October is recognized as Breast Cancer Awareness month, and it is difficult not to notice the theme at every turn, from worldwide landmarks with pink lights—Buckingham Palace, the White House, and Tokyo Tower, to name a few&mdash;to professional athletes altering their uniforms with pink socks, sweatbands, and caps. During this month, you can also find seminars, conferences, and screenings centered around breast cancer. Advertisements on television and social media, too, are loaded with the color pink and the symbolic pink ribbon.

Despite all these efforts to bring awareness to breast cancer, as an African American woman, it is heartbreaking to read the statistics about my ethnic group and the treatment disparity that still exists in 2019. 

 reports that among African American women with breast cancer younger than 50 years old, they have a mortality rate double that of white women with breast cancer.

Not only are more aggressive forms of breast cancer diagnosed in African American women than white women

—such as triple-negative breast cancer (TNBC), which has limited treatments available and can’t be treated with hormonal therapies&mdash;but the disease is being diagnosed at more advanced stages. Contributing factors to these inequalities include social and economic disparities, cultural differences, biological differences, and lack of access to high-quality healthcare. The socioeconomic disparities stem from fewer opportunities and lack of access to resources, such as employment, income, education, housing, healthy foods, and standard of living compared to white Americans. The higher cancer burden may also reflect different rates of behavioral risk factors for cancer such as smoking.

Are we looking close enough at the biological differences? Why are black women more opt to develop TNBC that is most likely not due to a 

 Does socioeconomic status determine the type of breast cancer diagnosed in these women? Could there be a gene mutation expressed in black women that has not yet been identified? In order to dive further into the germline DNA, clinical trials need to include more African American women.

With what we already know, how can we begin to close this disparity gap? I believe knowledge is power and without knowledge, life is lost. Education is key to closing this gap. The American Cancer Society has done a lot of work to bring awareness to underserved communities through prevention and early detection programs and services, by providing transportation to treatment and lodging during treatment, and by assisting with navigation through the healthcare system.

 Community leaders, cancer advocates, health care workers, organizations, associations, and anyone who has an interest in the community must join forces to help bring their own awareness to the unique challenges that African American women with breast cancer face.

The technology is available, and new breakthroughs and treatments are continuing to be revealed, but African American women are not receiving many benefits from these advancements. Much work is still needed to improve the mortality rate and close the disparity gap of African American women with breast cancer.

DeSantis CE, Ma J, GHaudet MM, et al. Breast cancer statistics, 2019 [published online October 2, 2019]. 

Forster V. Breast cancer death rate continues to drop, but black women have far higher mortality rates. 

forbes.com/sites/victoriaforster/2019/10/02/breast-cancer-death-rate-continues-to-drop-but-black-women-have-far-worse-chance-of-survival/#681548922054

Cancer Facts & Figures for African Americans 2019-2021

. Atlanta, GA: American Cancer Society; 2019. 

cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf

The biology of cancer health disparities. National Cancer Institute website. 

cancer.gov/research/progress/discovery/biology-cancer-health-disparities

Articles

Despite advanced technology and new treatment breakthroughs in cancer care, treatment disparity remains among African American women with breast cancer.
 

African American Women Aren't Receiving the Benefits of Breast Cancer Awareness

Many patients receiving cancer care treatment may experience multiple appointments from outpatient to inpatient, radiation, and other specialty areas. To ensure that our patients are receiving the same consistent quality care across appointment offices, collaboration among nurses is paramount. I have firsthand experience in witnessing the power of nursing coming together for one common goal: our patients. 

In the history of our institution, never have such collaboration existed. However, in the efforts to deliver the same care across buildings and practice the same safety model, the 2 sides decided to come together and join forces in this first-time effort. Although a huge undertaking, the 2 sides were eager to jump on board. The successfulness of this initiative would not have been possible without the collaborative efforts from nurse educators and nurse management from both sides of the fence. This collaboration also included other disciplinarians such as pharmacy, corporate health, environmental services, and risk management. This was a yearlong effort with continuous meetings among all parties, reviewing and aligning policies and procedures, streamlining equipment’s and supplies, and integrating skilled competencies with both in-patient and out-patient nursing staff. 

During this process, much more was gained than what we could have ever anticipated. Nursing staff from both sides of the street began to network with each other, learning more about each other’s practices. Some of the nurses went on a field trip to the other side to understand each other’s work flow. Relationships were built and each side truly began to understand how valuable one another is and how this coming together was essential in giving the best quality care to our cancer patients. Because these relationships were developed communication have improved between both sides when patients have to go from outpatient to inpatient or vice versa. Whereas before, communication was minimum to none and it was not always clear to nurses what was happening with their patients when they left and went to either inpatient or outpatient. 

Due to this collaboration, areas for improvements were identified and resolved, new processes were established, and a paging support system was put in place for chemo spills. 

