2002 Congress Abstracts

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END OF LIFE (EOL) NURSING EDUCATION CONSORTIUM (ELNEC). Rose Virani, RNc, MHA, OCN^®, Betty R. Ferrell, PhD, FAAN, and Marcia Grant, DNSc, FAAN, City of Hope National Medical Center, Duarte, CA.

Previous research has demonstrated that nursing education has not prepared nurses to provide optimum EOL care; and yet, care of patients at the EOL is contingent on adequate preparation of healthcare providers. To date, there has not been a unified or organized effort to broadly address the preparation of nurses in EOL care. The purpose of this Robert Wood Johnson Foundation-funded project (2000–2003) is to develop and implement a comprehensive national effort to improve EOL care by nurses through a joint collaboration between the American Association of Colleges of Nursing (AACN) and the City of Hope Cancer Center. Based on the AACN “Peaceful Death” document, the ELNEC curriculum focuses on nine EOL core areas: nursing care at EOL; pain management; symptom management; ethical/legal issues; cultural considerations; communication; grief, loss, and bereavement; preparation and care for the time of death; and achieving quality care at the EOL. This project is a synthesis of research and knowledge in EOL care and is intended to assist clinical nurses with implementing scientifically based care in practice. Eight national training courses follow the development of the core training curriculum to enhance EOL expertise in faculty in undergraduate nursing programs (five courses) as well as in continuing education programs (two courses) and the National Council of State Boards of Nursing, Inc. staff and state boards (one course). Development of the ELNEC program includes detailed teaching materials to integrate EOL content into existing nursing curricula and clinical teaching. The projected outreach is to 135,000 registered nurses who will receive EOL training/education through schools’ or agencies’ educational programs as a result of these eight training programs. This presentation will provide description of evaluation methods as well as preliminary results for the five undergraduate courses: standard course evaluation summaries; curriculum surveys conducted pre-course and at 12 months; and participant goals conducted pre-course, immediate post-course, and at six and 12 month post course. This national organized effort is a major step toward preparing nurses in EOL care to improve care of the dying.

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IMPROVING CARDIOPULMONARY RESUSCITATION SERVICES IN A COMPREHENSIVE CANCER CENTER. Karen Jones, RN, MS, CPHQ, Shawn Elliott, RNC, MSN, CNS, and Beverly Nelson, RN, MS, University of Texas M.D. Anderson Cancer Center, Houston, TX.

The management of cardiopulmonary resuscitation (CPR) is challenging in a comprehensive cancer center. Most patients who arrest are experiencing end-stage disease and multi-system failure. Therefore, post-code survival is generally poor. Even so, MDACC is committed to continuously improving CPR services.
In 1999, anecdotal reports suggested possible problems related to timeliness of code blue team response. At the same time, JCAHO published new standards requiring effective CPR services and outcome measurements.
A multidisciplinary team was formed whose first accomplishment was to map the code blue process in order to identify problematic areas. The document revealed process steps, participating disciplines, functions with unclear assignment of responsibility, and delays in the process.
The JCAHO standards and process map were used to develop an aim statement and establish priorities.
The MDACC outcome and process measures developed by the multidisciplinary team were derived from the “In-Hospital ‘Utstein Style’” guidelines recommended by the American Heart Association (AHA). The key measures led to the development of data collection tools, specifically, the Code Blue Documentation form, the CPR QI Data Collection Tool, and the Post-Code Blue Evaluation survey. The first two instruments provided objective data and the latter tool provided qualitative information about the code.
We have experienced numerous improvements to date. The response processes have been expedited using new pagers and an improved paging system. Code team membership was expanded to include the police to direct the responders, a chaplain to support the family, and a phlebotomist to hand carry specimens for immediate processing. All crash carts were replaced and contents were updated to meet standards. An orientation program for the code team was developed. We established our status as an AHA community CPR training center to increase our ACLS and PALS certified personnel. Finally, AEDs have been placed throughout the institution in non-patient care areas.
Our quarterly data reveal that our post-CPR survival rate remains stable, the response time appears to have improved, and implementing ACLS guidelines is more consistent. Following the dissemination of outcome information, the number of post-code DNR designations increased to ninety-one percent (91%).

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EVALUATION OF LEADERSHIP STRATEGIES UTILIZED WHEN COMBINING TWO POPULATIONS OF CRITICAL CANCER PATIENTS. Laura Espinosa, RN, MSN, CS, and Cynthia Segal, RN, MSN, CNOR, University of Texas M.D. Anderson Cancer Center, Houston, TX.

In December of 1999, the combination of two distinct cancer patient populations in the critical care units (CCU) of The University of Texas M.D. Anderson Cancer Center (MDA) required special attention and leadership skills. Historically, the surgical intensive care (SICU) and medical surgical care (MICU) units were managed and located on separate floors. As MDA embarked on the utilization of a group of critical care physicians for medical management of the 42-bed CCU, the challenge for cancer nurses was to unify and enlist a true sense of teamwork among these very clinically different and once separate services. Using Deming’s theory of teamwork as a conceptual framework for the combination of these two units, unique management skills balanced the staff’s strengths and weaknesses.
Initially, the name was changed from SICU and MICU to critical care unit (CCU). A nurse manager was hired to lead the unification of the units. With her goal of providing 24-hour management leadership, the single assistant nurse manager (ANM) position was increased by three, while clinical expertise was supported with two clinical nurse specialists (CNS). Agency nurse utilization was eliminated through aggressive hiring to meet core staff levels. Professional teambuilding consultants were enlisted to create a shared vision and mission for the CCU. Subsequent teambuilding events were directed toward establishing common rules and a mutual language to gain a collective CCU ownership and pride.
The impact of two years of teamwork resulted in a significant reduction of personnel turnover rates in the CCU. The 1999 CCU separation rate reduced from 16.6% to the 12.5% in 2000.
Moreover, the CCU internal personnel transfer rates decreased from 17.7% in 1999 to 8.9% in 2000. Total personnel cost was decreased by $95.00 per patient day. Additionally, the average variable cost per patient day has decreased by $90.00 per patient day.
A shared vision, common patient goal, teamwork, and collaboration created a successful environment in which to care for the critically ill cancer patient.

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UTILIZING JCAHO STANDARDS TO ACHIEVE PAIN MANAGEMENT. Kristin Feldkamp, BSN, RN, and Barbara Schroeder, MS, RN, Mayo Clinic, Rochester, MN.

Despite the availability of highly effective therapies for pain, research suggests that 42% of cancer patients do not receive adequate treatment of their pain. Their fear of pain is so great that 69% report they would consider suicide if their pain reached unacceptable levels. Although patients are highly motivated to seek out effective pain management, personal barriers often hinder them. After evaluating the current practice on a large medical center’s oncology unit, it was found that patients using opioids often fear possible addiction, side effects, and appearing “weak” or “bothersome” when asking for pain medications. Though nursing staff verbally reassured patients and families about misconceptions and concerns, no written pain education materials were consistently provided. To address these concerns, a two-goal project was formulated.
To enhance effective pain management communication between nurses and patients, an educational card was developed. The key components of this card, taken directly from the Joint Commission on Accreditation of Healthcare Organization’s 2001 pain standards, explains the rights and responsibilities of the patient concerning pain management and includes the numeric, facial, and color pain scales. These pain scales were also laminated and placed in each patient’s room.
To assist in providing a more comprehensive educational resource, Pain Control, A Guide for People with Cancer and their Families was used to address barriers patients have to taking pain medication and non-drug therapies for pain management.
To evaluate outcomes, a pre-pilot audit was done on 30 charts to assess patient pain scale ratings on admission and discharge and nursing interventions. During the pilot, nearly 70% of nurses stated that the materials led to further discussion with their patients. They also felt patients were more willing and able to rate their pain due to the posting of the pain scales. A post implementation chart audit revealed increased utilization of educational resources and a decrease in patient-reported pain levels.
The importance of controlling cancer pain merits high priority. This project has demonstrated that patient education may decrease patient barriers, resulting in pain being more effectively treated.
This produces a higher quality of life for each patient.

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HEALING TOUCH AND REIKI: INDEPENDENT NURSING FUNCTIONS TO SUPPORT CANCER PATIENTS. Cynthia A. Teague, RN, BSN, CPON, University of Texas M.D. Anderson Cancer Center, Houston, TX.

Touch therapies have been used for centuries to relax patients and promote healing. Therapeutic touch, from which many aspects of Healing Touch are derived, was formally introduced into nursing in the early 70’s by Delores Kreiger. She developed a research base, and taught nurses to use therapeutic touch to balance the body’s energy field and restore harmony, allowing the patient to heal.
Reiki (ray-kee) is an ancient Japanese form of energy healing with the primary purpose of restoring the balance in the body to promote the individual’s ability to heal. Both of these techniques are considered forms of energy healing. Theoretical work in energy healing was pioneered in nursing by Martha Rogers who described the body as an energy field in interaction with other energy fields and the global energy field. Although these therapies are ancient, the research base for them is still in its infancy. Benor (1993) reviewed 155 studies on energy healing and concluded that energy healing can be an effective treatment, especially for immune compromised conditions.
Healing touch has traditionally been a primarily nurse-initiated intervention and Reiki is becoming almost as popular among nurses who espouse energy healing. These therapies have been used with patients of all ages, including children, with a minimum effect of calming the patients, decreasing pulse rate, and increasing skin temperature. The stress reduction effect has obvious implications for cancer patients who experience stress-provoking events from diagnosis through the treatment and outcomes period. Of these therapies, healing touch and Reiki have the greatest potential as noninvasive techniques to be used on a regular basis by the clinical nurses as they provide daily care to the patient. This presentation will include an overview of Reiki and Healing Touch including the underlying tenets, available research to support its use, the techniques involved, and future directions.

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REIKI TREATMENTS FOR PEOPLE LIVING WITH CANCER. Larraine M. Bossi, RN, MS, CS, Children’s Hospital, Boston, MA; Susan DeCristofaro, RN, MS, OCN^®, and Mary Jane Ott, RN, MN, MEd, CS, Dana-Farber Cancer Institute, Boston, MA.

Background: Reiki is a healing method that uses “laying on of hands” in a precise method that connects the universal energy with the body’s innate power to heal. The goal of a Reiki treatment is to restore the harmonious balance of mind, body, and spirit. Reiki has been used with both adult and pediatric populations to achieve improved quality of life. Published reports describe the benefits of Reiki, including improvement in post-surgery pain.
Program: Reiki treatments have been integrated into the care of cancer patients at our institution, an NCI-designated comprehensive cancer center. Patients, who receive both standard and experimental cancer therapies, are generally self-referred for the Reiki and pay out-of-pocket. Attending physicians are notified about the scheduled treatments, allowing for dialogue with the Reiki practitioner. The treatment sessions take place in private clinic rooms and last 45–60 minutes, which differ from shorter, more impromptu Reiki treatments that may be offered during routine nursing care. Often these treatments are scheduled just before or after scheduled radiation therapy, chemotherapy, or a procedure. Description of the Reiki treatments, patient symptoms, and functional level are documented in the medical record.
Evaluation: Between November 2000 and July 2001, 82+ Reiki sessions were provided. Women utilized this service more than men (93% versus 7%), and most referrals (over 80%) were for symptom management. There were no reported side effects from any Reiki treatments. However there were many benefits that were voiced and documented: decreased pain and increased mobility with peripheral neuropathy; improved sleep patterns; and decreased anxiety about treatment options, helping with decision-making. Patients reported immediate results as well as some changes noticed hours after treatment. A formalized evaluation tool was implemented in August 2001 to provide additional descriptive data about the Reiki treatments.
Discussion: Reiki is safe and appears to provide symptom relief in many cancer patients. Many cancer patients are seeking out this alternative treatment that can be easily learned by oncology nurses and readily integrated into their practice. Reiki is another tool for oncology nurses to use as they care for and comfort cancer patients.

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PATH TO HEALING WITH CANCER: AN INNOVATIVE SUPPORTIVE GROUP USING EXPRESSIVE AND CREATIVE THERAPIES, MEDITATION, AND MASSAGE. Martha W. Healey, RN, MSN, FNP, Susan Bauer-Wu, DNSc, RN, Dana-Farber Cancer Institute, Boston, MA; and Elana Rosenbaum, MS, MSW, LICSW, University of Massachusetts Medical School, Worcester, MA.

