In 2002, I returned to work at my prior hospital of employment and found many examples of forward-thinking in place.  One seemed like an oxymoron. A palliative care nurse practitioner was now employed within the Medical Intensive Care Unit (ICU). I wasn’t sure what to make of this addition at the time, but years later, I’ve realized the very appropriate allocation of this advanced practice nurse within this setting.

The overall death rate in the ICU is high: 20%-35% of patients admitted to intensive care die.

 In addition, admissions to the ICU in the last month of life have increased to nearly 30%.

 Within cancer care, contemporary data confirms the importance of addressing the needs of patients with cancer within the critical care setting. Consider the following:

In the past decade, up to a third of patients admitted to ICU have a cancer diagnosis.

Overall, 1 in 10 patients experience a life-threatening condition that requires the supportive technologies and monitoring rendered within the ICU setting.

The use of aggressive cancer therapies heightens the prevalence of emergent scenarios; this is especially the case in the treatment of hematologic malignancies and with the use of hematopoietic stem cell transplantation.

Associated with the increased prevalence of oncology patients within critical care settings are other corollaries. 

Within the context of patients being unable to speak on their own behalf, surrogate or proxy decision-making has a plethora of problems and controversies.

 The prevalence of considerable symptom distress is another issue. In addition to cancer treatment-related sequelae, palliative care-related symptoms (i.e., thirst, anxiety, sleep disturbance, dyspnea) also require management.

 Lastly, poor communication amongst numerous physician specialists and with family members is pervasive.

There are several interventions to be considered to address these issues. They require implementation within the critical care and oncology unit settings. Consider the following:

Establish a routine schedule for rounding with the palliative care team in both the oncology unit and intensive care settings. This includes developing a proactive approach to identifying patients who could benefit from palliative care interventions with the delineation of triggers for palliative care consults.

In the ICU setting, have a plan for routine family meetings based on the projected or estimated length of stay.

Create comfort care protocols for the management of common distress sequelae.

Consider the development of family education approaches to enhance their awareness of common sequelae they are likely to encounter in critical care.

Mandate communication training opportunities that address common scenarios likely to be encountered within critical care.

I had the opportunity to work with a research initiative within the 5 University of California hospitals to train critical care nurses in communication skills.

 The program’s goal was to provide needed instruction in the clinical setting about how to speak with the families of ill patients and the training consisted mostly of role-playing communication strategies with families, physicians, and family meetings.

Oncology nurses are one of many nurse specialties that care for patients with cancer.  Emergency Department, PACU, surgical, rehabilitation, home care, dialysis, medical, and critical care nurses care for our patients at various phases of their cancer experience. The inevitability of oncology patients being cared for, and possibly dying, in the critical care setting is a real one in today’s acute care environment. Because of the prominence of cancer today, all nurses need to ensure they have the expertise and confidence to care for oncology patients at varied points along the cancer continuum.

Angus DC & Truog RD (2016).  Toward better ICU use at the end of life. 

Teno JM, Gozalo PL, Bynum JP et.al. (2013). Change in end of life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. 

Boyle DA, Barbour S, Anderson W et.al. (2017). Palliative care communication in the ICU: Implications for an oncology-critical care nursing partnership. 

Mercadente S, Gregoretti C, Cortegiani A (2018). Palliative care in intensive care units: Why, where, what, who, when, how. 

Puntillo KA, Arai S, Cohen NH et.al. (2010). Symptoms experienced by intensive care unit patients at high risk of dying. 

Oh YS (2017). Communication with health professionals and psychological distress in family caregivers to cancer patients: A model based on stress-coping theory. 

Milic MM, Puntillo K, Turner K et.al. (2015). Communicating with patients’ families and physicians about prognosis and goals of care. 

Fumis RR, Martins P, Schettino G (2015). The impact of poor prognostic patients admitted to the intensive care unit on family members emotional disorders. 

Wright AA, Keating NL, Ayanian JZ et.al. (2016). Family perspectives on aggressive cancer care near the end of life. 

Anderson WG, Puntillo K, Boyle D, Barbour S, Turner K, Cimino J, Moore E, … Pantilat S.  ICU bedside nurses’ involvement in palliative care communication: A multicenter survey. 

Boyle D & Anderson WG. Enhancing communication skills of critical care nurses: Focus on prognosis and goals of care decision-making. 

Articles

The stigma around palliative care is that it is only associated with end of life, and in some minds, giving up. But that isn't the case, as palliative care is a vital part of any critical care.  

