 Nurse staffing varies from institution to institution, depending on many factors, both internal and external. To gain a better understanding of nurse staffing, ratios of nurses to patients, and productivity, a survey was sent to ONS members. At the ONS 37th Annual Congress, responses to the survey pertinent to inpatient oncology settings were presented and discussed by Angela Adjetey-Appiah, RN, patient care director, New York-Presbyterian Hospital/Columbia University Medical Center, New York City. Due to the survey’s findings, she said, the ONS plans to add a section with staffing exemplars to its website.

	“The goal of staffing each oncology inpatient unit is to ensure patient safety in healthcare delivery,” Adjetey-Appiah explained. “Nurses are scheduled in sufficient numbers to provide quality and safe care. The staffing mix is a determinant of the safety of the work environment and the safety of patient care. Nurse recruitment and retention efforts are critical to retaining expert staff.”

	According to Adjetey-Appiah, the American Nurses Association’s principles for nurse staffing suggest that the following factors be identified:

		Intensity level of the care needed by patients

		Characteristics of the work environment, including architecture and available technology

		Experience and expertise of the nursing staff

	The support of a multidisciplinary staff is important, she added, as is a facility’s involvement, or lack thereof, in research at the basic-science or clinical level.

	Because patient needs are ever-changing, Adjetey-Appiah said, patient classification and acuity systems that are used to track and predict nurse staffing needs can be helpful, and easily understood by nurses when taught appropriately.

					The total number of oncology beds in inpatient hospitals ranged from 30 to 217.

					Overall, the average nurse-to-patient ratio was 1:5; with chemotherapy, the average ratio was 1:4 or 1:3.

					Patient populations at respondents’ institutions were as follows: 32% included medical oncology; 12.5% had non-oncology medical; 15.5% had surgical oncology; and 8% had non-oncology surgical.

					Twenty nine percent of respondents’ institutions utilized non-licensed staff; 6% did not; and 65% did not specify.

					Productivity measures were used to determine staffing in 26.5% of respondents’ institutions and were not used in 5.5%; 68% of respondents did not answer this question.

					Non-licensed personnel were included in the productivity measure, according to 24% of respondents, while 2.5 % of respondents said they were not included and 73.5% did not answer the question.

					When asked which productivity measures were used to set staffing, 18.5% used hours per patient day; 1% used hours per adjusted patient day; 0.5% used budgeted hours; 0.5% used budgeted productive hours; 5% used nurse/patient ratio; 1% used “other”; and 73.5% did not answer the question.

	“To determine how many patients one nurse can care for is a difficult question to answer due to the variety of settings in oncology inpatient units. Any nurse will tell you it all comes down to the individual patient and how much care he or she needs,” Adjetey-Appiah commented.

	Two hundred people responded to the ONS survey (

). Responses give a bird’s-eye view of staffing situations in various inpatient units; however, about two-thirds of respondents did not answer several questions.

	Based on the survey results and on staffing principles, some examples of staffing guidelines are as follows, with the same number of registered nurses (RNs) needed for either a day or a night shift:

	“The survey confirms why ONS opted not to have set guidelines on staffing,” Adjetey-Appiah said. “The diversity and variety of inpatient units are too complex to set one standard. However, the survey revealed a need to use exemplars as guidelines when staffing oncology units. Examples collected from different institutions will be posted on the ONS website.”

Articles

Nurse staffing varies from institution to
institution, depending on many factors, both
internal and external. To gain a better
understanding of nurse staffing, ratios of nurses to
patients, and productivity, a survey was sent to ONS
members.

Oncology Nurse Staffing Is Variable and Multifactorial

Although the role of adequate nutrition in cancer patients is gaining recognition as being important, the area is often neglected as a key component of nursing care, according to a speaker at the ONS 37th Annual Congress.

	Since about 50% of cancer patients have nutritional issues at diagnosis, and treatment can exacerbate weight loss and deteriorate nutritional status, it is vital for oncology nurses to ensure that malnutrition is diagnosed and treated, said Meghan Routt, MSN, RN, James Cancer Hospital, The Ohio State University Medical Center, Columbus. The issue should be given attention across the cancer care continuum, she said, since oncology patients can encounter nutritional challenges at any time from diagnosis through curative treatment or palliative care.