Background: Many cancer survivors want to learn new tools to enhance their recovery and live well beyond cancer. Studies have documented the benefits of support groups, mind-body techniques, massage, and expressive therapies. Traditionally these different interventions have been offered separately to patients, rather than integrating them within one therapeutic format. Recognizing the value of each of these interventions, coupled by patients’ requests for “more than a typical support group,” an innovative “supportive” group, Path to Healing With Cancer (PHWC), was created.
Intervention: PHWC is a monthly group for persons with cancer. Two healthcare professionals facilitate the group; one, an advanced practice oncology nurse with training and experience in expressive therapies and meditation, the other, a clinical social worker who is also a cancer survivor and meditation instructor. The group, held at Hope Lodge, an American Cancer Society “home-away from home” for cancer patients, takes place from 6–9 pm. Cancer patients in the community as well as those at Hope Lodge attend. The evening combines guided meditation, gentle body movement, art, writing, and dialogue. Each session has a theme, usually consistent with the seasons (i.e., “planting our seeds and blossoming”). After two hours, massage, Reiki, and reflexology are offered, without charge, by certified professionals who volunteer their services. The evening ends with informal sharing and light refreshments.
Evaluation: Since its inception in December 1999, the group has grown with approximately 12 participants each month, many coming since its inception. Some participants travel over an hour to attend this group. Although formal evaluations have not been conducted, consistent participation and verbal feedback are indicative of its benefits: “This is the one thing I do for myself each month that I never want to miss.” “This group gives me strength and peace of mind more than any other group I’ve attended.”
Interpretation: Success of this innovative group is evident. Cancer patients are seeking group interventions that incorporate various integrative therapies to enhance their recovery. PHWC is a unique group and provides a model for oncology nurses and other professionals to refer or offer such programs to complement the care of their cancer patients.

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OUTCOMES OF A SLEEP INTERVENTION FOLLOWING ADJUVANT CHEMOTHERAPY. Ann M. Berger, PhD, RN, AOCN^®, University of Nebraska College of Nursing, Omaha, NE; Patti Higginbotham, MS, RN, OCN^®, Wings of Hope Cancer Center, Council Bluffs, IA; Susanna VonEssen, MD, MPH, UNMC-Pulmonary, Omaha, NE; Brett Kuhn, PhD, UNMC-MMI, Omaha, NE; Barbara Piper, DNS, RN, AOCN^®, FAAN, UNMC-CON, Omaha, NE; and Sangeeta Agrawal, MSc, UNMC-CON, Omaha, NE.

Significance: Fatigue and difficulty sleeping are frequent and distressing symptoms in women during and following adjuvant breast cancer chemotherapy (ABCC). Poor sleep adversely affects daytime activity and mood and leads to more intense and distressing symptom clusters. Interventions need to be tested to modify sleep and fatigue and promote recovery following ABCC.
Problem and Purpose: There is a high prevalence of fatigue and insomnia in women treated with ABCC. This study examined the outcomes of a sleep intervention consisting of sleep hygiene counseling, relaxation therapy, sleep curtailment, and stimulus control methods following ABCC.
Theoretical Framework: Components of Piper’s Integrated Fatigue Model (innate host factors, patterns of sleep/wake, activity/exercise).
Methods: A prospective, repeated measures design was used for this feasibility study developed by a multi-disciplinary team. Caucasian women (N = 21) had surgery for stage I or II breast cancer followed by adriamycin-based chemotherapy (eight also had Taxol, 10 had radiation, 18 were taking Tamoxifen). They had no unstable co-morbidities, they were between the ages of 43–66 (X = 55.3), most of them had some post-secondary education, and most were married and employed. Reliable and valid instruments were used: Daily Diary, Pittsburgh Sleep Quality Index (PSQI), wrist actigraphs, and Piper Fatigue Scale (PFS). An Individual Sleep Promotion Plan (ISPP) was negotiated by the researcher and each woman at 30, 60, and 90 days after the last chemotherapy dose, and reinforced one week later. Follow-up occurred one year after the first treatment.
Data Analysis: Epi-Info, Action 3, and SPSS data programs.
Findings/Implications: Latency, time wake after sleep onset (WASO), sleep efficiency, total rest and feelings upon awakening data (diary & PSQI) demonstrated wide ranges, with means within normal limits for all except WASO. Actigraphic measures of mean activity (mesor and amplitude) slowly and steadily returned to normal by one year. Actigraphic measures revealed frequent (10–11) awakenings/night at early measures and less frequent (8.8) at one year. Fatigue (PFS) ranged from 3.2–3.4 early, and was down to 2.87 at one year. The intervention assisted in promoting activity, obtaining quality sleep, and keeping fatigue levels mild. Reductions in the time WASO are needed and will be tested using an experimental design and a larger sample.

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NURSES CARING FOR THE SPIRIT: CANCER PATIENT AND FAMILY CAREGIVER EXPECTATIONS. Elizabeth Johnston Taylor, PhD, RN, Loma Linda University School of Nursing, Loma Linda, CA.
Oncology nurses are increasingly expected to provide spiritual care to their clients. Research findings underscore the need for nurturing client spiritual health, especially for cancer care recipients. Yet scanty and outdated evidence exists to document what spiritual care giving cancer patients and their family members expect from nurses. Understanding client perceptions can help oncology nurses to inoffensively and effectively provide spiritual care. One purpose of this cross-sectional, descriptive, qualitative study was to describe, from the perspective of patients and family caregivers, what are their expectations of nurses regarding having spiritual needs addressed. Conceptually, this investigation was influenced by several scholars (especially, Reed, Frankl, and Travelbee) who have theorized about how and why spirituality is important when living with a health challenge, and Clinebell who identified categories of spiritual need. Methods for collecting data included conducting audio-tape-recorded semi-structured interviews with 27 white or black cancer patients and family caregivers. Concurrent data analysis of transcribed interviews followed Miles and Huberman’s approach to content analysis which includes data reduction (coding), data display (categorizing themes after constant comparative analysis), and verification. Results suggest a continuum of client responses regarding nurses providing spiritual care. This continuum was anchored by those who expressed open receptivity to nurses caring overtly for their spiritual health and by others who were adamant that a nurse should not meddle with client spiritual needs. Negative responses to nurses providing spiritual care often reflected confusion about any difference between spirituality and religiosity (e.g., informants frequently equated spiritual care with nurses initiating religious conversation or rituals). Findings also include nursing approaches identified by informants that would “boost the spirit,” as well as those that informants perceived would not be helpful or even harmful. These results offer client perceptions about the role and practices of nurses regarding spiritual care. With these findings, nurses can be sensitive and informed while offering spiritual care. Nursing spiritual assessments, indeed, may need to include an assessment of client perceptions about nurses providing spiritual care. Client perceptions of what is spiritual care may need to be reshaped prior to any overt spiritual assessment or care activities. (Funded by the Oncology Nursing Foundation/Glaxo Wellcome Oncology Small Research Grant.)

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WHY HAVEN’T YOU GONE BACK? PREDICTORS OF NOT RETURNING FOR DIAGNOSTIC FOLLOW-UP AFTER AN ABNORMAL MAMMOGRAM. Alexis Bakos, PhD, MPH, RN, C, National Cancer Institute, Bethesda, MD.

Mammography is one of the most important means of breast cancer screening. It is estimated that as many as 60% of the women who have an abnormal mammogram do not return for further medical evaluation. The purpose of this study was to determine factors related to a woman’s decision to obtain appropriate diagnostic follow-up after an abnormal screening mammogram. Cox’s Interaction Model of Client Health Behavior was used as a conceptual framework to identify key predictor variables that are elements of client singularity and client-professional interaction. The study used a retrospective design. A convenience sample of 243 women with abnormal mammograms from two urban university medical centers was invited to participate in the study. The study sample included 75 women. Forty-four women who returned for diagnostic follow-up and 31 women who had not returned were interviewed using a telephone survey method to determine which variables predicted follow-up and most accurately classified women into either category. The ages of the women ranged from 29–85 years with a mean age of 52 (SD = 11) and 89% of the women were African American. A majority of women (69%) had insurance coverage for their mammogram. Telephone interviews assessed demographic variables (including social influences, previous healthcare experience, and environmental resources), cancer fatalism (Powe Fatalism Inventory, alpha = .88), anxiety (Trait Anxiety Inventory, alpha = .91), depression (Beck Depression Inventory, alpha = unstable estimate), perceived cancer screening experience (Screening Satisfaction Scale, alpha = .76), and mammography induced pain (Painometer-Words, internal consistency reliability = n/a). Data were analyzed using chi-square, ANOVA, and logistic regression to aid in prediction. The results suggest that women who had greater cancer fatalism and depression, experienced less mammography induced pain, were age 50 years or younger, and had less perceived breast cancer risk, had significantly greater odds of not returning for diagnostic follow-up (model chi-square = 47.94, df = 10, p = .000). The logistic regression model correctly classified 81% of the women on the outcome variable. The findings can be used by nurses in cancer detection to increase awareness of those at risk for not returning and test suggested intervention strategies to improve diagnostic follow-up after an abnormal screening mammogram.

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PHYSICAL AND PSYCHOLOGICAL HEALTH OUTCOMES IN PATIENTS WITH CANCER PARTICIPATING IN A STRUCTURED EXERCISE PROGRAM. Stacey Young-McCaughan, RN, PhD, AOCN^®, U.S. Army Medical Research & Materiel Command, Fort Detrick, MD; Stacey Dramiga, MA, Brooke Army Medical Center, San Antonio, TX; Linda Yoder, RN, MBA, PhD, AOCN^®, Walter Reed Army Medical Center, Washington, DC; John Caton, Jr., MD, Sonya Huizar, BS, Geneva Foundation, San Antonio, TX; and Mary Mays, PhD, Eagle Creek Research Services.

Problem & Purpose: Recent research studies that have investigated exercise rehabilitation in patients with cancer have documented dramatic improvements in physiological and psychological functioning. The purpose of this study was to investigate the capability of an exercise program patterned after a phase II cardiac rehabilitation program to improve selected physiological and psychological parameters of health in patients with cancer.
Theoretical Framework: The Roy Adaptation Model was the framework used for this study.
Methods: This prospective, repeated measures study enrolled 62 patients diagnosed with cancer within the previous two years into a structured exercise program patterned after a phase II cardiac rehabilitation program. Subjects met two days each week for 12 weeks for exercise and education. The dependent study variables were changed over time in exercise tolerance as measured with a graded exercise test, activity and rest patterns as measured with a wrist actigraph, and quality of life as measured with the CARES-SF.
Data Analysis: Descriptive statistics and repeated-measures analysis of variance were used to analyze the data.
Findings: Half of the participants were male and half female. Subjects were predominantly Caucasian, married, and well-educated, with almost three-quarters of the sample having college preparation. Ages of participants ranged from 24–83 (mean = 59). Participants had a wide range of cancer diagnoses. Most subjects had early stage I or II disease. Seventeen subjects were undergoing treatment when they were enrolled into the study. More than half of the subjects exercised prior to their cancer diagnosis, however, fewer than half of these patients were able to resume an exercise routine following their cancer diagnosis. Forty-six subjects were able to complete the 12-week exercise protocol. Significant improvements were observed over time in exercise tolerance and quality of life (p < .05). Completed analyses will include an examination of sleep indices.
Implications: These findings indicate that patients with various types and stages of cancer can safely exercise using a cardiac rehabilitation model and that significant improvements in exercise tolerance and quality of life can be realized in this patient population.
(Funded by the Department of Defense TriService Nursing Research Program N98-051.)

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CARING FOR THE DYING: DEVELOPING NEW NURSES TO FACE THE CHALLENGE. Caryl Fulcher, MSN, RN, CS, and Sheree Dunn, RN, Clinical Nurse IV, Duke University Health Systems, Durham, NC.

One of the experiences most feared by new nurses is that of caring for dying patients and their families. Often their nursing school experience has been limited in this area, and their curriculum content may have been minimal as well. Because death is so feared by many in our society, and because it is associated with so many personal, cultural, and spiritual beliefs, many new nurses have not taken the opportunity to reflect on their own loss history and its impact on their developing philosophy. The purpose of this project is to assist new oncology nurses to develop comfort and skills necessary to provide sensitive end-of-life care.
In an attempt to assess the perceptions, the new graduate nurse brings to clinical practice a 12-item questionnaire entitled, “How Do I Really Feel About the Person Who Is Dying?” which was completed during the orientation period by the eleven graduate nurses enrolled in an oncology nurse internship program. The responses from the questionnaire guide the assigned advanced practice nurse mentors to discuss fears or biases and “process” actual clinical experiences with patients and families to create a helpful learning experience. In addition to this nurse-mentor discussion, didactic content on grief and loss is presented. It is well known that nurses who work closely with dying patients are at high risk for grief reactions and burnout, so resources available to support the nurse are specifically identified. As a means of evaluation, the questionnaire will be repeated after the nurse has practiced for eight months to see if the concerns expressed have changed to indicate more comfort with end-of-life care. Remaining gaps can then be addressed in an effort to aid nurse development and also retention.

