is a way to improve patient care, develop evidence-based practice, promote ones personal and professional growth and development, enhance opportunities for career advancement, attain national recognition within the nursing community, and to secure tenure in the academic setting. Professional publication is one avenue to nursing excellence. Yet, writing does not come naturally for most nurses. Most nurses were not prepared through their nursing curriculum for writing and publication. There are barriers that prevent nurses from the process of writing. The main barriers are not knowing where and how to begin, not having enough time, and not having enough confidence in your writing ability. Writing is a skill that can be learned, developed, and mastered. While writing is work that requires discipline and practice, it can be easier than the novice writer suspects. This poster will utilize a “how to” approach for the novice writer. It will cover basic principles of writing, as well as provide strategies to overcome the fear of writing and identify opportunities for the novice writer to begin contributing to his/her profession. 183 Leptomeningeal metastasis (LMD) occurs in 3%–8% of all cancer patients,
most commonly adenocarcinomas of the breast, lung, and melanoma, as well
as, leukemia and lymphoma. Invasion of the cerebrospinal fluid by tumor
cells allows access to all regions of the central nervous system (CNS).
The diagnosis of LMD is a devastating neurological complication of cancer
and is associated with major neurologic disabilities and a high mortality
rate. 184 Without use of adequate personal protection, nursing staffs are at risk
of drug exposure. In Korea, government legally has not yet issued guidelines
for use of personal protection by those handling antineoplastics. So each
hospital developed their work practice guidelines based on the literatures
and American OSHA guidelines. We investigated the level of knowledge and
compliance with guidelines for safe handling of cytotoxic drugs by the
nurses’ job careers and work sites. 255 nurses working at two university
hospitals, located at Seoul, Korea, were asked to fill out questionnaire.
Tools for this study were developed by investigators based on the guidelines
issued by OSHA and Oncology Nursing Society in America. 185 Malignant pleural effusion is present in 50 percent of patients at the initial diagnosis of cancer. Advanced cases of breast cancer, lung cancer, and lymphoma represent 75 percent of total incidence. Symptoms of malignant pleural effusion are often painful and frustrating for patients at a time when they need quality interaction with loved ones. Historically, the treatment options such as long-term chest tube thoracostomy with eventual pleurodesis, with or without sclerosis, often proved more painful than the initial symptoms they palliate, with a recurrence rate of 97 percent within 30 days after initial thoracentesis alone. Shifting to a patient-centered approach is now possible with the development of a soft, fenestrated silicone catheter with a one-way valve and polyester cuff. Chronic pleural drainage can be managed in the home or outpatient setting and is simple to perform. Increased patient satisfaction with therapy, a decreased inpatient LOS, and empowerment to comfortably manage symptoms of end-stage disease are demonstrated benefits. While this technology can be used in the inpatient setting, and nurses are easily trained in drainage technique, the goal is to have the patient go home. Cost savings can be measured in decreased inpatient LOS and equipment charges and decreased readmission rates. The patient’s support team includes medical and surgical oncologists, CNSs, nurse clinicians, patient resource managers, and bedside nursing staff, who educate and follow patient progress. The collaborative approach promotes well-rounded treatment and a multi-pronged support system for the patient’s transition to the outpatient setting. Case presentation to include clinical presentation and typical volumes, pitfalls to success, patient condition over time, technology, implantation technique and clinical management, patient education, and cost analysis. 