The American Nurses Association (ANA) defines collaborative care as, “Integrated enactment of knowledge, skills, and values and attitudes that define working together across the professions, with other health care workers, and with patients, along with families and communities, as appropriate to improve health outcomes.”

Because nurses are specifically trained to understand the role of other health care providers, according to 

, this training provides a strong foundation for successful collaboration.

As an educator from the outpatient setting and collaborating with inpatient educators we were able to share resources, thoughts and ideas. The educators from both side came together and developed an all nurse competency that brought all infusion nurses under one building in one conference room working and learning with one common goal.

At the conclusion of this massive gap bridging construction the educators from both sides decided to not just end here but to continue regular meetings for further collaboration in streamlining education opportunities, oncology nursing grand round, evidenced base practices and any other opportunities that may present itself for continued collaboration.   

It is proven that when nurses come together and collaborate the best outcome is patient satisfaction.

1. American Nursing Association. Collaborative health care: nurses work in team base setting 2016. American Nursing Association website: 

https://www.nursingworld.org/education-events/career-center/nursing-career-resources/

2. Health Times. Nurses in collaborative care teams 2017. Health Times website: 

https://healthtimes.com.au/hub/nursing-careers/6/guidance/healthinsights/nurses-in-collaborative-care-teams/2879/

Collaboration among nurses is paramount, and when they come together the best outcome is patient satisfaction.

Finding Success Through Nurse Collaboration

The World Health Organization (WHO) has validated burnout in the workplace by identifying it as a medical diagnosis and adding it to the 11

 version of the International Classification of Diseases (ICD) if certain criteria are met. WHO lists 3 areas to diagnose burnout: feelings of energy depletion or exhaustion, increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job, and reduced professional efficacy.

Burnout is common in nursing and can be more common depending on the area or specialty the nurse works in, such as oncology.

 concluded that, “the presence and the risk of burnout among these staff members are considerable.”

Studies have given attention to oncology nurses due the type of care provided for patients with pathologies that can cause death and/or dramatically alter their lives. Oncology nurses oftentimes have to cope with the grieving, suffering, and loss of not only their patients but within their own families.

Now that burnout is a medical diagnosis, how will companies address this with their employees? Many organizations have available, employee assistance programs (EAP). EAPs provides support, counseling, and resources for life issues that can take a toll on your emotional well-being or take time away from the things you value most. Other options that an organization can offer is training to help employees identify stress, normalize work-related stress, and promote self-care. Mindfulness meditation and gentle mindful movement classes are offered in the cancer center I work twice a month. However, is this enough?

Nurses work under very difficult conditions including long shifts, rotating shifts, increased patient load with high acuity, and understaffing.  Other factors contributing to nurse burnout is the combination of aging baby boomers, retirement of nurses, and a lack of facilities to train more qualified nurses.

Considering all of this, it is projected that nursing shortage will be severe between 2020 and 2030. These factors, along with caring for patients with cancer, is enough to cause nurses to be burned out, exhausted, fatigued, and produce low productivity. In order to improve burnout syndrome, the root causes have to be addressed. What is being done today to help identify solutions today and for the future?

The American Association of Colleges of Nursing (AACN), is working with schools, policymakers, nursing organizations, and the media to bring attention to this healthcare concern. AACN is leveraging its resources to shape legislation, identify strategies, and form collaborations to address the shortage.

 Thankfully, work is being done by associations and employers to help minimize burnout phenomenon. However, due to the nature of the nursing career nurses are the most important ones to minimize their own burnout. Nurses have to take an active role in their own lives.

Nurses can help themselves by keeping professional life and home life separate and avoiding dwelling on work issues at home, which will allow for easier relaxation when off the clock. Take time for self-care by maintaining a well-balanced diet, exercise, and getting adequate rest. Enjoying hobbies and investing in relaxation techniques like meditation or journaling are also excellent ways to relieve stress.

Fellow nurses, just as we love and care for our patients we must love and care for ourselves if we are going to continue in the field of nursing healthy both physically and mentally.

Prior R. CNN. Burnout is an official medical diagnosis, world health organization says, CNN website. 

https://www.cnn.com/2019/05/27/health/who-burnout-disease-trnd/index.html

. Published May 27, 2019. Accessed June 18, 2019.   

Gullermo A, Canadas-De la Fuente JL, Gomez-Urquiza EM. et al; Prevalence of burnout syndrome in oncology nursing: a meta-analytic study. 

Nursing shortage. American association of colleges of nursing. AACN website. 

https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage

Nurse burnout. Nursing.org. Nursing .org website.  

https://www.nursing.org/resources/nurse-burnout/

The nursing shortage will be severe, ultimately increasing the number of burnout syndrome among nurses. Nurses will have to take an active role in their own lives to minimize burnout.