	In helping such patients, Routt added, nurses should be aware of several studies demonstrating that individualized nutrition counseling by a registered dietitian can help reverse weight loss/malnutrition and improve overall health and social functioning, functional status, and quality of life.

	“Every patient who walks through the door should be screened for malnutrition,” she advised. “Patients should be followed closely to be sure they are paying attention to nutrition. The patient is a partner in the process.”

	Nutritional complications from chemotherapy, surgery, radiotherapy, and immunotherapy are frequent, can be expensive to treat, and can limit therapy, Routt said. In particular, she said, malnutrition can impair wound healing and increase morbidity, mortality, muscle loss, the rate of infection and other complications, the likelihood of hospital admission, and the length of hospital stays.

	Among the side effects of cancer or its treatment that can affect nutritional status is cachexia (ie, ongoing loss of skeletal muscle mass), which cannot be fully reversed through conventional nutritional support. The diagnosis of cachexia should be suspected, Routt said, if a patient experiences weight loss in excess of 5% over 6 months or the body mass index (BMI) falls below 20 and the patient experiences more than a 2% weight loss over the same time period.

	Other common side effects—often related to treatment&mdash; that affect nutritional status include nausea, vomiting, anorexia, mucositis, esophagitis, fatigue, and diarrhea or constipation. About 50% of patients experience some degree of nausea and vomiting, Routt said, and this commonly affects nutritional intake.

	In a study of 191 cancer patients treated with chemotherapy, 49% were malnourished, 46% required symptom management and/or nutritional intervention, and 89% had five or more nutrition-related symptoms [

. 2010;62:220-228]. Surgery for cancer also is associated with nutritional problems. Malnourished surgical patients are at increased risk for postoperative morbidity and mortality, so weight loss should be taken seriously, Routt noted.

	Cancers that affect the digestive tract pose specific nutritional risks, she said. Surgery for head and neck cancer can create problems affecting the ability to speak, chew, salivate, swallow, smell, and taste. Enteral feeding tubes may be necessary. Treatments for gastrointestinal cancer can result in gastroparesis, alterations in digestion, malabsorption of nutrients, and a host of related digestive-tract abnormalities.

	Side effects of radiation can affect ingestion, digestion, and absorption of nutrients, Routt added. Diarrhea, nausea, vomiting, enteritis, and malabsorption are common gastrointestinal side effects of radiation. Side effects of immunotherapy can also compromise nutritional status.

	“Nutrition is an aspect of care where early recognition [of malnourishment] and intervention are vital,” Routt said. “This may be the only area of care where a patient can have a sense of control over his/her life. Instead of making nutrition a source of tension and anxiety, the cancer nurse can try to address patients’ needs by encouraging them to become involved in maintaining adequate nutritional status early in the treatment process, so that they become proactive about their nutritional needs.”

Although the role of adequate nutrition in cancer patients is gaining recognition as being important, the area is often neglected as a key component of nursing care.

Importance of Adequate Nutrition Emphasized

 Diagnostic tests are common across the spectrum of cancer care, but results may not always be easily interpreted or applied clinically. In certain types of cancer, related conditions can interfere with the accuracy of diagnostic testing. Thus, it is important to choose the best test, taking into consideration timelines, invasive versus noninvasive testing methods, specificity (a test’s accuracy in identifying negative results), and sensitivity (a test’s accuracy in identifying positive results), two speakers said during a presentation at the ONS 37th Annual Congress.

	“Diagnostic tests have specific indications, contraindications, and circumstances that make their results inaccurate or uninterpretable. Use of diagnostic tests should appreciably offer information that can drive clinical decisions,” said Brenda K. Shelton, MS, RN, clinical nurse specialist at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore, Maryland. She spoke on the topic with Anna Antonowich- Jonnson, MSN, City of Hope, Duarte, California.

	The wealth of diagnostic tests related to cancer care includes lab tests, imaging tests (x-ray, ultrasound, CT, MRI, nuclear scans), and scopes that allow direct visualization of an anatomic area. Each test has a different purpose, and nurses should be aware of ideal indications, as well as contraindications. Among the variables that can confound diagnostic test results are age, gender, fluid balance, body fat, albumin, diet, medications, sexually transmitted diseases, and recreational drugs, Shelton said.