Incorporating Palliative Practices Into Critical Care

My observations over the years have led me to believe that there is a nursing hierarchy among the nursing specialties, and critical care nursing is considered by many the pre-eminent nursing specialty.  Case in point, within all general areas of nursing, the Medical ICU, Trauma ICU, Peds ICU, Neonatal ICU, are perceived to require the highest skill set of nurses. General nursing experience is often mandated before consideration of position placement within these units, hence, critical care positions itself as being a ‘cut above’ generalist medical, surgical, and pediatric nursing.

The ICU’s elevated status is directly associated with technology’s overwhelming presence in these areas. The use and manipulation of machinery are perceived to be associated with the highest level of nursing skills, and closely related to technology’s presence is heightened acuity correlated with the need for ideal ratios of nurse to patient staffing.

In the hospital setting, I practiced as an oncology clinical nurse specialist in collaboration with a critical care nurse educator on multiple projects.  This colleague, a highly skilled and long-tenured critical care nurse, decided to return to school to pursue becoming a family nurse practitioner.  One of her lengthy clinical practicums was on a general in-patient medical-surgical unit for 3 weeks.  My colleague used multiple vacation days to complete this clinical requirement and nearly a month had passed since I had seen her.  Upon one of her first days back to her educator role she asked if we could have lunch, and the reflections she shared were quite telling.  

My colleague was astounded as to the complex nature of the patients she encountered in this unit. The majority of patients were elderly, diagnosed with multiple co-morbidities, and prescribed a myriad of medications. Many of these patients could not get out of bed on their own and needed assistance with the basic elements of daily performance. Their clinical symptoms reflected a wide array of potential etiologies, many of which were not detectable from a definitive laboratory marker or radiologic finding.  She went on to share her reflection of the comparison between critical care nursing and it’s medical-surgical corollary.

In critical care, she described, abnormalities are technologically calculated on a number of platforms. Hemodynamic, urinary, hepatic, and neurologic parameters are spelled out in objective measures. The data portending demise and emergent scenarios are printed out in front of us. In medical-surgical nursing, there are no such measures to aide decision-making. Medical-surgical nurses must rely heavily on their critical thinking skills, collating and comparing numerous data sets, and past knowledge to determine and anticipate clinical scenarios.  Medical-surgical nursing she summarized, is so much harder than critical care nursing. This is exacerbated by these nurses having at least twice if not more patients they must care for in a shift than ICU nurses have.

Secondly, my personal and professional impressions also credence to my colleague’s reflections. The overwhelming influence of technology in critical care has diminished the importance of humanistic care. With the heavy reliance on machinery, comes an over-emphasis on numbers. This minimizes the importance of addressing the interpersonal distress observed in the hovering family members and the anxious patient in respiratory distress.  My clinical experiences within critical care have left me with the impression that emotional support takes a back seat to lines, tubes, drains, and pumps. 

I believe that in contemporary health care, oncology nursing has evolved into a ‘pseudo’ critical care specialty. The technology is not as pervasive as in critical care, but it is dominant in everyday practice. I worry that this could falsely place competency in managing machinery as being more important than mastering how to talk to patients and families in crisis. I have always embraced the expectation that we must be equally proficient in our interpersonal skills as we are in our technical ones. Striving for this dual excellence positions us uniquely as a nursing specialty.  

When you plan or consider attending, the next oncology nursing continuing education program, look closely at the nature of what is being presented. Is comparable emphasis given to recognizing patient suicide risk and minimizing caregiving burden to knowing early symptoms of oncologic emergencies, managing central line complications, and using personal protective devices?  Ongoing deliberation of what we are teaching will ensure that the dual domains of oncology nursing excellence are alive and well in practice.

Among the various specialties of nursing, a sort of hierarchy has formed that may be putting competency with machines over nurse and patient interactions.

Is There a Nursing Specialty Hierarchy?

I vividly remember calling the wife of a patient after the death of her husband, as I wanted to see how she was doing. I purposely waited to call a month after the patient’s death as I knew from my research with families whose loved one died in the hospital setting, that this is a particularly rough time. The cards and calls no longer come. The visitors have left, and the primary caregiver is left in an empty house to face the reality that their loved one is gone forever. I also knew caregivers find these calls particularly supportive because they feel the nurses who cared for their loved one truly know what they went through, especially when the cancer trajectory was a difficult one. This wife told me that she returned to work earlier than expected after taking a leave of absence during her husband’s treatment. She said she felt isolated and lonely in her house so she thought her return to work and the company of her co-workers would be helpful to her, but she found the opposite to be her reality.