ICD 11-Code Burnout: Oncology Nurses Are at Risk

The airline attendant instructs passengers in the event of an emergency to always put their safety equipment on first then help those who need assistance. This same message is resonating across healthcare systems from regulatory bodies to nurses and other healthcare providers administering and handling hazardous drugs (HDs). In order to safely treat and care for our patients, healthcare providers must first protect themselves.  

In the effort to provide patients the best care possible, many nurses have sacrificed their own safety from skipping out on lunch, having minimum to no bathroom breaks, and not properly wearing their personal protective equipment (PPE). However, this effort from nurses can be detrimental to their own health. If nurses are not healthy how can they care for their patients?   

As I sat in a small group session with other oncology nurses from different communities and infusions centers to discuss PPE, I heard many reasons why it is difficult for nurses to comply with PPE guidelines. Some of the reasons I heard were, “It takes too much time to put it on,” “I’ve been a nurse for many years and I’m OK,” I’m too busy to have to stop and put all that on,” and “the PPE makes me hot.” I was amazed to hear some of these reasons from oncology infusion nurses, although I understand them the potential risks associated with 

The use of PPE provides healthcare workers protection to reduce exposure to HD aerosols and residues.

 Unintentional exposure to HDs can affect nervous system, impair reproductive system and increase risks of developing blood cancers.

PPE have always been strongly recommended, but never mandated. As I round through the infusion centers, I have observed PPEs half worn or not worn at all. I have witnessed nurses being exposed to chemotherapy during spills because PPE was not worn properly. As an educator, I encourage nurses to wear PPE and continue to educate them on the importance of this protection. However, we now have support to regulate and enforce the use of PPE.

The latest United States Pharmacopeia chapter 800 (USP800) has expanded upon recommendations from the National Institute for Occupational Safety and Health (NIOSH), Oncology Nursing Society (ONS), Occupational Safety and Health Administration (OSHA) and American Society for Health-Care Pharmacists (ASHP) to provide a complete set of standards for all healthcare workers to ensure the safe handling of HDs across the healthcare system. As of December 2019 this latest chapter will be enforceable by each state’s board of pharmacy or delegated agency.

USP 800 requirements include responsibilities of personnel handling HDs; facilities and engineering controls; procedures for deactivating, decontaminating and cleaning; spill control; and documentation.

 These standards apply to all healthcare personnel who receive, prepare, administer, transport or otherwise come in contact with HDs and all the environments in which they are handled.

I believe this is a step in the right direction with increasing new HDs arising for the treatment of various cancers. This protection will allow those who work with HDs to continue their work with decreased risk of exposure from these drugs and decrease potentially long term complications.

Healthcare workers must take care of themselves first so that we can continue to care for their patients. It is easier to stop and take a few minutes to protect yourself than to find yourself in a position of dealing with a compromised health that could have been prevented.  

USP. USP general chapter 800 hazardous drugs-handling in healthcare settings. USP website. 

Live Science. Nurses exposed to toxic cancer drugs, study finds. Live Science website. 

https://www.livescience.com/15721-nurses-exposed-toxic-cancer-drugs.html

. Published August 24, 2011. Accessed May 17, 2019.

Eisenberg S; Hazardous drugs and USP 800. 

. 2017,21(2): 179-187. doi: 10.1188/17CJON.179-187

Beans B.E; USP 800 adds significant safety standards. 

Taking a few minutes to protect yourself from exposure to hazardous drugs is better than your health being compromised.

Safety First: The Importance of Personal Protective Equipment

The month of February brings hugs, kisses, flowers, and lots of chocolate. It is difficult to ignore all the advertising this month to convince us to buy chocolate for ourselves or someone else. But aren’t we told to avoid sweets such as chocolate to decrease our risks for heart disease and cancer? You might be surprised that chocolate is not as bad as you think.

Research have shown that some types of chocolates may actually be beneficial to your health. Chocolate contains a phytochemical compound called flavonoids found in cocoa beans. A flavonoids is an antioxidant that can prevent or slow damage to cells caused by free radicals thereby potentially assisting in the prevention of cancer

. A study for potential preventive effects of cocoa in cancer found that, “Cocoa and its main polyphenols have been reported to interfere at the initiation, promotion and progression of cancer.”

 More specifically, another study showed that cocoa could reduce inflammation in the colon due to the anti-inflammatory bioactive compound in cocoa. Further, much evidence exists that connects intestinal inflammation and colorectal cancer.

Who would have thought chocolate could prevent cancer? That sounds amazing! But before you run to buy loads of chocolate, it is important to know that all chocolate is not created equal. To reap the most benefits from flavonoids you will have to eat dark chocolate, which has a higher percentage of cocoa. Dark chocolate is defined as having at least 60% cocoa with little to no add sugar. The American Cancer Society recommends a high-quality dark chocolate with at least 70% cocoa.