186 Nurses are encountering more patients who are undergoing PET (positron emission tomography) imaging due to the increased utility in the oncology setting. Therefore, the oncology nurse needs to know the basic concepts, unique features, and relevance to particular cancer diagnoses in order to provide optimal teaching and support to patients undergoing this procedure. PET is a nuclear technique by which metabolic processes in healthy and malignant cells can be visualized and measured using short-lived radionuclides. The basis for PET imaging differs from MRI and CT scanning which detect disease processes based on alterations in structure or anatomy. Since biochemical alterations will precede structural changes that may indicate active or progressive disease, PET scanning provides an additional dimension to further characterize disease. Other factors that have contributed to the acceptance of PET scanning are increased accessibility of machine and radionuclides, better reimbursement from third party payers, and more data to validate the specificity and sensitivity for certain cancers. Historically, PET has been used for the detection of cardiac and neurologic conditions. Most recently, however, there has been increasing evidence of the usefulness of PET imaging in the oncology setting. In specific diagnoses, PET has been found to be a useful tool for making differential diagnoses, staging preoperatively, differentiating scar tissue from residual disease, demonstrating suspected recurrence, and measuring response to treatment. Future trends in PET imaging are based on the development of diagnostic and therapeutic tracers as well as combining imaging modalities. This presentation will review the rationale, indication, and application of PET imaging in the oncology setting, describe the specific nursing education plan, including the avoidance of any substances that could falsely alter metabolic activity, and share written education materials developed. 187 Nationwide, the rate at which oncology nurses are seeking OCN® certification
is on the decline. As the oncology nurse clinician/educator at a multi-hospital
facility, a look around showed minimal OCN® certification for bedside
RNs. The radiation oncology departments have 3/8 RNs currently OCN®
certified, one is the nurse manager. The inpatient oncology units have
6/69 RNs with certification, only 2 are bedside RNs. Encouraging staff
to seek out certification first involved investigating what changes needed
to be implemented. 188 Significance: Nursing practice based upon science optimizes predictable
positive outcomes for patient care. 189 Successful role development, job satisfaction, and retention of APNs (nurse practitioner-NP/clinical nurse specialist-CNS) must begin with a sound orientation. Although APNs assist with orientation of new staff, how are they oriented to their role and by whom are they oriented? Often, the APN assumes this role upon completion of an advanced degree without formal orientation to the unique role as clinical expert, educator, consultant, and researcher. The ambulatory APN council at this NCI-designated cancer center identified the need to develop a more structured orientation to the APN role and a task force was formed. A literature search identified articles related to the APN role but little on their orientation. DiMauro’s (1989) competency-based CNS orientation model was adapted and job descriptions and ONS performance standards guided the development of the competencies. The NP and CNS roles required different clinical competencies, but had similar education and research competencies. Other issues addressed were: 1) the feasibility of completing the APN and the hospital’s general orientation within the human resources mandated three months, 2) prioritizing the three-month competencies, 3) the logistics of having the APN facilitator work in another ambulatory area of the center, 4) the unique needs of the orientee depending on her APN experience at entry level to the role, 5) training APN facilitators, and 6) ensuring compliance with administrative policies. Ambulatory nurse leaders, educators, and the APN council were consulted periodically and apprised of progress. The complexity of the APN role warranted that many competencies could not be achieved in three months so they became goals to be completed before the first year’s annual performance appraisal. Evaluation of this orientation process includes structured interviews with the nurse educator, nurse leader, orientee, and APN facilitator at completion of the orientation, and review of the competencies to assure completeness. This presentation will review the APN competencies, the process, and evaluation results. This competency-based orientation model is useful for APNs in other oncology settings. 190 Managing wounds in an oncology setting can be a challenge for the healthcare
professional. Conventional dressing changes can be time consuming for
nursing personnel as well as physically and psychologically unpleasant
for the patient. An alternative is the use of negative pressure wound
therapy. Vacuum-assisted wound closure (V.A.C.) was developed at Wake
Forest University in Winston-Salem and approved by the FDA in 1995 for
use in the treatment of stage III and IV pressure ulcers, diabetic ulcers,
surgical, chronic, or trauma wounds, and pre- and post-flaps and grafts.