	Nurses who perform or prepare patients for diagnostic tests should be familiar with optimal technique, because suboptimal technique can lead to incorrect, incomplete, or questionable/uninterpretable results. Safety issues are also important, as is the need for special handling, she said.

	Some specific diagnostic tests that may be needed prior to initiation of cancer therapy are complete blood count (CBC) with differential, chemistry panel, renal function/urine studies (ie, glomerular filtration rate [GFR], serum creatinine test), and hepatic function tests, Shelton said. Equations and formulas for estimating GFR and serum creatinine level are available on the Internet.

	To illustrate a scenario in which a series of diagnostic tests would be needed, Antonowich- Jonnson reviewed the case history of a patient with colorectal cancer receiving capecitabine who was found to have anemia. Further tests, she said, would include CBC with differential, B

 level, iron tests, stool exam for guaiac and 

, and possibly, endoscopy and/or colonoscopy.

	She said that causes of anemia could include bleeding secondary to mucositis, hemorrhoids, or chemotherapy, and recommended that prior lab tests, medications, iron and ferritin levels, and other prior treatment be reviewed. Regarding guaiac stool testing, Antonowich-Jonnson said that oral iron supplements do not give false-positive results, but that intake of vitamin C, red meat, and dietary peroxidases (ie, turnips and radishes) can lead to false-negative results. She stated that an adequate stool sample is 10 mg/g.

	Although some institutions may use several stool samples to evaluate the presence of 

, only one sample is necessary, given the current accuracy of the stool test for toxin, Antonowich- Jonnson told listeners. Patients with diarrhea and suspected infection should be isolated until the diagnosis is established, she said, and outpatients and their families should be educated about appropriate hand hygiene and eliminating risks.

	Diagnostic tests have specific indications, contraindications, and circumstances that make their results inaccurate or uninterpretable. Use of diagnostic tests should appreciably offer information that can drive clinical decisions.”

	According to Antonowich-Jonnson, electrolytes should be assessed and adequate hydration ensured. After that, she said, the patient should be re-evaluated; blood transfusions are generally needed if hemoglobin level is <8, the hematocrit is <23, or the patient is symptomatic.

	Shelton and Antonowich-Jonnson reviewed other cases and discussed the considerations involved in selecting several diagnostic tests, including those for dysrhythmias, glucose abnormalities, blood cultures, neutropenia, brain natriuretic peptide, cardiac function, liver function, pulmonary function, 

	For any diagnostic test, Shelton said, interpreting the findings should include consideration of status of disease, severity of organ dysfunction, impact of disease status on current choice of treatment, undiagnosed comorbidity, differential diagnosis, additional tests that could be helpful, and essential preparation for diagnostic tests.

 as a resource to help nurses learn about diagnostic tests and access calculators for body surface area, corticosteroid conversion, opiate equianalgesics, carboplatin area under the curve, creatinine clearance, anion gap, and absolute neutrophil count status.

	“In addition to choosing the right diagnostic test, critical thinking and excellent assessment skills are needed,” Shelton said.

Diagnostic tests are common across the
spectrum of cancer care, but results may not
always be easily interpreted or applied
clinically.

Considerations in Interpreting Diagnostic Test Results

	Nurses involved in cancer care should be up to date on the growing number of applications for interventional radiology in oncology, since some centers may call upon them to work within the quickly developing area, a speaker suggested during the ONS 37th Annual Congress.

	In fact, the oncology nurse’s role is vital in the management of patients receiving such procedures, noted the speaker, Diana Wortham Maultsby, RN, an oncology clinical nurse specialist who works in Asheville, North Carolina as a clinical infusion data consultant for CareFusion, which is based in San Diego, California.

	Interventional radiological procedures entail the use of minimally invasive, image-guided, ablative strategies. In oncology, the strategies are typically aimed at reducing tumor volume, preventing cancer progression, and minimizing the risk of new tumor growth in nonsurgical populations with selectively advanced cancers. The procedures include radiofrequency ablation (RFA), chemoembolization, radioembolization, and high-intensity imageguided focused ultrasound (MRIgFUS), Wortham Maultsby said.