“It was awful,” she said. “I felt like a leper. People I had worked with for years avoided me like the plague. No one even mentioned the fact that Jim had died; it was like my personal tragedy never happened. I felt even more alone than when I was at home and I was angry at my co-workers who treated me this way. I wasn’t asked to go to lunch or socialize with them like we used to do. They avoided me, I think, to eliminate the possibility that I would bring up Jim’s death and they didn’t want to talk about it. Jim’s death and my grief were topics no one wanted to talk about. I was around people I had known for years, had a relationship with yet I experienced such alienation, it was painful. I eventually quit my job and decided to try something new, go somewhere where people weren’t aware of my situation and my sadness.”

Never could I have imagined at this time, that I would personally experience this same phenomenon, not once but twice.

Following my own husband’s death from metastatic bladder cancer and my daughter’s untimely death following a tragic car accident, I returned to my work in the hospital setting. I was met with similar insensitivity from some co-workers. However, in my case, the avoidance and isolation did not come from laypeople with little exposure to and much discomfort with death. In my instance, it was my colleagues, nurses, and doctors, many of whom witness tragedy on a daily basis, who were the ones finding my presence uncomfortable. These are the people who were supposed to be knowledgeable about offering comfort to families who were suffering from the loss of loved ones. 

After returning to work following my husband’s death, I was on the elevator and it stopped on the floor housing the OR. When the door opened, there stood my husband’s urologist waiting to get on. I actually saw the discomfort on his face when he saw me. He made a brief attempt at a greeting, but he then abruptly turned saying, “Oh there’s something I forgot to dictate about my last case” and turned away from the elevator. Very similar to the patient’s wife whom I called, when I returned to work after my daughter’s death, the avoidance and isolation from the group of nurses I worked closely with was abhorrent. Not one of them ever mentioned the fact that she died, never mentioned her name or asked about my sorrow. The first time I returned to work after an extended bereavement leave, the only people who mentioned what had happened was the director of volunteer services and an administrative intern. 

I am sure there are many other comparable stories like mine.  I feel strongly that every work setting should have a support program for employees who return to work after the death of a close relative. Focus groups with employees who have personal experience with this issue would generate many ideas about what would help.

For example, it would have been very comforting for someone from work to have met me in the lobby of the hospital to welcome me back and accompany me back to my unit or if there was a card waiting for me signed by my co-workers telling me they missed me and thought a lot about me around the loss of my child. They could have had an EAP counselor come to me on one of the first days back (rather than expect me to go to them) to offer support and to determine if I might want more counseling in the future. A session with my co-workers might also have been beneficial for the counselor to discuss how to talk to someone with intense grief and how to interact with them upon my return. 

Knowing what to say and emphasizing the importance of positive communication skills might have made them less anxious about knowing how to interact with me. It could have let them know I didn’t want to hear their stories of their losses, but rather that I would have found a listening ear more beneficial. I didn’t want to keep my sadness hidden and this would have allowed me to give it a voice. Also, for me personally, it would be great to just be hugged, no words necessary.

The grieving process doesn't stop when you think you're ready to go back to work, and it can be made worse when your coworkers are unsure how to console you. Which is why workplace assistance is essential for grieving employees.   

Why Workplace Assistance is Needed For Grieving Employees

I have recently been reading a lot about compassion. I’m not sure whether it’s triggered by a specific event or due to a long-standing interest in the interpersonal domain of oncology nursing. I have always wondered about the varying degrees of compassion I have observed at the bedside over the decades. Why are some of us so virtuous in our caring and others so distant and disconnected? Where does compassion come from anyway? Was a family member a role model for it for us when we were young or was it a profound reaction to some event we observed? And what, exactly, is compassion?

In 2017, Canadian colleagues published the results of a study in which they interviewed 53 patients with advanced cancer and asked them about their perceptions of sympathy, empathy, and compassion.

They also asked the patients what these constructs looked like in healthcare providers. Sympathy was depicted as an unwanted, pity-based response.

Empathy was perceived as an affective reaction whereby the professional attempts to understand the patient’s suffering. Compassion was the most preferred response. It was perceived to have empathy embedded in it and was distinguished by 2 unique characteristics, both relating to action rather than just feelings.

Compassionate professionals had a desire to relieve suffering rather than merely understand it. They acted on their feelings. There was an altruistic nature to their demonstrations of kindness, which were identified as going above and beyond the expected. Thus, if compassion is highly desired by patients who are suffering, we need to consider whether we can teach compassion as a necessary competency.

Contemporary neuroscientific research has identified a link between the mental and emotional foundations of compassion with brain functioning. Another study described that our brains don’t remain fixed over our lifetime and that by engaging in activities that foster connectivity and sensitivity at the bedside, we can enhance our capacity to read others’ cues and empathically respond.

A growing body of work posits that our interactions can have physiologic effects that influence healing, improve functional impairment, and relieve psychological pain.