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THE LONG AND WINDING ROAD OF THE ADVANCED PRACTICE NURSE (APN): INTEGRATING PALLIATIVE CARE EARLY IN CANCER TREATMENT. Rose Anne Indelicato, RN, MSN, CS, ANP, OCN^®, Jean Adelhardt, RN, MA, Candace Coggins, CARN, MS, MA, NP, and Jackie Levin, RN, MS, HNC, CHTP, Beth Israel Medical Center, New York, NY.
Topic: Palliative care can provide physical, psychological, and spiritual support for patients and caregivers at every stage of cancer treatment. At present, however, the need for palliative care often goes unnoticed until patients become terminally ill. This presentation will highlight how one facility has incorporated the unique talents of a group of advanced practice nurses (APNs) in the provision of comprehensive palliative care across many clinical settings and stages of disease.
Rationale: The ONS position paper asserts that “APNs are a vital component of the healthcare team that provides care to patients with cancer, and the role is essential to providing cost-effective, quality care for diverse populations.”
Interventions: We will describe the multi-faceted roles of APNs in a department of pain medicine and palliative care (DPMPC) at a 710-bed lower Manhattan hospital with a diverse patient population. In addition to education and research, APN clinical activities include DPMPC clinic sessions (NP and CNS), outpatient cancer and fatigue centers, telephone-based case management, and providing continuity of care between active cancer treatment and end-of-life care through hospice. We will highlight the APN in the provision of palliative care early in the course of disease by illustrating areas of clinician expertise in pain and symptom management, home care, hospice, psychiatric nursing, chemical dependency, and complementary/alternative medicine (CAM) therapies. We will discuss barriers faced in providing palliative care such as reimbursement issues, provider limited expertise in symptom management, and lack of comfort in discussing advance directives and goal of care; patient/caregiver equating palliative care with “suboptimal” care; the inconsistencies between cultural/religious beliefs and the ability to offer quality symptom control. Through case presentations, we will show the impact that APNs can have on implementing early palliative care.
Interpretation/Discussion: APNs are poised to bring palliative care into patient management early in the cancer trajectory. Patients and caregivers can be better served if oncology nurses communicate, from the start, that palliative care, with its focus on quality of life, is as essential to ongoing patient care as is treatment for the underlying disease.

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LIVING WITH DYING: SPIRITUALITY AT THE END OF LIFE. Pamela Shockey Stephenson, RN, MSN, CS, OCN^®, CHPN, Forum Health Cancer Care Center, Warren, OH.

Little is known about the experience of spirituality in the lives of hospice patients despite the fact that it is during the end of life that spiritual development is thought to be of central concern to patients. Nurses report feeling unprepared to address spiritual needs because they lack an understanding of the meaning of spirituality in the lives of hospice patients (Taylor, Highfield, & Amenta, 1999).
This study used interpretive phenomenology to explore the experience of spirituality from the perspective of the hospice patient (Benner, 1994). Unstructured, in-depth interviews, during which participants were asked to describe the experience of spirituality in their lives were conducted with six hospice patients. A four-member interpretive team analyzed the data using the strategies outlined by Diekelmann, Allen, and Tanner (1989).
All the participants shared stories about spirituality and dying that were consistent with their views about spirituality throughout their lives. They did not demonstrate any significant spiritual transformations when they learned they were dying.
Two sub-themes emerged from the data which indicated what issues were most important to the participants as death approached. The first sub-theme of “who is in charge” reflected the participants’ consistency regarding who was in charge of their life, illness, and dying, be it themselves and/or God. The second sub-theme of “connecting and disconnecting” revealed the importance of joining with either other humans and/or God throughout life and in death.
The participants’ expectation of nurses was not to participate in spiritual tasks or to engage in in-depth spiritual dialogue, but to reinforce their sense of spirituality, to display the “good” qualities of humankind. These findings suggest that nurses should respect the patients struggle to determine who is in charge and, rather than perform “spiritual tasks,” and provide a meaningful connection to the dying patient.

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TEACHING END-OF-LIFE: MULTIMEDIA TOOLKIT FOR NURSING. Diana J. Wilkie, PhD, RN, FAAN, University of Washington, Seattle, WA; M. Kay M. Judge, EdD, RN, University of Washington and Nursing Consult, LTD., Seattle, WA; and Stuart J. Farber, MD, University of Washington, Seattle, WA.

Most nursing programs lack sufficient palliative care content meaning that nursing students may have insufficient knowledge to provide high-quality care for people facing death. A solution to this problem is for a team of interdisciplinary, end-of-life experts to create tools that can be used by nurse educators in academic and clinical settings. TNEEL (Tool-Kit for Nursing Excellence at End-of-Life Transition) provides nurse educators with such a solution. TNEEL, a CD-ROM-based program, is an easy-to-access, user-friendly package of tools to teach palliative care. Multiple teaching strategies are included in this evidence-based, multimedia toolkit of instructional aids. Educators can use these tools to engage students in meaningful learning activities. TNEEL includes six core end-of-life care topics: Comfort goals and preferences including assessment and management of pain and other symptoms; ethical and legal decision-making; connections (communications and relationships supporting patient and family-centered care); grief loss and bereavement; well-being (hope, suffering, complementary comfort therapies, spiritual and psychosocial needs); and impact (the impact of end-of-life care on patients, families, and society). Within each of these topics, the TNEEL teaching portfolio includes: student learning objectives; pre- and post-assessment items; common myths and misconceptions, definitions of terms; teaching materials (lecture outlines and text materials); PowerPoint™ slides with speaker/instructor notes using multimedia (video, audio, graphics) to illustrate learning activities; case studies for problem-based learning; learning activities that promote critical thinking; and resources (references, bibliographies, web resources, movies, books, arts). Core concepts are woven throughout TNEEL including individual and cultural diversity, family centered care across the lifespan, interdisciplinary collaborative care, settings and systems of care, and values and attitudes. TNEEL gives nurse educators access to electronic teaching aides that will meet their needs and preferences. With future advances such as hand-held and bedside computers, TNEEL could mentor students in effective end-of-life care when and where they need it most—with vulnerable individuals and families facing end-of-life transitions. TNEEL will be delivered, free of charge, to every academic nursing program and to 1,000 clinical agencies as a gift from the Robert Wood Johnson Foundation. This presentation will orient nurses to TNEEL’s innovations and benefits.

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DEVELOPMENT OF A BREAST CANCER RISK ASSESSMENT PROGRAM. Laurel Snyder, RN, MS, National Naval Medical Center, Bethesda, MD; Lynda L. Lahl, RN, MS, National Cancer Institute, Bethesda, MD; Michele Nehrebecky, RN, CRNP, National Cancer Institute, Bethesda, MD; Peter Soballe, MC, USN, U.S. Navy, Bethesda, MD; and Pamela Klein, MD, Genentech, Inc., South San Francisco, CA.

Advances in the chemoprevention of breast cancer over the last five years have given women at high risk management options for the first time. Results from the Breast Cancer Prevention Trial (BCPT) clearly demonstrated that tamoxifen, a selective estrogen receptor modulator (SERM), could reduce breast cancer by 50%. The FDA approval of tamoxifen in 1997 for use in prevention challenged providers to identify women who might benefit from tamoxifen, as well as those women in which the risks outweigh the benefits.
The Breast Care Center at the National Naval Medical Center is a multidisciplinary facility jointly run by the National Cancer Institute and the Navy. In response to the numerous requests for prevention information after the results of the BCPT were released, a breast cancer education session and risk assessment program was developed. The intention was to provide patients with general information about breast cancer, risk assessment, and prevention. It was anticipated that there would be an increased need within the clinic for healthcare providers to discuss options available to women not only at increased risk for breast cancer, but for those individuals looking for overall breast cancer prevention information. There was a concern that many of the providers would be unable to adequately discuss this information with the patients in both a timely and efficient manner.
Since the implementation of the bi-monthly education program in March 1999, the session has effectively provided baseline information on breast cancer, risks, prevention options, clinical trials, and information regarding their personal risk of breast cancer. This has allowed more appropriate triage for the high-risk patients needing further consultation from those patients who just required general information. Patients have provided both verbal and written satisfaction with the information provided in the class and have thus become active participants in their health care. In addition, this baseline information allows for a more focused and time efficient consultation with a provider. This experience suggests that group education may be a viable and acceptable way to bring new advances in breast cancer prevention to large groups of women and their significant others.

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COLON CANCER GET CHECKED PROGRAM: AWARENESS TO ACTION PROGRAM. Sandra J. Donnelly, RN, OCN^®, Nora Katurakes, RN, MSN, OCN^®, and Charlene Marinelli, BSN, OCN^®, Christiana Care Health Services, Wilmington, DE.

Colon cancer is the third most common malignancy and the second leading cause of cancer mortality in the United States. The American Cancer Society (ACS) has estimated 130,200 new cases of colon cancer and 56,300 deaths for the year 2001. Delaware is ranked fifth in the nation for colon deaths. ACS reports that only 17.9% of Delaware men and 24.6% of Delaware women have had a recent fecal occult blood test (FOBT). Annual screening with FOBT can result in a 15%–33% reduction in mortality as reported in clinical trials.
In October 2000, the Christiana Care Cancer Outreach Program (CCCOP) implemented the Colon Cancer: Get Checked Program that includes information about risk factors, prevention guidelines and screening. The program goal is to screen 250 men and women who are age 50 years and older by March 2002. CCCOP message is “Take Four Easy Steps for a Colon Check”: 1) Learn about it, 2) Decide to get tested, 3) Get a test kit, and 4) Talk about the results. An 11-item tool is used to determine average or high-risk and eligibility for a FOBT kit. A group of 15 men, mostly African-American over the age of 50, piloted this program including review of the promotional flyer, risk assessment tool, and kit instructions. Revisions were made based on the findings. An outreach worker recruited participants at 36 community educational events including churches, civic associations, worksites, and health fairs.
Preliminary results as of August 2001 show 53 requested to participate. Three were found to be high-risk and were referred to their physician to discuss a screening plan. Twenty-eight of 50 (average risk) consented to receive kits for testing, and nine have been returned to CCCOP for processing. All returned were negative. A reminder letter was issued to all participants who did not return kits as scheduled. No additional contact was made after this step. The next steps include promoting the program on the Christiana Care Health System web site, analyzing the data from late- and regional-stage disease to help develop a specific outreach plan, and surveying recent participants for feedback about the program’s components.

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THE MAP OF DECISIONS TO DELAY BREAST SYMPTOM EVALUATION. Noreen C. Facione, RN, PhD, University of California, San Francisco, CA; and Peter Facione, PhD, Santa Clara University, Santa Clara, CA.

Problem and Purpose: Early diagnosis and treatment of breast cancer requires women to appraise their self-discovered symptoms as posing the threat of breast cancer and to decide to seek immediate evaluation from a provider. Research has shown that this appraisal and decision process is a reflective judgment process influenced by social and psychological variables.
Theory: This cognitive decision-making process results in a confidence that one is making good judgments about cancer risk. However, the symptom appraisal and decision process itself has not been adequately studied. Cognitive theory grounds this study of women currently experiencing breast symptoms.
Methods: In depth interviews were conducted in the homes of 25 symptomatic women recruited in a community-based study of breast health behavior. The sample women were Latino (36%), Black (16%), and White (48%). They ranged in age from 24–72 years (mean = 40.0 years, sd = 16.5), and varied across income levels.
Analysis: This study used two analytical methods (content and argument analysis) to analyze the content and the reasoning process in these interviews. Decision maps were then constructed to display the thinking processes involved in each woman’s symptom appraisal and to display each woman’s decision about whether or when to seek evaluation. The 25 decision maps were then compared for similar reasoning patterns.
Findings and Implications for Practice: In five of the interviews, women appraised their symptoms as cancer and sought immediate evaluation. In seven of the other interviews, women attributed their symptoms to cancer and yet were among the 10 (40%) of the women who decided to delay seeking evaluation. The analyzed decision processes and analysis of the aptitudes and knowledge used in these decisions explained women’s appraisal as malignant or benign, and their subsequent decisions to delay, even when they attributed the symptom to breast cancer. The findings suggest new clinical approaches for counseling women about the risk of delaying the evaluation of self-discovered breast symptoms and new media approaches for early cancer detection.

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A PROSPECTIVE STUDY OF PATIENT SENSATIONS AFTER BREAST CANCER SURGERY. Roberta H. Baron, RN, MSN, AOCN^®, Jane V. Fey, MPH, and Kimberly J. Van Zee, MS, MD, Memorial Sloan-Kettering Cancer Center, New York, NY.

Topic: Many breast cancer patients describe distressing postoperative sensations and question if these feelings are normal. This phenomenon remains poorly understood. Few studies have evaluated sensations in patients who had sentinel lymph node biopsy (SLNB) compared to axillary lymph node dissection (ALND). Our study evaluated sensations over time and with different surgical procedures.
Purpose: To evaluate prevalence, severity, and level of distress of sensations at one week (baseline), 3, 6, and 12 months after breast cancer surgery.
Theoretical Framework: This study is based on the University of California San Francisco Symptom Management Model in which careful symptom assessment is a prerequisite for effective symptom management.
Methods: Patients completed the Breast Sensation Assessment Scale (BSAS), an instrument developed by the investigators. The BSAS contains 18 descriptors of breast/axilla sensations. Patients recorded each sensation as present or absent, and if present, rated it on severity and level of distress. The BSAS demonstrated good reliability and validity in our previous studies.
Data Analysis: Prevalence, severity, and distress of sensations in different populations were compared using Fisher’s Exact Test.
Findings and Implications: 261 patients completed the BSAS at baseline, 3, 6, and 12 months. Surgery included SLNB + Breast Conservation (BCT)(53%), SLNB + Total Mastectomy (TM)(13%), ALND + BCT(20%), and ALND + TM(14%). At baseline, tenderness and soreness were the most prevalent in SLNB and ALND. In SLNB, this remained constant at 3, 6, and 12 months. In ALND, numbness and tightness became the most prevalent at 3, 6, and 12 months and were significantly more severe and distressing (p < .05) when compared to SLNB. Prevalence of phantom breast/nipple sensations in the TM population remained fairly constant. Prevalence at baseline was 38%, 3 months 40%, 6 months 36%, and 12 months (38%). TM patients with tissue expander reconstruction (TE) had significantly more aching and tingling at baseline (p < .05) than those without TE. There was no significant difference in prevalence of sensations at baseline in patients who had SLNB + TE compared to ALND + TE. Certain sensations remain prevalent, severe, and distressing even one year after surgery. This information will help nurses better understand patients’ experiences so they can provide more accurate education before and after surgery.