	The clinical results of interventional oncology can be comparable to those achieved through surgery, and these procedures are often effective options for medically and surgically ineligible patients, she said. They target cancerous tissue while sparing healthy adjacent tissue, and are associated with reduced side effects, lower morbidity and mortality, shorter hospital stays, fewer complications, and improved quality of life when given in conjunction with or instead of traditional treatment approaches. Procedural advantages of such treatments include the ability to identify targets with imaging and reduced resource utilization compared with conventional surgery, Wortham Maultsby said.

	Despite these potential advantages and the fact that there are about 6000 interventional radiologists in the United States, public awareness about these types of treatments is low, Wortham Maultsby said. Still, she said, there are a number of organizations developing guidelines and infrastructure to standardize the roles, services, reimbursement, and delivery models of care in interventional radiology. They include the American College of Radiology, The American Society of Interventional and Therapeutic Neuroradiology, and the Society of Interventional Radiology.

	Interventions that are image-guided include all thermal and cryoablation procedures and catheter-based delivery of chemoembolization and radioembolization, she said. For example, interventional radiologists commonly deploy embolization, cryoablation, and microwave and transarterial chemoembolization (TACE) for liver, prostate, lung, and gastrointestinal / colorectal cancers.

	Wortham Maultsby described more about such techniques:

	Radiofrequency thermal ablation (RFA) precisely delivers increasing levels of heat to tumor tissue with the aid of radiographic imaging (ultrasound, CT, or MRI), and the heat causes cell death. Current indications for RFA include liver and metastatic lesions, and the treatment will probably play a role in the management of other primary cancers, including renal, non-small cell lung cancer, adrenal, and breast cancers, as well as painful bone metastases. The technique can be used to treat patients who are otherwise not surgical candidates or who have failed other therapies. As with other interventional radiology techniques, potential advantages of RFA include lower rates of bleeding, shorter recovery times, and minimal side effects.

	Cryoablation utilizes a cryoprobe inserted into a tumor to deliver super-cooled gas that freezes the tumor tissue, and thereby achieves cellular death. Cryoablation is reimbursable through health insurance for prostate cancer and, in some states, for liver cancer. Use of cryoablation at other tumor sites, including the kidney and lungs, is considered investigational.

	MRIgFUS is being studied for the treatment of breast fibroadenomas and metastatic bone tumors, with promising results in phase III trials.

	Interventional vertebral augmentation can be achieved with percutaneous vertebroplasty or kyphoplasty for patients with symptomatic neoplastic and noncancerous vertebral compression fractures. The technique is proven to be as effective in the reduction of overall pain severity and improved mobility as conservative medical management.

	When TACE is used to treat liver tumors, the procedure is performed percutaneously in the angiographic suite, and combines intra-arterial delivery of chemotherapy plus embolic agents. Drug-eluting microspheres have been developed for use with TACE, allowing more precise delivery of chemotherapy into blood vessels surrounding the tumor, and giving the provider better control of bead placement for sustained and predictable dosing. Several clinical trials utilizing TACE with microspheres containing chemotherapy or radiation have been performed, with reliable and positive patient outcomes.

	In preparation for interventional procedures, most patients can expect to have IV fluids, premedications for symptom management, and either a radial or femoral arterial line for vascularbased approaches, or a probe or needle route for equipment introduction for nonvascular-based interventions to access the targeted treatment site. During the procedure, patients will need monitored sedation and local anesthetic with standard postprocedure care. Patients may need subsequent treatments for inoperable lesions, a decision that is typically made during an evaluation 4 to 6 weeks post-procedure.

	Interventional radiology procedures are a burgeoning area in oncology, and professional competency will be needed to meet the growing demand for these treatments, Wortham Maultsby emphasized.

	“A multidisciplinary approach—including the nurse&mdash;is vital to success,” she said.

Nurses involved in cancer care should be up to date on the growing number of applications for interventional radiology in oncology, since some centers may call upon them to work within the quickly developing area.

Alice Goodman

Articles

Oncology Nurse Staffing Is Variable and Multifactorial

Importance of Adequate Nutrition Emphasized

Considerations in Interpreting Diagnostic Test Results

Interventional Radiology: A New Frontier in Cancer Care