 In the context of compassionate exchanges, we can trigger immunologic, hormonal, and neurologic processes, not just by what we say but by how we say it. Decades ago, in championing the modern hospice movement, Cicely Saunders, OM, DBE, FRCS, FRCP, FRCN, shared her insight that the power of listening and the ability to embody a compassionate presence in the face of suffering might be as important as any medical intervention.

In the book Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference, the authors speak of a “compassion crisis in healthcare.”

 In physicians, this can be characterized by brief, clinical interactions devoid of compassion, poor listening skills, and depersonalization, or the inability to connect with patients. Unfortunately, especially in teaching facilities, these behaviors may be exemplified in physician leaders and are emulated by those in training. How can we change this current problematic paradigm?

First and foremost, we must solicit more feedback from patients and families about their experiences, and we need to share these results. Years ago, as part of a grief group I cofacilitated, we asked family caregivers what it was like to be in the hospital setting when their loved one was dying. Results revealed that the nursing staff was perceived as extremely compassionate and concerned about the family’s well-being. In describing their loved one’s physicians, however, this was not the case.

The majority of comments were negative. Families felt abandoned. Their interactions with the physicians were void of compassion. They sensed the oncologists’ discomfort and saw this linked to their limited conversations, brief visits, or staying away altogether. In a subsequent cancer committee meeting, I shared this feedback with the predominantly physician group. I quoted the responses verbatim, making it hard to refute the accurateness of the comments. Little was said following my presentation, and the next item on the agenda was quickly brought forth. Despite this, I felt I had accomplished my goal, namely, to be the voice of our families and advocate on their behalf.

In a time of crisis, no one wants to be cared for by a healthcare professional devoid of compassion. I believe compassion can be taught and that this topic needs to be part of all healthcare professionals’ basic education. Subsequent skill enhancement should also be a component of ongoing education in the work setting.

I have been the recipient of non-compassionate and compassionate care by healthcare providers, over the years, mostly as a family caregiver. I can tell you that the difference between the two is palpable. Marketing the positive aspects of exemplary compassion might be a strategy to consider in motivating colleagues to embrace and learn this competency.

With compassion comes reciprocity. Personally, the extension of myself to suffer with a patient leaves me with the sense that I showed up and made a difference. What a gift. Mark Twain said that kindness is the language which the deaf can hear and the blind can see. True compassion has no limits.

Sinclair S, Beamer K, Hack TF, et al. Sympathy, empathy and compassion: a grounded theory study of palliative care patients’ understandings, experiences, and preferences. 

. 2017;31(5):437-447. doi: 10.1177/0269216316663499.

Contemplative Caregiving: Finding Healing, Compassion, and Spiritual Growth Through End-of-Life Care

. Boulder, CO: Shambhala Publications; 2019.

Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference

The Compassion Connection: The Healing Power of Empathy and Mindful Listening

. New York, NY: Oxford University Press; 2018.

Providing compassion to your patients won’t just help their day-to-day care, it can also change their treatment journey for the better.

The Compassion Connection in Cancer Care

This year’s depiction of “the best” hospitals generated by the 

garnered significant attention after its release. Institutions that made the coveted list were quick to buy up media advertisement space to widely market their rankings. However, on social media, I saw numerous physician commentaries stating that the criteria used for the rankings were flawed.  This made me curious about what variables were used to identify “the best” of this year’s hospital rankings when nursing is taken into consideration.

The hospitals were categorized within the 

 of outcomes and patient experience, and process and outcomes. Some examples included discharge to home, availability of technology, presence of intensivists, patient volume, patient experience, presence of select patient specialty offerings (i.e., fertility clinic, hospice, pain management, palliative care, translators, wound management) and the expert opinion by physicians. There were only 2 criteria that addressed the quality of nursing: staffing and Magnet status. 

After looking in detail at the criteria, this ranking methodology is indeed flawed. Why? Because it does not reflect the robust nature of nursing excellence that is required to be “the best” hospital in any category, and most certainly within the nurse-intensive nature of cancer care. The isolated use of nursing positions (i.e., staffing) does not reflect the quality of nursing care required to render optimum patient care. You may think, well Magnet status is taken into consideration, but that is a sign of practice excellence. Only 1 point is given to hospitals holding this prominent recognition, while all other criteria are judged on a wide spectrum with their own factors taken into consideration. Furthermore, even the top hospital is only given an “above average” for its nursing staffing while scoring “very high” or “excellent” in every other category.

Irrespective of the number of intensivists and the latest technologies, without nurses, no hospital can function. All cancer therapies and supportive care interventions require the expertise of oncology nurses to assess, treat, monitor, support, teach, and counsel patients and their caregivers in ways that physicians or other members of a patient’s care team cannot. It is timely that nurses speak up about their absence within the criteria used to measure “the best” when rankings like this are not taking crucial aspects of a patient’s care into perspective.  