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A RANDOMIZED TRIAL OF EXERCISE FOR NEWLY DIAGNOSED PATIENTS RECEIVING CHEMOTHERAPY: EFFECTS ON BONE DENSITY AND BODY COMPOSITION. Anna L. Schwartz, PhD, FNP, Marjorie King, MS, C-FNP, Catherine Samson, MPH, Tracy Beil, MS, and Jennifer Holub, MS, Oregon Health & Science University, Portland, OR.

Problem: During chemotherapy, it is common to observe declines in functional ability and muscle strength and increases in body weight. Chemotherapy, particularly doxorubicin or methotrexate in combination with steroids, increases the potential for significant physical decline and predispose patients to osteoporosis. Exercise may be a means of minimizing these negative effects and decreasing risks for long-term treatment-related complications such as osteoporosis and weight gain.
Conceptual Framework: The hypokinetic theory forms the conceptual basis for this study that examines the effects of exercise on bone health, body composition, and functional ability.
Purpose: The purpose of this longitudinal, randomized, repeated measures study was to examine the effects of exercise on functional ability, muscle strength, bone density (BMD), and body composition in newly diagnosed cancer patients beginning chemotherapy with doxorubicin or methotrexate and a steroid.
Methods: 66 newly diagnosed cancer patients (5 males/61 females) beginning chemotherapy regimens were randomized to aerobic exercise (AE) (N = 23), resistance exercise (RE) (N = 22), or usual care control (CG) (N = 21). Exercise subjects were instructed to follow a four-day/week home-based program. All subjects returned for follow-up exercise testing at three-month intervals and bone densitometry scanning (DEXA) of the L-spine and total body at baseline and six months.
Data Analysis: Descriptive analyses and repeated measures analysis of variance were use to examine differences between the groups over time.
Findings: Greater increases in functional ability were observed in the AE (16%) than the RE (9%) or CG (8%). Muscle strength significantly increased in the AE and RE group, and declined in CG (p < .05). The mean decrease in BMD at the L-spine was 4.3% (SD = 4.6, range = -16.4 to 2.9). Significantly less decline in L-spine BMD was observed in AE (-1.6%) compared to RE (-5.3%) and CG (-5.9%) (p<.05, F=4.7). No significant changes in body fat were observed between groups.
Implications: Findings support the idea that AE may reduce the bone-wasting effects of chemotherapy and may assist in maintaining or improving body composition, functional ability, and muscle strength during chemotherapy. These outcomes may be critical to improving quality of life and reducing risks for long-term treatment related side effects.
Funding: NIH R29 NR04945

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CHEMOTHERAPY DOCUMENTATION FORMS: GUIDING PRACTICE AND ASSURING COMPLIANCE WITH ONS GUIDELINES. Kathleen Beaudoin, RN, BSN, and Kristine Rossof, RN, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL.

Chemotherapy administration and documentation is an ongoing challenge for hematology, oncology, and BMT nurses. Our institution utilizes a two-day ONS certification workshop to update chemotherapy drug information and practice for oncology nurses. The ONS encourages the implementation of their guidelines to improve clinical performance and safe patient care. One nurse’s concern for her own documentation practice led her to develop a basic documentation tool, incorporating the guidelines of the ONS teaching manual. The staff nurses were included with a poster presentation and discussion on the use of the form. The nurse manager, clinical pharmacist, and risk manager reviewed the form for input. The form was divided to provide separate notations for initiation, completion, and continuous-infusion chemotherapy. Despite the institution’s practice to house patients receiving intensive, high-dose chemotherapy within the oncology units, the situation does occur requiring nurses outside those units to administration chemotherapy. The documentation tool was therefore evaluated for its usefulness to guide the chemotherapy practice for non-certified nurses, incorporating proper dosing, safety factors, side effects, and patient education. The long-term proposed plan is to distribute the hospital-approved form as part of the chemotherapy kit currently delivered to the nursing unit by pharmacy, promoting consistency of practice hospital wide. The oncology nursing staff immediately acknowledged the usefulness of such a form to improve their individual practice. For the experienced nurse, the tool serves as a reminder for practice and thorough documentation of care delivered. It is an educational tool for the novice oncology nurse and provides for safe chemotherapy administration to nurses administering chemotherapy infrequently. The poster presentation will display the chemotherapy documentation forms, explaining the content necessary on initiation, completion, and for continuous infusion chemotherapy. It is anticipated that documentation of practice will improve on and off the oncology units. This improvement can be evaluated through staff written and verbal feedback and medical record evaluation. The forms could be easily adapted for use in other settings.

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“ATAQ”ING NEUTROPENIA MANAGEMENT. Cathy Mazzone, RN, MS, OCN^®, National Institute on Aging, National Institutes of Health, Baltimore, MD.

Concerns over delays in initiation of a broad-spectrum antibiotic with first fever in the neutropenic cancer patient heightened when this institution began to see an increase in the number of these patients as a result of an increase in the leukemia population. A baseline assessment showed a mean time to initiation of a broad-spectrum antibiotic was five hours, five minutes. Lack of education among the nursing staff was one of several factors identified as influencing this time.
Multiple entries of access to care also contributed. The goal, reached by consensus with outside hematology and infectious disease experts, along with the performance improvement committee, was that a broad-spectrum antibiotic be hung within one hour from the time the fever is documented (inpatient) or from the time the patient arrives at the hospital (outpatient). Re-education of the oncology staff focused on neutropenia management, ANC calculations, and sharing the one-hour goal. Emergency room nursing staff was also included. Next, a first fever order set was developed for use by oncologists. Finally, the performance improvement committee developed business cards that were given to patients at the end of their cycle of treatment that outlined their period of neutropenia, and provided instructions to unfamiliar staff as to the importance of prompt treatment. Patients were instructed to hand the card to the triage nurse in the emergency room when they came with fever. Current performance, two years after the initiative, is a mean time of one hour, twenty minutes to initiation of a broad spectrum antibiotic, including those patients coming through the emergency room. The poster will outline the specifics of the education program, the order set, the business card to be used when visiting the emergency room, along with trending the improvements as these initiatives were implemented.

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DEVELOPING A CONSISTENT, EVIDENCE-BASED APPROACH FOR G-CSF (FILGRASTIM) ADMINISTRATION: IMPLEMENTING A QUALITY IMPROVEMENT PROCESS TO IMPROVE NEUTROPENIA MANAGEMENT. Nancy L. Budzinski, RN, BSN, and Mary Fran Overcash, RN, BSN, Joliet Oncology-Hematology Associates Ltd., Joliet, IL.

The purpose of this clinical practice project was to develop guidelines for hematopoietic colony-stimulating factor (CSF) administration in order to more consistently and effectively manage chemotherapy-induced neutropenia. Joliet Oncology Hematology Associates is a six-physician community oncology practice treating an average of 1,000 outpatients per month. Specialty trained nurses administer chemotherapy and assume a primary role in toxicity assessment and symptom management. Nurses identified that variations in physician practice with respect to myeloid CSF administration resulted in an inconsistent approach to neutropenia management. The nursing staff used a quality improvement approach to address this clinical practice issue. The assessment process began with a retrospective chart review of chemotherapy administration for aggressive NHL (n = 15) and adjuvant breast cancer (n = 20) patients. Data was collected regarding dose delays, dose reductions, use of hematopoietic CSF, and incidence of febrile neutropenia. Analysis of data revealed that neutropenia was one of the primary causes for dose delays and reductions. Inconsistencies in CSF dosing and initiation and duration of therapy were found. The quality improvement plan involved developing a more consistent approach to the use of hematopoietic CSF in the proactive management of neutropenia. Two members of the nursing staff partnered with a physician to draft guidelines for growth factor administration based upon the ASCO 2000 Update of Recommendations for the Use of Hematopoietic Colony-Stimulating Factors. Guidelines addressed the key components of CSF administration such as appropriate dosing by weight, initiation and duration of therapy, frequency of laboratory monitoring, management of bone pain, and patient selection criteria for primary and secondary prophylactic administration. Guidelines were implemented in August 2001 after presentation to all six physicians for input, consensus, and approval. The nursing staff will conduct an ongoing evaluation of adherence to guidelines through periodic chart audits. Outcomes selected for monitoring include appropriateness of CSF dose, initiation and duration of CSF therapy, frequency of laboratory monitoring, management of bone pain, patient selection criteria, incidence of febrile neutropenia, and neutropenia related dose delays and reductions. These guidelines have further enhanced the nursing staff’s ability to provide autonomous, evidence-based, proactive symptom management to minimize the impact of neutropenia in their practice setting.

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THE NATURE OF CHANGE: USING THE FUNCTIONAL PERFORMANCE INDEX (FPI) WITH PATIENTS UNDERGOING CANCER TREATMENT. Lillian M. Nail, PhD, RN, FAAN, Oregon Health & Science University, Portland, OR; Susan Beck, PhD, APRN, FAAN, AOCN^®, and Karen Lindau, MS, OT, University of Utah College of Nursing, Salt Lake City, UT.

Although function is widely recognized as an important quality-of-life outcome, there is little information about types of activities that are compromised during cancer treatment. The purpose of this analysis was to describe the nature of self-reported functional impairment in patients beginning treatment with chemotherapy or radiation therapy and examine changes in function over the first few weeks of treatment. This study was guided by concepts suggested by self-regulation theory. An instrument that contains 65 detailed activity items, the FPI, was used. The FPI was developed as a measure of function for use with patients with COPD and has demonstrated reliability and validity in COPD (Leidy, 1999). In order to capture the nature of activity changes in cancer patients, 100 subjects participating in an RCT of an energy conservation intervention completed the FPI at the beginning of cancer treatment and several weeks later during treatment. The typical subject was a middle-aged (M = 56.7 years), married (74%), woman (87%) with breast cancer (79%).
At the beginning of treatment, 55 subjects ranked body care as the most or second-most important area of function, followed by social interaction (n = 42) and household maintenance (n = 32). As expected, few subjects reported activities as causing much difficulty. Activities requiring large muscle movement and stretching, like carrying groceries, painting, cleaning, or golf presented challenges to a few (<10) subjects. Changes in function over time were examined using paired t-tests computed on FPI subscale scores from baseline to during treatment measures within the control group (n = 54) only as the energy conservation intervention is expected to influence activity in the experimental group. There was a trend (p = .053) for physical activity to decline as treatment progressed. Recreational activity decreased over time (p = .019), but there were no changes in self-reported body care, household maintenance, and social interaction. The findings of these analyses indicate that changes in function are in areas other than personal care ADLs and suggest that measures of function in cancer patients need to encompass recreational and physical activity as well as traditional ADL items. Implications for measuring function, including gender-based items, preference, and attributions will be discussed.

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THE EFFECTS OF SYMPTOM UNCERTAINTY ON THE EMOTIONAL AND FUNCTIONAL OUTCOMES OF RADIATION THERAPY FOR CANCER. Norma J. Christman, PhD, RN, FAAN, University of Kentucky College of Nursing, Lexington, KY; Linda B. Cain, PhD, RN, Sherill N. Cronin, PhD, RN, Bellarmine University, Louisville, KY; and Donna J. Corley, MSN, Doctoral Candidate, Morehead State University, Morehead, KY.