191 Purpose: The purpose of this project was to increase the awareness of
the MGH Cancer Center nursing staff to the importance of assessing hypovitaminosis
D and hypocalcemia risk factors in the cancer patient receiving bisphosphonate
therapy. 192 193 The role of the oncology nurse in biomedical research is complex and multifaceted. The research nurse serves as the coordinator between the nurse at the bedside, multiple hospital departments impacted by the research, the patient, and the principal investigator, to assure protocol integrity, quality data management, and excellent patient care. Mastery of this complex role requires expertise in all components of the research process. To equip new research nurses at the National Cancer Institute (NCI) with this requisite expertise, the members of the education committee developed a program entitled “Fundamentals in Clinical Trials.” The goals of the program are to establish a knowledge base regarding the role of members in the research team, and the life cycle of a protocol to include the principal investigator, sponsor, associate investigator, research nurse, and data manager; and to implement new practices when developing protocols, collecting, managing, and analyzing data, conducting data audits, and reporting clinical trial data. The content is presented over two and a half days using local and regional experts in the field as speakers. A three-level evaluation program has been instituted to provide ongoing quality improvement for the program. Participants evaluate the speakers and the program. Knowledge acquisition is evaluated with a pre-post test design, and an outcome evaluation has been developed for participants to self assess application of the content into their research nurse practice. The outcome evaluation consists of participants establishing practice goals during the program. They are contacted three months after completion of the program to evaluate their progress in meeting their goals. This poster will present the program development process, the curriculum of the program, and the results of evaluations, including the findings of the outcome evaluation. The development of an educational program for the oncology research nurse at the NCI has helped to improve patient outcomes, establish standards based on good clinical practice guidelines, expand the expertise of the oncology research nurse, and provide a foundation for clinical research excellence. 194 Baccalaureate level nursing curriculum has limited cancer nursing content,
which diminishes the attractiveness of the oncology specialty to new graduate
nurses. The Massachusetts General Hospital (MGH) nursing leadership team
developed and implemented a program that creates an opportunity for nursing
students to observe and practice with expert nurse clinicians in the MGH
cancer center. The MGH cancer nursing fellowship is a ten-week, paid,
precepted clinical experience, designed to enhance interest in and commitment
to oncology nursing as a substantive area of practice. Developing an orientation and practice revalidation program is challenging and exciting. New employees need a comprehensive orientation program that makes them feel confident in providing care to patients with a wide variety of disease processes and complex needs. While it is important to standardize an orientation program for new nurses, the program must be flexible enough to provide opportunities for experienced nurses to build on their existing knowledge and skill base. After completion of an orientation program, staff evaluations alone may not be adequate to assess current competency levels. Therefore, an annual revalidation program with a focus on education and staff development is vital to maintain practice standards within the clinical setting. The purpose of this project was to update the current orientation program and to create a practice revalidation program. An orientation manual is used to guide the preceptors and preceptees through the orientation process. Pediatric program of care competencies are completed during orientation. From this list, specific competencies were chosen for annual revalidation. The annual revalidation program is completed after staff answer a written questionnaire showing knowledge, demonstrate selected skills, and participate in a peer discussion that demonstrates critical thinking skills related to unit specific case scenarios. Demonstration of clinical competence is an ongoing process. With changing technology and treatment regimens, clinical nurses will continually have the opportunity to enhance their skills and knowledge. Developing a detailed orientation program and practice-based revalidation program in the clinical setting promotes excellence in clinical skills and clinical care. 196 Significance: The shift to using evidence-based practice (EBP) to guide
clinical decision-making meets major obstacles when applied at the unit
level. Barriers include lack of an organized approach, access to literature,
inexperience with synthesizing evidence, and time. Nevertheless, nursing
needs to critique clinical practices in the light of available clinical
information based on research and guidelines. 197 The role of the research nurse in clinical trials is essential in ensuring adherence to principles of good clinical practice. Research nurses at the National Cancer Institute in Bethesda, MD, recognized their pivotal role in research, and the need for formal integration of research concepts with successive levels of mastery and clinical competencies. In 1996, the research nurse position description (PD) was reviewed and upgraded to reflect three distinct levels of practice: novice, intermediate, and advanced. Skill sets were abstracted from each PD creating a single skill inventory, clearly delineating the characteristics of high performance. The inventory provides a basis to develop educational programs and outcome measures, to support administrative program decisions, and to help staff focus their career and educational objectives. The Research Nurse Skill Inventory Matrix displays performance expectations for the research nurse |