A recent ranking of "the best" hospitals in the country did not take a key aspect of cancer care into proper consideration, the oncology nurse.

Taking Oncology Nurses' Roles Into Consideration When Determining Hospital Rankings

One of the topics in oncology nursing that I am passionate about is the unparalleled stress we encounter in our work. It is multifocal, often unrelenting, and overwhelmingly unappreciated by others. It emanates from difficulties in teamwork; staffing; competing demands on our time between technology and the human side of caring; under-recognition of our skills by physicians and the organizational hierarchy; and our constant exposure to the grief of others. Unlike other colleagues, nurses can’t leave the scene when the stress becomes so overwhelming you want to implode. We are immersed in a work setting often characterized by negativity. Some may even call this environment toxic.

I have recently noted an increased press about health professionals’ burnout. Physicians are generally highlighted as being prone to this phenomenon. Rarely are nurses acknowledged for their risk. Being a frequent speaker on the emotional sequelae of nursing, one of the issues I often stress is the distinction between burnout and compassion fatigue. I often find myself critiquing the correctness of these concepts’ definitions and association, however, I recently had a realization: Does it matter what we call it? Ultimately, the most important thing is that we acknowledge this adversity and get help to minimize and manage it.   

Nurses’ emotional distress has numerous roots. They include moral anguish, grief, frustration, impatience, guilt, witnessing constant trauma, and feelings of powerlessness. These can culminate in physical, social, and work-related sequelae such as fatigue, insomnia, loneliness, purposeful isolation, work performance compromise, and turnover. It is time that the reality of our stressful practice is not just recognized by oncology nurses, by the larger healthcare world as well.

Decades ago, an insightful chief nursing officer at my place of employment, decided to develop a program to expose non-nurses to the realities of our work. It was called “Walk in a Nurse’s Shoes.” Representatives from the mayor’s office, large insurers in our area, philanthropists, chief executive officers of major employers, university presidents, religious leaders, police and fire officials, and others, were invited to spend a day at our hospital to learn what nurses do. Each visitor spent 4 hours with 2 different nurses. I spent my day accompanied by the mayor’s assistant and a managed care insurance official. At the end of the day, there was a large group de-briefing.

When sharing their experiences, a number of these community leaders were moved to tears. Many voiced a sense of awe about what nurses were responsible for, and what they were able to accomplish. The majority relayed personal dismay at their lack of understanding about nursing work. They also shared that their time spent in this program completely changed their perceptions of nurses.

This is 1 example of showing, rather than telling, what the emotional labor of nursing practice looks like. It is exemplars like this that can drive the needed awareness of decision-makers about the realities of nurses’ work. We need people resources and financial backing to provide counselors, mentors, and teachers who can provide us with the needed skills to work in this stress-laden context. 

I have decided not to get fixated on the name given to the stress that is part of our daily practice.  Rather, I am going to lobby for interventions that will enlighten the power-brokers’ understanding of the resources we need to cope with this often-unrelenting stress. I encourage you to identify who a prominent decision-maker is in your setting who needs to witness firsthand the emotional sequelae you face when you nurse. Take their phone away and invite them to immerse themselves in your world to understand your situation better.

To fight the issues of burnout within oncology nursing, nurses must allow others to step into their world and understand the issues they face. 

What's In a Name?

My first oncology nursing role was as a chemotherapy research nurse at our regional cancer center during the mid-1970s. Most of our patients had progressive or advanced cancer with limited treatment options, and thus were receiving clinical trial regimens. We saw a lot of malignant melanoma because one of our senior oncologists focused his research on it.

Following my clinic experience, I was in graduate school and went to the student health service to have a mole evaluated. It was on my lower forearm where I wore my watch, so it wasn’t always visible, but I noticed that it had turned maroon and had irregular borders. Yet during this visit, I was told it was nothing to worry about.

My first job after receiving my master’s degree took me 3000 miles from home to live on the opposite coast. A professional portrait was needed. Sensitive about the number of moles on my neck (later I would be told that I had dysplastic nevus syndrome), I made an appointment to have them removed. While there, I said to the dermatologist, “Do me a favor and remove this one from my forearm too. I’ve been told it’s nothing, but I want it taken off.” He acquiesced to my request.

Soon after that minor procedure, I traveled to Alaska to teach a weeklong oncology nursing core course. While there, I received a phone call from my physician telling me that I had malignant melanoma on my forearm and needed to return home immediately to undergo a wide excision and skin graft. Thus, my personal cancer journey began.