Uncertainty about health-related experiences may profoundly influence patient outcomes. Much of what is presently known about illness uncertainty is based on the use of measures developed from cognitive models of information processing and stress and coping with statistically derived subscales. Studying uncertainty about specific aspects of health-related experiences, for example symptoms, might lead to new understandings and more specific intervention strategies.
The effects of symptom uncertainty (SU) on emotional and functional outcomes were examined in 76 persons having radiation therapy (RT) for gynecologic, lung, or head/neck cancers. Most had stage II or less disease (63%), were within one month of diagnosis (83%), and were white (92%), female (68%), and married (61%). All were treated with curative intent.
SU was measured with 10 items either modified or drawn from Mishel’s Uncertainty in Illness Scale. Internal consistency was .67. A non-significant correlation (.15, p > .05) between body awareness and SU supports the scale’s discriminate validity; correlations between SU and measures of predictability (-.47, p < .0001) and understanding (-.27, p < .05) support concurrent validity. SU, emotional and functional outcomes, and number of symptoms were measured treatment week three, and two, and four weeks after RT. Outcome indicators were the summed scores from the Profile of Mood States anxiety, depression, and anger subscales, and from linear analog items derived from the Sickness Impact Profile household management and recreation/pastimes scales, plus a linear analog item measuring time spent away from home. A measure of optimism, the Life Orientation Test, also was obtained. The effects of SU on outcomes were examined with hierarchical regression controlling for optimism and number of symptoms.
SU explained 15% (p < .001, b = .43), 5% (p < .05, b = .23), and 14% (p < .001, b = .38) of the variance in emotion treatment week three, and two, and four weeks after treatment respectively. Symptom uncertainty contributed to the explanation of functional outcome only two (6%, p < .05, b = -.26) and four (6%, p < .05, b = -.26) weeks following treatment. Incorporating specific information about typical symptom experiences into symptom management strategies may lessen negative effects of SU.
Further study about uncertainty due to specific aspects of health-related experiences also is needed.

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FATIGUE AND PHYSICAL FUNCTIONING DURING BREAST CANCER TREATMENT. Victoria Mock, DNSC, AOCN^®, Johns Hopkins Cancer Center, Baltimore, MD; Ruth McCorkle, PhD, FAAN, Yale University School of Nursing, New Haven, CT; Mary E. Ropka, PhD, RN, FAAN, University of Virginia School of Medicine, Charlottesville, VA; Mary Pickett, PhD, RN, University of Pennsylvania School of Nursing, Philadelphia, PA; and Barbara Poniatowski, MS, RN, C, AOCN^®, Greater Baltimore Medical Center, Baltimore, MD.

Fatigue during cancer treatment often leads to decreases in activity level and subsequent reductions in functional capacity that affect quality of life. Little research has focused on describing these important side effects of cancer treatment. The purpose of this descriptive, correlational study was to determine the relationship between fatigue levels and physical functioning in women receiving adjuvant therapies for breast cancer. The Levine Conservation model served as the study’s conceptual framework. In this model, cancer treatment presents challenges that threaten conservation of energy (represented by fatigue) and conservation of structural integrity (represented by physical functioning). The sample included 120 patients recruited from five academic cancer centers as part of a larger study. The women were a mean age of 52 years and were receiving adjuvant chemotherapy (60%) or radiation therapy (40%). Before treatment began and again at the end of treatment, subjects were assessed for fatigue with the Piper Fatigue Scale, for self-reported physical functioning with the MOS-SF 36 Physical Functioning Subscale (PhFx), and for objective changes in functional capacity with the 12-Minute Walk Test. All instruments were valid, reliable, and widely used in cancer research. Data were analyzed using Pearson correlations and descriptive statistics. Results indicate a moderately strong inverse correlation between fatigue levels and self-reported physical functioning (p = -.45, r < .0001). Although physical functioning scores were equivalent at pretest, women with the lowest posttest fatigue levels (lowest quartile) reported a mean PhFx score of 89.6 (possible 0–100) and a mean Walk Test score of 3,385 feet walked in 12 minutes, while women in the highest quartile of posttest fatigue scores (mean of 6.8 on the PFS) reported a mean PhFx score of 66.5, and a mean Walk Test score of 2,941 feet. Findings support the need for additional research as well as for more comprehensive clinical assessment of changes in functional status accompanying unmanaged fatigue during cancer treatment. The significant decrease in physical functioning seen in subjects with high fatigue levels represents a concerning loss of ability to perform daily activities that may not be readily reversible when cancer treatment ends.

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CHRONIC SLEEP LOSS IN FAMILY CAREGIVERS: IS DEPRESSION AN OUTCOME? Patricia A. Carter, PhD, RN, CNS, University of Texas School of Nursing, Austin, TX.

Problem: Caregivers may experience levels of depression that can impact their daily functioning, quality of life, and ability to continue in the caregiver role. Depression is a normal response to a family member’s diagnosis with cancer; however, other factors amenable to intervention (chronic sleep loss) may severely exacerbate this response.
Purpose: This pilot project described caregiver sleep and depression patterns over time and explored the feasibility of data collection methods and instruments.
Specific Questions: How do family caregivers’ sleep patterns and depression levels change over time? Are the proposed data collection methods and instruments feasible?
Framework: Pearlin and colleagues developed a caregiver stress process framework that illustrates the relationships between physical stressors (sleep loss) and emotional outcomes (depression). The questions addressed in this study flow logically from this framework. In order to understand caregiver depression one must first understand the patterns of sleep loss and depression over time.
Methods: A descriptive correlational design was used. Ten family caregivers of persons with advanced stage cancer were recruited from cancer clinics in central Texas. Weekly sleep quality (Pittsburgh Sleep Quality Index {PSQI}) and depression (Center for Epidemiological Studies Depression {CESD}) measurements were obtained by telephone. Caregivers wore an actigraph and recorded daily activities in a log at three separate times (for 72 hours) during the ten-week study. Visual plots of PSQI and CESD scores were generated for each subject. The actigraph data were analyzed using Action W software and sleep latency, duration, and efficiency scores were generated for each subject. Actigraph and PSQI scores were compared.
Findings: Visual plots of caregiver sleep and depression scores reveal significant changes over time. Actigraph scores are reflective of self-report (PSQI) of sleep latency, duration, and efficiency.
Implications: This pilot provided a visual mapping of caregivers’ sleep and depression patterns over time. Understanding sleep and depression patterns is essential to determine the critical time points to administer and measure interventions. This pilot study provided information regarding the feasibility of using the Actigraph in this population as well as the need for weekly measurements of sleep and depression in order to capture changes over time.

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MEDICATION SAFETY FOCUS: A MULTIDISCIPLINARY APPROACH TO MEDICATION SAFETY IN THE ONCOLOGY PATIENT. Mary Ann Long, RN, BSN, Roswell Park Cancer Institute, Buffalo, NY; Ellen Zupa, RN, MSN, Brian Cotter, RPh, Camille Wicher, RN, JD, and Meur Wetzler, MD.

This poster presents an overview of the Medication Safety Initiative conducted at a comprehensive cancer center. This initiative was taken in response to the concerns raised by the November 1999 Institute of Medicine report and specifically targeted the systems and procedures involved in medication administration. Medication safety, while important in all healthcare agencies, has special significance for both oncology patients and providers. The scope of this initiative included all of our patient care settings such as critical care and pediatrics, ambulatory care including chemotherapy and infusion clinic, the operative center, and all diagnostic and treatment centers. The interventions that were adopted as a result of the initiative will be presented and include the following.

1. The strategies utilized to conduct an evaluation of our current practice of medication prescription, preparation, and administration. This included an analysis of available data, the identification of risk points, and the subjective concerns identified as related to safety multiple focus groups. Each participant in these groups was involved in one or more of the processes included in the medication delivery system.
2. The roles of the various members of the multidisciplinary group responsible for the initiative.
3. The findings and recommendations immediately implemented as well as future plans. The improvements include technology implementation, staff and patient education, policy and procedure changes, system changes, and a process for ongoing reporting and analysis of medication variances that is efficient, comprehensive, and non-punitive.
4. Because of the complexity of oncology care, the responsibility for safe medication delivery is a major component of oncology nursing practice. This poster provides information that will be applicable to oncology nurses, their colleagues, and their patients and will contribute to the goal of an error-free medication delivery system.

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DEVELOPMENT OF AN AMBULATORY PUMP PROGRAM TO ENHANCE SAFETY FOR PATIENTS ENROLLED IN CLINICAL TRIALS. Barbara Rattner, MS, RN, Joanne Perri LaFrancesca, MN, RN, Joan Agretelis, PhD, RNCS-ANP, AOCN^®, Massachusetts General Hospital, Boston, MA; and Gayle Fishman, RN, MBA, Health Care Redesign, Wellesley, MA.

Background & Rationale: The Massachusetts General Hospital Cancer Center has expanded patient participation in clinical trials by 50% over the past three years. Many of these clinical trials require patients to receive medication via continuous infusion. A variety of ambulatory infusion pumps were being used for the delivery of both standard and investigational chemotherapy. Nurses identified a high risk for error because each pump had different specifications, programming, and operation requirements.
Additionally, home infusion companies are not licensed to monitor drugs in development. This meant that patients receiving investigational agents at home were not eligible for home nursing visits, adding to the misgivings of staff. In response to these concerns, the nursing leadership initiated the development of a program to address these patient safety issues.
Interventions: A multi-disciplinary committee was convened to examine our existing resources and ability to manage a self-contained ambulatory care investigational drug program. One infusion pump was selected which utilizes bar-code technology and eliminates the potential for human error in the programming process. A pilot project was undertaken with conventional, non-vesicant infusional therapy considered a lower risk for patient adverse events. Patients and families attended a structured education program developed and presented by a nurse prior to initiating therapy. Twenty-four hour nursing telephone coverage was provided.
Interpretation: Product reliability testing conducted by our biomedical engineering department demonstrated safe, reliable delivery rates. Safer pump technology along with a structured patient/family education process created an environment of acceptance among our patients and professional staff. On-call nursing utilization for patient care issues was minimal. After evaluating the results from the pilot project, the program was expanded to incorporate patients enrolled in clinical trials.
Discussion: The ambulatory pump program is ready to meet the growing demands of our clinical trials program. Physicians and nurses have confidence in this program and technology. Investigators are now mandated to use this pump for trials involving continuous infusions, eliminating the danger of multiple infusion pumps.

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TO ERR IS HUMAN—DESIGNING SAFER SYSTEMS FOR CHEMOTHERAPY ADMINISTRATION. Rose Taibbi, RN, BSN, OCN^®, Diane Gissinger, RN, MSN, OCN^®, Gertrude Kane, RN, MSN, OCN^®, Claire Meci, RN, BSN, OCN^®, and Anthony Negri, RPh, North Shore University Hospital, Manhasset, NY.

Chemotherapy errors can be lethal. Investigations of highly publicized chemotherapy errors show that multiple system failures must occur for an error to reach the patient. All disciplines involved in ordering, preparing/dispensing, and administration of chemotherapy must be highly trained and receive ongoing education. Antineoplastic agents are unique in that there is such a wide array of doses and schedules used. To address the concerns within our institution and identify areas for improvement, a multidisciplinary Chemotherapy Performance Improvement Committee meets monthly. The literature clearly recommends the use of computerized ordering systems. However, for institutions without computerized programs, other interventions must be developed, implemented, and re-evaluated on an ongoing basis. Review of errors with root cause analysis is crucial to understanding your institution’s process and potential for improvement. In addition, much can be learned from “potential errors.” Our focus is on review of orders that require intervention or revision before the patient is treated. We identified five levels of severity with the first four reflecting problems that were corrected prior to treatment. The fifth level reflects any error that reached the patient. Education focuses on heightening awareness of the need to report all orders that required interventions. We stressed non-punitive action, the ability to learn from “potential errors,” and identification of methods to prevent actual errors. Chemotherapy order writing guidelines, maximum dosing charts, and guidelines for administration and monitoring were developed. Most importantly, a multidisciplinary algorithm of check processes was developed to ensure comprehensive review of each order by physicians, pharmacists, and nurses. Each discipline understands their accountability in the process. “Potential errors” are tracked for trends, and staff is educated accordingly. Staff is recognized for their assistance with problem identification and reporting. Over the past year, we administered 50,107 drug preparations, identified 484 “potential errors,” and had one actual error. Despite the increasing complexity of treatments, our error rate was .002% using the protocols discussed. Designing safer systems protects patients and allows oncology nurses to implement all possible safeguards as we strive for an error rate of zero.

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IMPROVING SYMPTOM MANAGEMENT IN AN AMBULATORY ONCOLOGY CLINIC. Marybeth Singer, MS, RN, AOCN^®, APRN, BC, and Arati Patel, MD, New England Medical Center, Boston, MA.

Symptom distress significantly contributes to diminished quality of living for cancer patients and their families. The JCAHO recently mandated that certain minimum standards for assessment/treatment/re-assessment of pain occur throughout the trajectory of illness for patients receiving care within healthcare systems. Patients with cancer frequently experience pain, as well as other symptoms, which can lead to distress. Our urban ambulatory care center implemented a symptom survey for patients to complete at each clinic visit. Goals of the patient symptom survey were: 1) to assess and implement strategies to improve symptom outcomes as a quality improvement initiative, 2) compliance with JCAHO standards for pain management, and 3) provide a vehicle for increased communication between patients and clinicians regarding symptom distress. Symptom survey data collection is continuous. The findings below are reflective of the initial symptom survey pilot over a period of one month.
Initial data yielded 136 completed symptom surveys, with 80% of those patients having a hematologic malignancy. The eight most frequent symptoms, listed in order of severity, were lack of energy, negative quality of life, difficulty performing activities of daily living, depression, anxiety, difficulty with concentration, pain, and coping distress. When symptoms are evaluated based on diagnosis, the rank ordering and severity are similar regardless of cancer diagnosis. Symptom intensity greater than 7 (0–10 scale) occurred in 35% of patients, 66% of whom had 1–3 concurrent symptoms with an intensity greater than seven. The most compelling information was gleaned at the time of follow-up telephone interviews with those patients with symptom intensity greater than seven. Only 29% of patients had discussed the symptoms with their MD or NP at the time of their visit. When discussion occurred with the clinician, 100% of patients felt that steps were taken to address their symptom distress. When discussion did not occur specific to symptom survey, 83% of patients felt no steps were taken to address their symptom distress.
More than 50% of ambulatory oncology patients in our pilot survey reported symptom distress related to their disease and treatment. Data collection is on-going as part of a continuous quality improvement initiative to ensure optimal symptom management for patients.
Comprehensive cancer care means attending to all symptoms associated with patient distress and allocating resources to meet those needs.

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EVALUATION OF THE ONS SYMPTOM MANAGEMENT WORKSHOP ON PERIPHERAL NEUROPATHY. Terri Armstrong, RN, MS, NP, CS, Mark Gilbert, MD, M.D. Anderson Cancer Center, Houston, TX; Lois Almadrones, RN, MS, C, FNP, MPA, Memorial Sloan-Kettering Cancer Center, New York, NY; Anita Nirenberg, RN, MSN, Columbia University School of Nursing, New York, NY; Ruth Gholz, RN, MS, AOCN^®, Cincinnati VAMC, Cincinnati, OH; and Gail Wilkes, RNC, MSN, OCN^®, Massachusetts General Hospital, Boston, MA.

Peripheral neuropathy (PN) is an increasingly common side effect of cancer and cancer treatment. It is estimated that nearly 20% of all patients with cancer will experience neuropathy during the course of their illness. In addition, peripheral neuropathy is a dose-limiting toxicity of three commonly used chemotherapeutic agents: Paclitaxel, Cisplatin, and Vincristine. Despite this fact, many oncology nurses are not aware of how to assess and manage this symptom in their patients.
In an effort to improve knowledge of PN in oncology nurses, the Oncology Nursing Society, through a grant from Aventis Pharmaceuticals, supported a workshop for 200 oncology nurses. The workshop consisted of multi-disciplinary didactic lectures on anatomy, physiology of the nervous system, an overview of the causes of neuropathy, pain management, physical and occupational therapy needs, and nursing interventions. In addition, hands-on experience in exam techniques and case studies were completed. All participants received a toolkit consisting of workshop content slides, a pocket sized information card, and instruments including a reflex hammer and tuning fork to assess patients. Participants agreed to present at least one educational program on peripheral neuropathy to other nurses or to patients.
To evaluate the effect of the program on participant knowledge levels, participants completed a pre- and post-test multiple choice questionnaires. This test was developed by an expert interdisciplinary panel and face validity was established by administering the pilot test to 10 oncology nurses. The test underwent minor revisions for clarity. This test was completed by attendees at the start of the workshop and at the conclusion, prior to turning in their evaluations. The percentage of correct responses increased from 76.7% to 99.6% at the completion of the program. A six-month evaluation to query their individual educational programs, and administer the workshop test and a self-efficacy questionnaire was also completed and the results will be reported.
This effort to improve oncology nurse knowledge of this devastating side effect was shown to improve nurse knowledge by direct testing and can be utilized as a framework for other symptom management programs.

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PAIN AND FATIGUE MANAGEMENT: RESULTS OF A NURSING RANDOMIZED CLINICAL TRIAL. Barbara Given, PhD, RN, FAAN, Michigan State University, East Lansing, MI; Ruth McCorkle, PhD, RN, FAAN, Yale University, New Haven, CT; Bernadine Cimprich, PhD, RN, FAAN, University of Michigan, Ann Arbor, MI; and Charles Given, PhD, Michigan State University, East Lansing, MI.

Patients with breast, colon, lung, and other solid tumors who undergo a course of chemotherapy are at high risk of experiencing pain and fatigue. Pain and fatigue can have significant impact on the presence of others symptoms and upon level of physical functioning. To assist patients to better control pain and fatigue, a randomized clinical trial (RCT) of a nurse-directed, 20 week, 10 contact intervention was implemented for patients undergoing a new course of chemotherapy and their family caregivers.
The purpose of this report is to compare patients undergoing an initial course of chemotherapy who report pain and fatigue and who are receiving conventional care alone with those receiving conventional care plus the nursing intervention with respect to the severity and limitations of pain and fatigue, and numbers of other symptoms reported at 20 weeks.
A cognitive-behavioral conceptual framework focusing on problem solving approaches to symptom management, improving physical functioning, and emotional health were implemented at each contact. Pain and fatigue were sentinel problems toward which the intervention was directed.
Sample. The sample consisted of 35 patients in each arm of the trial who reported pain and fatigue at baseline following recruitment and consent. Seventy-one percent of the sample was female with mean age of 54 (SD = 8). Interviews were conducted at baseline, 10, 20, and 32 weeks. Outcomes were measured by the brief pain and brief fatigue inventories. All measures met acceptable psychometric standards.
Results. Groups were assessed for equivalence at baseline and to determine if there were differences by accrual setting. Analyses of variance were used to assess group effects, group by time, and group by time by covariates (age, gender, stage (II or III–IV). Patients who received the intervention reported significantly less severity and fewer limitations from pain and fatigue at the 20- and 32-week observations. In addition, patients receiving the intervention reported fewer “other” symptoms at both observations.
Implications. These data support the need for targeted interventions to assist patients undergoing chemotherapy to manage pain and fatigue.

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THE PREVALENCE OF SYMPTOMS CLUSTERS AND COMORBIDITIES IN ONCOLOGY OUTPATIENTS. Marylin J. Dodd, RN, PhD, FAAN, Christine Miaskowski, RN, PhD, FAAN, Claudia West, RN, MS, Steven Paul, PhD, and Kathy Lee, RN, PhD, FAAN, University of California, San Francisco, CA.

The prevalence of a number of symptoms including pain, fatigue, nausea and vomiting, depression, and sleep disturbance has been investigated in oncology outpatients. The traditional approach used in these investigations was to perform detailed assessments of individual symptoms. However, clinical experience suggests that oncology outpatients present with multiple symptoms and a variety of comorbid conditions. Therefore, the purposes of this cross-sectional study, in a sample of oncology outpatients, were: 1) to determine the prevalence of pain, fatigue, and/or sleep disturbances, and 2) to determine the prevalence of a number of comorbid conditions. The UCSF Symptom Management Model served as the conceptual framework for this study. One hundred oncology outpatients were recruited from three outpatient settings. Patients were over 18 years of age and were receiving active treatment for their disease. Patients were asked to complete the Wisconsin Brief Pain Inventory (BPI), the Lee Fatigue Scale (LFS), the General Sleep Disturbance Scale (GSDS), and a checklist of common medical conditions. Patients were categorized into one of eight symptom clusters using the following cutoffs: a worst pain score of greater than three, an LFS score of greater than five, and a GSDS score of greater than 60. Descriptive statistics and frequency distributions were generated. The average patient was 59.4 years of age, female (76.8%), and had a Karnofsky score of 77.2. The prevalence of the eight symptom groupings were as follows: no symptoms, 42.3%; only pain, 10.3%; only fatigue, 6.2%; only sleep disturbance, 8.2%; pain & fatigue, 4.1%, pain & sleep disturbance, 9.3%; fatigue & sleep disturbance, 6.2%; and pain, fatigue, & sleep disturbance, 13.4%. The most frequently reported comorbid conditions by these patients were back problems, 65.2%; allergies, 58.5%; headaches, 50.5%; hemorrhoids, 46.3%; arthritis, 33.3%; and hypertension, 30.4%. These findings suggest that oncology outpatients do experience multiple symptoms simultaneously and are living with a number of comorbid conditions in addition to their cancer.

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INFORMATION AND DECISION PREFERENCES OF MEN WITH PROSTATE CANCER AND THEIR PARTNERS. B. Joyce Davison, PhD, RN, The Prostate Centre, Vancouver General Hospital, Vancouver, British Columbia, Canada; Lesley F. Degner, PhD, RN, University of Manitoba, Winnipeg, Manitoba, Canada; S. Larry Goldenberg, MD, FRCSC, FACS, and Martin E. Gleave, MD, FRCSC, FACS, The Prostate Centre, Vancouver General Hospital, Vancouver, British Columbia, Canada.

Previous research has shown the majority of men newly diagnosed with prostate cancer do want to be involved in medical decision making, and they want to be informed. However, the information of preferences of partners and the extent to which they want to be involved in treatment decision making has not previously been studied. The purpose of this study was to identify and compare information and decision preferences of men with prostate cancer and their partners at the time of diagnosis. A convenience sample of 80 couples was recruited from the Prostate Centre in Vancouver, Canada. Participants used a touch screen computer program consisting of two previously used measures with this population: 1) Control Preferences Scale, used to elicit patient preferences for control over medical decision making (based on Unfolding Theory), and 2) Information Survey Questionnaire (based on Thurstone methodology). Results showed the vast majority of men wanted to participate in decision making with their physician (92.5%), and partners (100%). The majority (55%) of partners wanted to play a collaborative role in treatment decision making. Couples identified prognosis, stage of disease, treatment options, and side effects as their top four information preferences. Men ranked information on sexuality more important than partners (P = .004), and partners ranked information on home self care higher than men (P = .01). Men who had sons, a positive family history, and lower levels of education ranked heredity risk significantly higher (P = .001). Profiles of information categories did not differ according to role preferences of either men or partners. The computer program has been shown to be a reliable and acceptable method of assessing the information and decision preferences of these couples. Group profiles demonstrated low to moderate agreement, but individual profiles were shown to be highly reliable. Findings support the need for using an individualized approach to the provision of information to these individuals at the time of diagnosis. Print outs from this computer program can be used to guide information counseling sessions in a variety of outpatient oncology settings.

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CULTURAL INFLUENCES ON BREAST CANCER EXPERIENCE: KOREAN WOMEN IN SOUTH KOREA. Eun-Ok Lee, RN, DNS, Seoul National University College of Nursing, Seoul, South Korea; Eun-Ok Im, PhD, MPH, RN, CNS, University of Wisconsin-Milwaukee, Milwaukee, WI; and Young Sook Park, PhD, Seoul National University, Seoul, Korea.

Women’s breast cancer experiences are influenced by a number of contextual factors, one of which is culture. Despite the importance of consideration on cultural background in understanding women’s breast cancer experiences, very little is known about it. The purpose of the study is to explore cultural meanings of breast cancer among Korean women in South Korea and determine cultural impacts on breast cancer experiences. Transition theory and feminist approach are used as theoretical frameworks. This is a descriptive longitudinal study utilizing methodological triangulation, and only qualitative findings are presented here. Fifty Korean patients who were newly diagnosed with a plan of surgery and subsequent chemotherapy and not having severe fatigue at the time of recruitment were recruited for the quantitative phase using a convenience sampling method; then 15 among them were recruited for the qualitative phase. Qualitative data were collected using two-hour, in-depth interviews, and analyzed using thematic analysis including line-by-line coding, categorization, inductive and deductive cognitive process, writing memos, and group discussions. The findings indicated unique impacts of Korean culture on women’s breast cancer experiences. The themes included: (a) “I did wrong”; (b) “I cannot ask male physicians”; (c) “I don’t want to show the operation site to my husband”; and (d) “I do household tasks by myself.” The themes certainly reflected patriarchal cultural influences and modesty issues related to Confucianism. Based on the findings, some implications including consciousness-raising on patriarchal cultural impacts and its unfairness, empowerment by providing information, and encouragement of women’s participation in decision making process were proposed.

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“TC CHECK”—TEEN CANCER AWARENESS PROGRAM. Elaine Kocsis, RN, OCN^®, CCRP, South Pointe Hospital/Cleveland Clinic Health System, Warrensville Heights, OH; Bev Waters Shankman, BA, MA, Cleveland Clinic Health System, Mayfield Heights, OH; and Barbara Demagall, RN, South Pointe Hospital/Cleveland Clinic Health System, Warrensville Heights, OH.