After I recovered from surgery, my early phase of survivorship was dominated by intrusive memories of all the patients with melanoma I had cared for who died. One, in particular, was a patient who presented with a small, unusual mole on his earlobe and was dead within 2 months. His gentle, smiling, freckle-laden face now became my constant companion. “Would I end up like him?” I worried. Somehow, I couldn’t recall any patient with melanoma who survived. I searched the literature to determine if this anxiety I was experiencing was common. I found some mention of this distress termed “recurrence anxiety.” However, little research had been done on this topic at that time.

Fast-forward to the present. Characterized as fear, worry, or concern relating to the possibility that cancer will come back or progress, recurrence anxiety is now recognized as the one response nearly all survivors can expect to experience.

 A theoretical model published in 1997 by Lee-Jones and colleagues

 suggested that a combination of cues with internal (ie, physical symptoms) and external (ie, physician appointments, media depictions) origins can trigger a range of cognitive and affective responses. These are often exacerbated by the misinterpretation of symptoms with an associated increase in somatic anxiety. Although the fear of cancer returning has received attention in more recent research, many gaps remain in our understanding of this phenomenon.

The majority of research has focused on breast cancer survivors with only isolated, small sample size investigations of other tumor types. The timing of the presentation of recurrence anxiety also requires more study, as it has been noted to occur both early in the treatment trajectory and after treatment cessation. The phenomenon’s association with specific cancers also merits scrutiny. Numerous risk factors have been identified, including younger age, introverted personality style, pre- or comorbid psychologic distress (ie, anxiety, depression neuroticism), fatigue, and unmet sexual needs, according to one study that focused on survivors with head and neck cancer.

Recent reports outline interventions to mitigate recurrence anxiety, including mindfulness-based stress reduction offered in 6 weekly group sessions, cognitive-behavioral therapy offered in 5 individual face-to-face sessions supplemented by 3 consults over 3 months, and combinations of these approaches.

 Smartphone applications have been developed to provide interactive, psychoeducational, phone-based problem-solving psychotherapy.

 This approach offers the advantages of brevity and portability. Early results of these interventions suggest considerable benefit.

Oncology nurses must expect some degree of recurrence anxiety in their patients who are navigating life following treatment cessation. Key nursing strategies include assessment, education, and resource identification. Even if patients do not verbalize worries, it is important that nurses ask about their concerns. With this inquiry, their fears are normalized. Patient and family education by the oncology nurse at the completion of cancer therapy should entail sharing information about the prominence of recurrence anxiety.

Talking about how patients will manage this response is critical, especially as family caregivers can experience their own version. Disparate approaches to recognizing a suspicious symptom (ie, a new source of pain, an increase in constitutional symptoms such as lethargy or changes in appetite) increase stress within the family. If the survivor chooses to cope by dismissing a suspicious symptom and the spouse urges immediate reporting of it, conflict can occur. Anticipatory discussion about how coping will prevail in the presence of anxiety about new symptoms fosters optimum decision making within a noncrisis situation.

Lastly, oncology nurses should be aware of the availability of cancer phase-specific support options. Groups addressing the stressors unique to the paradigm of living with a history of cancer offer the ideal platform for discussion about recurrence anxiety. Because of the often intense, long-term relationship oncology nurses have with their patients, their counsel about recurrence anxiety is critical to minimizing the emotional sequelae of living on after cancer.

Lebel S, Ozakinci G, Humphris G et.al. From normal response to clinical problem: Definition and clinical features of fear of cancer recurrence. 

Psychosocial Nursing Care Along the Cancer Continuum (3

2018. Bush NJ & Gorman L (Eds). Oncology Nursing Society Press: Pittsburgh, pp. 27-41, 2018.

Lee-Jones C, Humphris G, Dixon R, Hatcher MB. Fear of cancer recurrence: A literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. 

Mirosevic S, Thewes B, van Herpen C et.al. Prevalence and clinical and psychological correlates of high fear of cancer recurrence in patients newly diagnosed with head and neck cancer. 

Butow PN, Turner J, Gilchrist J et.al. Randomized trial of ConquerFear: A novel, theoretically based psychosocial intervention for fear of cancer recurrence

Atechi T, Yamaguchi T, Uchida M et.al. Smartphone problem-solving and behavioral activation therapy to reduce fear of recurrence among patients with breast cancer (Smartphone Intervention to Lessen fear of cancer recurrence: (SMILE project): protocol for a randomized controlled trial. 

Imai F, Momino K, Katsui J et.al. Smartphone problem-solving therapy to reduce fear of cancer recurrence among breast cancer survivors: An open single-arm pilot study. 

Oncology nurses must expect some degree of distress from their patients. Here’s how they can make a difference.