The incidence of testicular cancer in the United States has almost doubled since the 1930s and continues to climb. The age group at highest risk is the 15–35 year old men. Testicular cancer is curable by 90%–99% if reported and treated early. Unfortunately, testicular cancer has become the taboo cancer of the 2000s, much as breast cancer was in the 1960s–1970s. As with breast cancer, most testicular cancers are discovered by the individual themselves.
Public awareness and education in this country are sorely lacking. It was discovered that most high schools do not include TSE or BSE as part of the curriculum. However, once the need for this education is brought to the attention of the administrators and educators there is enthusiasm and willingness to permit healthcare professionals into the classroom to instruct the students. Most health education classes in the public schools are co-educational.
This required a needs re-assessment and it was believed that testicular and breast cancer issues could be presented in a manner that was educational and non-threatening to a mixed gender class.
The purpose of this abstract is to describe the components, implementation, and results of this program which targets 10th grade students in health education classes.
The objectives of the TC check program are that the student will: 1) recognize signs, symptoms, and identify risk factors associated with breast and testicular cancer, 2) demonstrate the correct methods of TSE and BSE, and 3) will maintain a healthy lifestyle through monthly self-exam. These goals are reached by use of lecture, video, anatomical models, handouts, and reinforced by the “TC Jeopardy Game.”
In 2000 the TC Check program was presented to 214 people at three health fairs and six health education classes by a team of healthcare workers. Participant ages ranged from 8–63 years of age. One hundred thirty six 15–16 year olds attended at school presentations. Ninety five percent rated the program as helpful; 5% had no opinion. Eighty six percent stated they acquired new information. First time instruction for TSE was 67%; BSE was 74%. Due to the efforts of such celebrities as Lance Armstrong, Tom Green, and Scott Hamilton, general awareness in the targeted age group has increased. Healthcare professionals can benefit from this changing awareness by devising or utilizing programs directed at young adults in the classroom. The TC Check program can easily be adapted to a variety of age groups and settings including colleges, health fairs, young people groups such as scouts, and work places with equal success.

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A TOBACCO CESSATION COUNSELING PROGRAM FOR HOSPITALIZED PATIENTS. Janice Kjellberg, RN, Karen Swenson, RN, MS, AOCN^®, Park Nicollet Institute, Minneapolis, MN; and Donald Pine, MD, Park Nicollet Clinic, Minnetonka, MN.

A hospital stay is an opportune time for tobacco cessation intervention because tobacco bans force abstinence, patients are removed from their usual triggers for tobacco use, patients are more focused on health concerns, and there is access to knowledgeable care providers. The tobacco cessation counseling program at this Midwest urban community hospital was developed out of a NIH-funded study that compared interventions to help hospitalized patients quit smoking. The study found that patients receiving counseling and follow-up had a 10% higher quit rate than those receiving less intensive interventions. The main goal of the current program is to help hospitalized patients quit tobacco, and to abstain from tobacco use after discharge. Eligibility criteria includes use of tobacco within the past three months; age greater than 17 years; not admitted for mental health, substance abuse, or eating disorder; and not too ill or impaired to participate. Intervention is given by a trained tobacco counselor who establishes eligibility, determines patient readiness to quit, and provides bedside counseling and appropriate tobacco cessation literature. The intervention is documented in patient charts and pharmacotherapy is recommended to the physician when appropriate. Tobacco users who are ready to quit are also offered three to six follow-up phone calls to promote abstinence after discharge. Program evaluation is done with a mailed survey or by phone if the participant does not respond. The survey assesses six-month quit rates, patient satisfaction with the program, level of program participation, and use of pharmacotherapy or other cessation aids. Over 20 months, 1,263 patients received in-hospital counseling, and 698 patients agreed to a six-month follow-up. Of the 244 for whom follow-up data is available, the quit rate is 105/244 (43%). From this group, 73 (30%) have not used tobacco since hospitalization and an additional 32 (13%) have been abstinent for the past seven days. Of the respondents, 78% found in-hospital counseling helpful, and 71% found phone follow-up helpful.
Thirty percent of participants used the nicotine patch and 24% used Zyban. The results support the efficacy of this tobacco cessation counseling program in the hospital setting.

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EFFICACY OF A REPRESENTATIONAL INTERVENTION FOR CANCER PAIN. Sandra Ward, PhD, RN, FAAN, professor, Ron C. Serlin, PhD, Heidi Donovan, MS, RN, Sigga Gunnarsdottir, MS, RN, and Susan Hughes, MS, RN, University of Wisconsin, Madison, WI.

Purpose: The purpose of this study was to test an educational intervention to improve pain management. The hypotheses were: (1) The intervention will decrease beliefs that are barriers to pain management, decrease pain severity, and improve QOL, and (2) Changes in beliefs (barriers) will mediate the effect of the intervention on pain severity and QOL.
Theoretical Framework: Leventhal’s Common Sense Model, a theory explicating the role of cognitive representations in coping with health problems, guided development of the representational approach to patient education which, in turn, guided development of a specific educational intervention—a Representational Intervention to Decrease Cancer Pain (RIDcancerPain).
Design: Randomized two-group design (RIDcancerPain versus Standard Education[SE]). Valid, reliable measures of barriers, pain severity, and QOL were used at baseline (T1), one month later (T2), and two months later (T3).
Sample: Patients with advanced cancer, 18 years or older, who had pain in the past week were eligible to participate. Two hundred twenty two subjects were recruited; 150 completed the study.
Findings: Hypotheses were partially supported. There was no main effect for group on T1 to T2 changes in outcome variables. However, there was a group effect on change in barriers from T1 to T3; those in the RIDcancerPain condition showed a greater decrease compared to those in SE [t(124) = 2.04, p = .02]. In addition, there was a group effect on T1 to T3 change in pain severity, with those in the RIDcancerPain condition improving compared to those in SE [t(136) = 2.35, p = .02]. The change in barriers from T1 to T3 mediated the effect of the intervention on the change in pain severity from T1 to T3. There was no main effect of group on T1 to T3 change in overall QOL.
Conclusions: The representational approach to patient education shows promise in that RIDcancerPain had a positive effect on some but not all outcomes.
Implications: Further testing of a strengthened version of RIDcancerPain should be done, and the representational approach to education needs to be tested in other health problems. Clinicians could consider systematic interventions to overcome patient-related barriers to pain management.

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MAKING THE CHOICE: HOW WOMEN AT RISK FOR BREAST CANCER FEEL ABOUT PROPHYLACTIC MASTECTOMY TO REDUCE BREAST CANCER RISK IF THEY WERE TO HAVE A POSITIVE BRCA GENETIC TEST. Karen Greco, RN, MN, ANP, oncology nurse practitioner, doctoral student, Nancy Press, PhD, Oregon Health & Science University, Portland, OR; and Wylie Burke, MD, PhD, University of Seattle, Seattle, WA.

Purpose/Objectives: This study is a secondary analysis of some qualitative data from the study, “Family Disclosure of Cancer Risk: An Ethnographic Study.” The study purpose is to better understand how women at risk for breast cancer feel about prophylactic mastectomy as an option to reduce breast cancer risk if they were to have a positive BRCA genetic test.
Sample: Data are from interviews with 246 women aged 40 to 60, of varying ethnicity, family history of breast cancer (negative, positive, borderline), and educational level.
Theoretical/Scientific Framework: This secondary analysis used grounded theory. The original study is a quantitative and descriptive ethnographic study.
Design: Data were collected in the original study using semi-structured interviews to assess women’s attitudes toward and hypothetical interest in genetic susceptibility testing for breast cancer.
Methods: Data from four questions in the original interviews were analyzed using a grounded theory approach.
Data Analysis: Open coding was done to identify concepts. Data were analyzed independently by three researchers; myself, the PI, and the co-investigator. Themes were identified and diagramed. Discussion of data analysis among the three researchers occurred throughout the process.
Findings: Women’s responses represented a continuum from “it is a mutilation” to “yes, it wouldn’t bother me at all.” The primary theme identified was “making the choice.” Women made a clear distinction between agreeing to have a predisposition genetic test for BRCA and agreeing to have prophylactic mastectomies should the test result be positive. Many women said they would obtain second opinions and would mistrust their provider for suggesting such radical surgery. Four subthemes were identified: search for alternatives, inadequate provider, let the cancer come, and keeping my parts.
Conclusions: Most women responded that they would likely agree to have a predisposition genetic test for BRCA if it were recommended by their physician. However, they would not automatically agree to prophylactic mastectomies even if that were the best treatment available to reduce breast cancer risk.
Implications for Research/Practice: Oncology nurses need to understand that although prophylactic mastectomies may be effective in reducing breast cancer risk, women may have strong responses to the suggestion.

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PRECHEMOTHERAPY SELF-CARE MANAGEMENT INSTRUCTION IN OLDER MALE VETERANS WITH A CANCER DIAGNOSIS: AN EXPERIMENTAL STUDY. Virginia Sicola, PhD, APN, AOCN^®, RN, oncology coordinator, Amarillo VA Health Care System, Amarillo, TX; and Gary Kelley, PhD, West Texas A&M University, Canyon, TX.

Instruction in self-care management before chemotherapy is provided to older adult males without knowing if it is beneficial. Therefore, the purpose of this prospective, randomized, control study was to examine the benefit of prechemotherapy self-care management instruction on post-treatment mental status, physical performance, and frequency of side effects in older male veterans diagnosed with cancer. The theoretical framework used Orem’s self-care as the process adults use to regulate their own functioning. A cancer patient experiences limitations and side effects of treatment, thus experiences a self-care deficit. The nurses’ role is to reduce the deficit. The sample included 67 veterans with cancer receiving at least two cycles of chemotherapy. No subjects younger than 55 years of age, with a previous cancer history, alcoholism, drug dependency, or mental deficiency were included. Each veteran was given the valid and reliable Mini Mental State Examination (MMSE) and Karnofsky Performance Status Scale (KPS) score by the research assistant (RA). Then, the veteran was randomly assigned to the control or experimental group by the researcher who gave both groups a 15-minute introduction to chemotherapy and its side effects. The experimental group received further instructions in self-care management. Prior to the second treatment, the RA retested the patients. Each subject reported the number of medically-treated side effects. With 35 control and 32 experimental subjects, the data were analyzed using t tests and means. Results showed that following treatment, the KPS approached significance (p value = 0.110) with the experimental group’s mean score dropping 2.8 points compared to the control group’s score dropping 5.8. Side effects significantly lower for the experimental group included constipation (p value = 0.009) and dizziness (p value = 0.05). At the 0.15 level of significance, the experimental group experienced less nausea, vomiting, and sleep difficulties. The findings indicate that self-care management provided prior to chemotherapy improves physical performance and reduced some side effects in older veterans. Further research calls to extend this study by evaluating older patients beyond the second cycle. In practice, instruction in self-care before chemotherapy is of benefit for older men.

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CANCER-RELATED FATIGUE: “IT’S SO MUCH MORE THAN JUST BEING TIRED.” Horng-Shiuann Wu, RN, PhD(c), School of Nursing, and Maryellen McSweeney, PhD, Saint Louis University, Saint Louis, MO.

Fatigue is highly prevalent among persons with cancer and has great impact on their lives, but the subjective experience of cancer-related fatigue (CRF) is not well understood. Because CRF is a subjective, multidimensional experience, developing a knowledge base about and effective interventions for CRF require understanding the phenomenon from the individual’s perspective.
Purpose/Objectives: This study explored the meaning of CRF from the person’s perspective to learn about the actual experience of fatigue.
Scientific Framework: A phenomenological perspective served as the philosophical framework of this study. Human behaviors were understood from the individual’s own context; CRF was interpreted through the meanings individual brought to it.
Design: Qualitative methods were used to understand the individual’s experience of CRF.
Sample: The sample consisted of 10 female patients with breast cancer currently receiving chemotherapy from a freestanding clinic in St. Louis, Missouri. Two African American and eight Caucasion women, aged 30 to 73 years, with various cancer stages, participated. Criterion sampling was used.
Methods: After giving informed consent, the subjects participated in audio-taped, semi-structured, 30–60 minute individual interviews (n = 10) and a two-week daily fatigue diary activity (n = 6 returned).
Data Analysis: Content analysis, using open and axial coding and coding frames, guided the coding and analysis in this study.
Findings: The analysis resulted in the following thematic categories: unique fatigue, physical sensations, emotional sensations, changes in daily life, causes of fatigue, fatigue management, fatigue trajectory, and reflection/meanings.
Conclusions: CRF as a multidimensional phenomenon that affects all aspects of an individual’s life is evidenced. Participants described that they were experiencing an unexpected degree and kind of fatigue that is much more than just being tired. Lack of awareness and knowledge to confront CRF were identified across interviews. Individualized strategies were learned from the person’s own experiences.
Implications: The findings will help cancer patients and clinicians better understand CRF from a holistic approach. They may prompt the development of interventions to help chemotherapy patients anticipate and respond to CRF. A CRF instrument is in development based on the findings of this study.

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NURSE INTERNSHIP FOR A BLOOD AND MARROW TRANSPLANT UNIT: AN APPROACH TO RECRUITMENT AND RETENTION. Katherine B. Mishaw, RN, MS, AOCN^®, University of Texas M.D. Anderson Cancer Center, Houston, TX.