When Patients Deal With Recurrence Anxiety, Oncology Nurses Can Help

It was the mid 1990s. The highly regarded nurse speaker, Tim Porter-O’Grady, DM, EdD, ScD (h), APRN, FAAN, FACCWS, came to our hospital to speak to the nursing leadership group about change, the future, innovation, and the role of nursing within this paradigm. He made a point of saying that nurses need to be more proactive than reactive within healthcare. This was around the time that technology was making its way into the daily lives of staff practicing in the acute care setting. Computers and electronic medical records were the focus. Porter-O’Grady addressed the more mature nurses in the audience. To paraphrase his remarks, he said something like the following.

Computers are coming whether you like it or not. They will be a huge part of your life at work, and their arrival is only the tip of the iceberg. The changes ahead of us are formidable mostly due to advances in health care technology. So, you have a choice. You can dig your heels in and keep your reactive way of being or you can proactively embrace what’s coming and get ready for a much different nursing future.

This statement was made over two decades ago. His remarks and predictions certainly have proven to be accurate. So, based on what we currently are seeing now in our workplaces, what can we envision in the next decades?

Wearable technology (many prototypes of such have already been created by the military) will prevail. This will facilitate communication of vital signs and other physiological parameters such as oxygen saturation remotely into centralized databases for monitoring and decision making. Genetic advances will continue to impact cancer treatment with the possibility that genetic discoveries will be able to stop cancer’s evolution in its’ tracks.

Choices about the ideal treatment regimen for a patient may be made by computers, not physicians. Drugs will increasingly be administered via non-invasive routes, with topical, intranasal, mucosal, and oral administration being the norm. This will require fewer infusion nurses and more staff to oversee adherence not only to medications but also to screening and follow up. With this, we can expect in the future that nurses will be paid for what they know, not for what they do. The ability to motivate and promote positive health-related behaviors will hopefully be compensated. Evidence-based algorithms generated by computers will dictate optimum interventions rather than physician-derived prescriptions. Those who chose not to adhere to wellness guidelines may pay higher insurance premiums.

What do you think about these crystal ball projections? The one thing I can be certain about is this: Just as we look back two decades and see enormous change between how we practiced in 1995 and how we practice in 2020, we must expect comparable change in the coming decades.

Technology continues to change the field of cancer care. Here are some other thoughts on what else might shift in coming years. 

A Nurse's Prediction on the Future of Healthcare

For nearly 10 years, I lived in the metropolitan Washington, DC, area. At any given time, our oncology unit was representative of a mini United Nations. You name the country, we had a patient from there. In the Fairfax County region of northern Virginia where I lived, over 100 languages were spoken within the elementary school system. I found myself practicing in a melting pot of immigrants, foreign visitors, and a considerable population where English was spoken only sporadically or as a second language. I became intrigued by the degree of this diversity I was exposed to, as this was not my norm in my formative years. I subsequently made it my mission to foster not only my own cultural sensitivity, but also that of my colleagues.

On the oncology unit, we established a series of “Brown Bag” lunches where we invited professional colleagues born outside the United States to have lunch with us to share with nursing staff their country’s beliefs, practices, and norms. I chaired the multicultural task force for my hospital. Our group organized lunches for hospital staff where restaurant owners from over 20 countries set up tables with their most popular foods for us to sample. It was a great event! We subsequently created a program on our computer system where staff could access information about a variety of cultural and religious norms— something that there was an established need for at the institution.

 Common phrases in Spanish, Korean, Vietnamese, Mandarin, and Farsi were on this site, and the nursing staff identified the most common statements or questions that were needed. A nurse could subsequently show the non-English equivalent of a phrase to the patient/ family to inform and educate them about what would be transpiring. Phrases such as, “You will be taken for an x-ray,” “Point to where it hurts,” or “This is the medicine to help you sleep” were translated. Our efforts were a huge success both for our patients throughout our hospital system and for our professional staff who were eager to enhance their cultural connections.

Now, more than 20 years later, this agenda of cultural sensitivity is even more pressing within our specialty. This is particularly true in the Unites States where our demographics are undergoing radical change. Consider the following:

• Non-Caucasians will more than double between 2012 and 2060 to represent 57% of the American populace;

• Within the past 5 years, Asians have doubled in number, now representing 8% of the US population:

• Hispanics are the most rapidly growing minority group in the Unites States; unfortunately, cancer in this group is diagnosed at earlier ages and the patients have mortality rates higher than non-Hispanics.