Today’s nursing shortage is evidenced by fewer nurses entering the workforce, acute nursing shortages in certain geographic areas, and a shortage of nurses prepared to meet specialty patient needs in a changing healthcare environment. This is clearly evident in the blood and marrow transplant unit at MDACC, which processes approximately 600 transplants per year. It is a challenge to recruit nurses with cancer experience, much less, with a background in this specialty.
Although nurses like the challenging environment, including the latest treatment and technology, many verbalize that the unit is too daunting in terms of the learning curve. Applicants are concerned whether the institution is committed to training for the nurses. In response to this concern, this BMT unit refined its current curriculum to include a three-month “internship program.” The program includes the hospital orientation, the BMT unit orientation, and additional clinical experiences to provide the “big picture” of the transplant process.
These experiences include the ambulatory BMT clinics (observe both the pretransplant workup and the immediate post hospitalization needs for both the allogeneic and autologous transplant patients), pheresis unit (observing photopheresis, stem cell, single donor platelet, and donor lymphocyte collections), and observation in the chronic GVHD clinic. Tools developed for the internship program include an orientation pathway, BMT course curriculum (includes ONS SIG recommendations and additional hematology/oncology), an orientee study guide, and patient case studies/vignettes. These vignettes are reviewed in weekly post-clinical seminars to enhance critical thinking, assessment, data collection, priority setting, and decision-making skills in these novice nurses. This program empowers the nurse with the knowledge to provide competent care for this patient population and may serve as a model for orientation of the advanced practice nurses for BMT as well as future “residency” programs for nurses in BMT arena. This presentation will detail this program, the tools utilized, cost analysis, and the outcomes.

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STAFF-DRIVEN ASSESSMENT OF RETENTION ISSUES FOR ONCOLOGY NURSES. Elaine M. Sein, RN, BSN, OCN^®, Maureen Mullin, RN, BSN, OCN^®, and Anne Jadwin, RN, MSN, AOCN^®, Fox Chase Cancer Center, Philadelphia, PA.

The national nursing shortage has hospitals competing for nurses from a continually diminishing pool. Competent oncology nurses are an extremely valuable commodity in this competitive market. The increased number of open nursing positions presented an opportunity for the Retention and Recruitment Committee at Fox Chase Cancer Center, an NCI-designated comprehensive cancer center, to address not only recruitment issues but also to implement a plan to retain quality oncology nurses. Within a shared governance model, this committee affords the staff nurse leadership opportunities that will directly affect nursing satisfaction. In order to address the issues, an assessment of retention factors at this Magnet hospital would provide crucial data.
In the fall of 2000, surveys were sent to all nursing staff. The survey instrument included seventeen Likert scale questions, a demographics section, a chart to rank order the three best and three least favorite things about working at this facility, and a section for open commentary and suggestions. The 80% response rate from full- and part-time staff was felt to be a representative sample. Analysis of the survey was done ensuring respondent anonymity. The top three retention factors were commitment to oncology nursing, competence of nursing staff, and quality of nursing care. The three least favorable factors were non-competitive salary scale, communication issues, and poor physical work environment. A demographic breakdown according to age, years in nursing, educational background, and years of service provided pertinent data as to what was valued by individual groups.
The results of the survey were presented to nursing administration and hospital administration. A summary letter was distributed to the nursing staff as a spin-off for dialogue at open nursing forums held between nursing staff and members of nursing administration. Oncology nurses have been empowered to impact nursing retention and recruitment as evidenced by salary adjustments, expanded benefits, increased tuition reimbursement, flexible scheduling options, enhanced unit and interdepartmental communication, and a plan for physical renovations. The retention and recruitment subcommittee has been expanded to include members from nursing administration, human resources and marketing for a more comprehensive approach in addressing retention issues.

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COLLABORATIVE NURSING EDUCATION: PAVING THE WAY FOR EXCELLENCE IN ONCOLOGY NURSING PRACTICE. Marilyn Tuls Halstead, RN, PhD, AOCN^®, and Sharon Eifried, RN, PhD, Towson University, Towson, MD.

Qualified, caring nurses are a critical component of oncology nursing practice. However, because of the current nursing shortage it is imperative to develop innovative methods to educate generic nursing students, RN to BSN students, and master’s level practitioners about the practice of oncology nursing. To achieve this goal, Greater Baltimore Medical Center (GBMC) and the Towson University (TU) Department of Nursing created a unique partnership that establishes GBMC as a clinical education center of TU, bringing nursing education and practice together. TU is helping GBMC to upgrade the credentials of oncology nurses. Incentives to complete BS and MS degrees include scholarships, location of classes in the hospital complex, and scheduling accommodations. Expected outcomes for GBMC and the community at large are that the need for qualified oncology nurses and quality oncology nursing care will be met. Under the terms of the agreement, GBMC will provide additional experiences for students, as well as collaborative relationships in clinical, research, and teaching opportunities. The role and responsibility of a master’s prepared oncology “teacher-practitioner” will be developed through master’s level education. Members of the GBMC oncology staff will work with students in teaching and supervisory roles in order to optimize the experiences of nursing students during their oncology clinical experiences. Expected outcomes for TU are that students will gain quality educational experiences, scholarship assistance, and enhanced faculty expertise.
Through these efforts, oncology nursing leadership will become more visible. GBMC is one of the few community hospitals that are nationally recognized for quality cancer care. Because of the multifaceted oncology care available at GBMC, the student clinical experience is rich and holistic. Of particular note is GBMC’s focus on psychosocial care throughout the cancer experience. GBMC facilitates the development of expert oncology nurses, as they become leaders in the field. This partnership also provides an opportunity for staff, faculty, and students to investigate joint research activity related to oncology nursing practice.

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CLINICAL SKILLS, CRITICAL THINKING, AND COMMUNICATION: USING A LEARNING CONTRACT TO DEVELOP THE NEW ONCOLOGY NURSE. Ellen Cowan, RN, BSN, OCN^®, and Linda Hood, RN, MSN, AOCN^®, Duke University Health System, Durham, NC.

A nurse internship is one strategy to retain and develop new nurses. New nurses may be attracted to an internship because of the additional structure, support, time, and opportunities offered during the first years of practice. Knowing that nursing students receive little specialty education in oncology, institutions develop internships to be competitive during a nursing shortage. However, the intern looking for clinical experience may become dissatisfied when personal goals do not match institutional expectations. For an institution, additional resources and financial bonuses may attract staff, but there is no legal guarantee that the intern will remain employed long enough for the institution to recoup their investment.
These issues were identified as major factors in the success of an oncology internship program. To address these concerns at Duke University Medical Center (DUMC), a learning contract was developed to clarify goals and expectations for the intern and the institution. The goals for the first six months of practice focused on demonstrating basic nursing competency as an RN within the DUMC system for the oncology unit population. During the second six months of practice, goals focused on developing the specialized knowledge required to manage the oncology patient and to provide educational rotations to sites across the oncology continuum of care. Goals for the second clinical year of the internship involved professional development and oncology nursing certification.
Del Bueno’s model of performance-based development was used in writing measurable objectives for three areas, clinical skills, critical thinking skills, and interpersonal skills to direct the learning activities needed to demonstrate professional practice as an oncology nurse. The contract included intern responsibilities, mentor resources, and target dates for completing objectives. By tailoring the experience to the needs of the adult learner, increased commitment demonstrated by retention and attainment of professional perspectives will be evidenced and are being evaluated as outcomes of the program. The intern also is evaluated based on the objectives identified for each of the time frames within the two-year period. This presentation will describe the evaluation and implications of using a learning contract to enhance commitment to an oncology nurse internship.

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NOVEL IDEAS FOR BREAST CANCER DIAGNOSIS AND TREATMENT: THE CONCEPT OF cDNA MICROANALYSIS. Arlene Berman, RN, National Cancer Institute, National Institutes of Health, Bethesda, MD; Georgia Cusack, MS, RN, Kim Maynard, BSN, RN, Clinical Center, National Institutes of Health; and JoAnne Zujewski, MD, National Cancer Institute, National Institutes of Health.

In 2001, approximately 192,000 women will be diagnosed with breast cancer and 40,600 women will die from the disease. Until now, we have relied upon histologic classification and the testing of a few prognostic markers by pathologists as our way of classifying tumors. The majority of oncology nurses are familiar with the prognostic indicators of tumor size, lymph node status, estrogen and progesterone receptors, and, more recently, HER2 status. What is not clearly understood is why two breast cancer patients, with identical prognostic indicators, can get the same chemotherapy or hormonal treatments, and yet have different outcomes. Complementary DNA micro array is a powerful new technology that allows the simultaneous measurement of the expression of a large number of genes and has the potential for tumor characterization, and may make it possible to predict patient response to therapy. The application of a large number of genes in a condensed array on glass slides comprises a DNA micro array. Genetic material from normal and tumor tissues is extracted, transcribed into cDNA, and labeled with fluorescent dye. The fluorescent color that results from the cDNA binding to the slide can tell us whether a set of genes are over expressed or under expressed compared to a reference standard. This information may help us identify gene patterns that predict for tumor response or drug resistance. Researchers at the National Cancer Institute are using this technology in a phase II neoadjuvant trial of women with stage II and III breast cancer. With this population, we are able to obtain tumor tissue before and during chemotherapy and apply this technology to look for patterns of gene expression. This technology may reveal to us hidden relationships that go beyond the pathological appearance of a tumor. Oncology nurses need to have a working knowledge of available technology for breast cancer in order to assist patients in understanding potential treatment options. Our hope is that in the future we will be able to apply this technology to tailor therapy to an individual’s tumor abnormality and therefore improve patient outcomes.

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FISH TESTING ENSURES ACCURATE IDENTIFICATION OF HER2-POSITIVE PATIENTS. Nathalie Chorn, RN, OCN^®, University of California, Los Angeles, CA.

Objectives: Herceptin (trastuzumab) is a humanized monoclonal antibody that has antitumor activity in HER2-positive breast cancer. Over expression of HER2 is frequently assessed using a standardized, semiquantitative immunohistochemistry (IHC) assay. An IHC score of 2+ or 3+ (on a scale of 0–3+) was used as the entry requirement for Herceptin clinical studies. Additional analyses have shown that HER2 gene amplification, identified by fluorescence in situ hybridization (FISH), occurs in 89% of 3+ tumors and in 24% of 2+ tumors, and that measurement of patient HER2 status by FISH may be a more accurate method of identifying patients for Herceptin treatment. Our primary objectives were to evaluate testing results of IHC assays and to reiterate the importance of accurate patient identification through the use of FISH testing for IHC-negative (0, 1+, and 2+) patients.
Methods: Our experience has shown the need to retest patients who initially test IHC 1+ and 2+ for HER2 over expression (1+ is considered mildly negative, and 2+ is considered mildly positive). Some of these patients continue to show clinical signs of aggressive disease and may benefit from further testing with FISH for HER2 gene amplification.
Results: Four hundred fifty one subjects who enrolled in the combination therapy pivotal trial were retrospectively tested using FISH. All were positive by IHC (i.e., 2+ and 3+). In the FISH-negative group, 38% (n = 56) were in the chemotherapy-alone arm and 38% (n = 50) were in the chemotherapy + trastuzumab arm. There appeared to be no benefit in adding trastuzumab to the FISH-negative group. In the FISH-positive group, only 31% (n = 169) of the subjects enrolled in the chemotherapy-alone arm responded compared with 54% (n = 176) of subjects who responded to the chemotherapy + Herceptin arm, therefore confirming the benefit of adding Herceptin to first-line metastatic breast cancer treatment.
Conclusion: Proper identification of patients who may benefit from the use of Herceptin is important in providing quality patient care. Although IHC testing is commonly used to determine the level of HER2 protein over expression, FISH testing for HER2 gene amplification appears to be the most accurate measure for selecting patients who will benefit from Herceptin therapy.

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MYLOTARG™—THE NEW ANTIBODY TARGETED CHEMOTHERAPY. Betty Prokop, RN, BSN, and Tracy Gosselin, RN, MSN, AOCN^®, Duke Medical Center, Durham, NC.

Due to the incidence of relapsed AML, researchers continue to look for innovative treatments that provide patients with a durable remission. One of the newest advances in the treatment of AML is an antibody-targeted chemotherapy known as, Mylotarg.
Mylotarg combines specific targeting of an antibody with the antitumor activity of a highly potent chemotherapeutic agent that affects the CD 33 antigen. Mylotarg is indicated for patients with CD 33+ AML in first relapse who are 60+ years of age and who are not candidates for other cytoxic therapies.
With advances in treatment, oncology nurses face the challenge of caring for this predominantly elderly population that often has other co-morbid diseases. The vast array of side effects/complications includes severe thrombocytopenia, neutropenia, anemia, bleeding, and infections including sepsis and pneumonia. Adverse events include fever, chills, nausea, emesis, asthenia, diarrhea, abdominal pain, headache, stomatitis, dyspnea, epistaxis, hypokalemia, anorexia, constipation, local reaction, and non-specific rash.
Due to the possibility of this population having a complicated medical history, oncology nurses attempt to minimize the treatment related side effects and enhance patient satisfaction through patient education and early recognition of symptoms. Patient/family teaching should include specific side effects, signs & symptoms of toxicity, standard precautions, and self-care needs.
The education of oncology nurses is imperative with the administration of Mylotarg. In order for nurses to implement excellent care, early identification and management of these complications is vital to the positive outcome and survival of this population. There are various avenues available for nurses to receive the required education needed for patient care. Handouts, audio-visual tapes, and pharmaceutical-supported in-services are a few methods being utilized. Unit-based testing can also be performed.
This poster abstract will provide educational tools for nurses that will enable them to provide better care for patients with relapsed AML.