As the country evolves and becomes more diverse, the presentation of prominent cancers will change, too. Immigrants may present with risk factors associated with their country of origin. Cancers associated with lifestyle factors (ie, diet, smoking, obesity) and viral exposure (ie, human papillomavirus, hepatitis B) may increase in regions with high numbers of select immigrant groups. This may influence the need for cancer-specific community education and screening in specific regions. Case in point is Asian immigrants living on the West Coast not receiving hepatitis vaccinations in their formative years and now being vulnerable to primary hepatocellular cancers.

Being culturally astute is much more than knowing cancer rates and risk factors specific to ethnicity and country origins. It requires sensitivity to numerous issues linked with patient and family attitudes and behaviors exhibited within the US healthcare system. These include participation in screening, interpersonal exchange using the word “cancer”; diagnosis disclosure; the roles of diet, rest, and complementary approaches; acceptance of care provided by other genders; role of the family in decision making; and symptom reporting.

 Of critical importance is the role of cultural sensitivity within the paradigm of end-of-life care. This is inclusive of religious orientation, communication of family norms, reluctance to withdraw life support, responses to pain, and the implementation of rituals at the end of life.

 Because of this broad scope of influence, health professionals’ perceptions, attitudes, and behaviors related to those of other cultures must be addressed. Considerable personal awareness underscores this sensitivity.

Most cultural norms are culturally prescribed. Those from outside the United States can differ from our American standard, often leading to judgmental reactions and frequent labeling of these interactions as “difficult.” The diversity of our American mosaic requires reflection. Does the traditional staunch New England norm of nondisclosure of feelings differ from those reared in the more liberal West Coast culture of expression? It is time to mandate all professionals consider their bias as our future portends a dramatically different cultural environment.

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U.S. Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century from Now

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The United States is home to people of many different backgrounds, making it important for oncology nurses to be culturally competent.

The Cancer-Culture Connection

Being a long-tenured oncology nurse who has resided in numerous cities over the years, I have frequently been asked for advice by family, friends, and colleagues who the “best oncologist” and the “best hospital” is in my locale. Historically, those of you who have been in similar shoes like mine responded to this query based on our professional experiences and knowledge of practice standards within our community. This was my case decades ago when my father was initially diagnosed with early-stage lung cancer and required surgery. I immediately sought advice from expert nurse and physician colleagues who worked in the city where he was to receive treatment.

Decisions on the receipt of contemporary cancer care, however, do not solely rely on opinion and word of mouth. In today’s healthcare environment, an evolving and increasing dataset of quality metrics is available to augment decision-making about the “where” and “by whom” cancer care is optimally delivered. Case in point were the results of a recent investigation evaluating mortality in Medicare beneficiaries treated in leading cancer hospitals and their network partners.

65 years) having undergone complex cancer surgery (i.e., lobectomy, esophagectomy, gastrectomy, colectomy, pancreaticoduodenectomy [Whipple procedure]) comprised the sample. Ninety-day perioperative mortality was the outcome measure. Two groups were compared. Group 1 included 17,300 older patients who underwent complex surgery at 59 top-ranked cancer hospitals. Group 2 included 11,928 older patients who underwent comparable procedures in 343 network-affiliated hospitals which represented a total of 49 networks. It was determined that surgery performed at affiliated hospitals was associated with a higher 90-day mortality rate. When hospital attributes were added to adjusted hierarchical regression analyses, surgical case volume and institutional teaching status influenced the magnitude and significance of the differential.

These findings enhance oncology nurses’ understanding of current treatment deliberations specific to surgical oncology. Probably most important is that the results challenged an assumed equivalence in cancer care based on affiliation status. With improved treatment outcomes being quantified in the top-ranked cancer hospitals, the researchers posited that perhaps the more complex, high-risk surgeries should be triaged to these sites. Greater experience relative to higher case volumes and the availability of specialty physicians and nurses may be associated with these findings. The second implication of this research was the need to share best practices and novel surgical techniques with network affiliation facility staff.

Surgical oncology nurses practicing within top-ranked cancer hospitals have numerous opportunities to share their expertise. This includes critical thinking (especially in the early recognition of negative patient sequelae), optimum management of wounds inclusive of dressings and other products, infection prevention (especially pulmonary interventions), and approaches to enhance early mobility (including ideal post-surgical pain management with the integration of physical therapists’ expertise).

Increased public access to quality metrics requires everyone on the specialty cancer care team to maintain a state of hyper-vigilance in reviewing outcome measures, sharing information about new approaches, and collaborating on the development of novel strategies to improve quality.

Hoag JR, Resio BJ, Monsalve AF et.al. Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. 

, 2019. 2(4): e191912. Doi: 10.1001/jamanetworkopen.2019.1912.

People often ask nurses where the best hospital or doctor for cancer treatment is. How much does the answer to that question matter?

Debi Boyle MSN, RN, AOCNS, FAAN