 The most advantageous way to eat dark chocolate without any added ingredients such as caramel, peanut butter, marshmallow, etc.

Not only does dark chocolate help fight cancer, but it is also believed to helps reduce the risks of heart attacks and stroke, improve blood flow to the brain and improve mood and symptoms of depression.

Debate no more if you should eat chocolate or not. Go ahead and enjoy a dark chocolate bar (in moderation) while decreasing inflammation and preventing cell damage. Check out this recipe for 

 and pair it with a glass of red wine, which also have the powerful antioxidant flavonoids.

Being able to add a chocolate component to your healthy lifestyle of fruits, vegetables, and exercise is like icing on the cake! Enjoy the Valentine season with no regrets.

Mesothelioma.net Health benefits of dark chocolate and its effects on cancer. 

https://mesothelioma.net/health-benefits-dark-chocolate-effect-cancer/

Martin MA, Gova L, Ramos S. Potential for preventive effects of cocoa and cocoa polyphenols in cancer. 

Rodriguez-Ramiro I, Lopez-Oliva E, Ramos S. et al: Cocoa polyphenols prevent inflammation in the colon of azoxymethane-treated rats and in TNF-α-stimulated Caco-2 cells. 

American Cancer Society. Can chocolate be good for you?  

https://www.cancer.org/latest-news/can-chocolate-be-good-for-you.html

Healthline. 11 health and nutrition benefits of cocoa powder. 

https://www.healthline.com/nutrition/cocoa-powder-nutrition-benefits

. August 9, 2018. Accessed February 1, 2019

Powerful antioxidants in dark chocolate may slow and prevent cell damage caused by free radicals.

Chocolate: To Eat or Not to Eat?

Throughout my career in oncology, I have often heard nurses say they love oncology because of the 

 they develop with patients and their families. Shikha Jain, MD, describes oncology as an intimate field: “Patients let you into the most intimate aspects of their lives.”

I have cared for patients for as long as 10 years. They became my family. We celebrated and cried together. Oncology nurses give patients hope and patients give oncology nurses humbleness and gratitude. But is this the only reason why nurses and other medical professionals choose oncology? What else does oncology have to offer?

There is no better time than the present to be in the field of oncology. It is exciting, rewarding, and forever evolving. In general, nurses want to grow in their field, be challenged with new research, treatments, and technologies. Oncology has all this to offer. Oncology is revolutionizing medicine with treatments such as hormonal therapy, immunotherapy, radiotherapy and more available oral therapies. Within just 5 years there have been 

 for the treatment of melanoma and lung cancer, the first new treatment for bladder cancer in 3 decades, a new class of treatments for breast cancer, and the first gene therapy for acute lymphoblastic leukemia (ALL).

 These breakthroughs are due to advanced technology and precision medicine.  

The explosion of this field calls for more advanced specialized nurses: infusion nurses, nurse educators, nurse researchers, advanced practice nurses, surgical nurses, and radiation nurses. Oncology nurses can practice in a variety of settings such as hospitals, cancer infusion centers, physicians’ offices, hospice centers, and in patients’ homes. There are numerous pathways an oncology nurse can explore. 

In addition, being certified as an oncology nurse will position you as an expert in the field, increase credibility, gain professional recognition, increase hourly rates, and open more career opportunities.

Being an oncology nurse allows you to be a part of professional organizations from which you can gain insight on what is new and trending in oncology, and meet and network with other oncology nurses from across the globe.

The oncology field is a one-stop shop of career prospects, from bedside nursing to coordination of care, education, research, leadership, and so much more. The opportunities for nurses in oncology are endless.         

With all of the great medical advances, technologies and opportunities available to be an expert in the field, my all-time favorite reason for being an oncology nurse is the smile, hug, and thank-you from patients who return months or years after receiving cancer care to express their appreciation.

Why oncology is an intimate field. Op-Med website. 

opmed.doximity.com/articles/why-oncology-is-an-intimate-field-d0cf0ce3-287a-46c7-8158-b2776ae4c65c

. Posted March 13, 2018. Accessed January 16, 2019.

Major milestone against cancer. ASCO website. 

asco.org/research-progress/cancer-progress-timeline

Seven reasons why oncology nurses should get certified. American Nurse today website. 

americannursetoday.com/seven-reasons-why-oncology-nurses-should-get-certified/

My all-time favorite reason for being an oncology nurse is when patients return after receiving cancer care to say thank you!

Why Choose Oncology as a Career Path?

Along with the continuation of new and exciting advancements in cancer care, comes the complexities of treatments, adverse events, and symptom management. To best care for patients, expertise is required and a preceptor program in oncology is critical to the sustainability of our practice.

Knowledge and critical thinking are just some of the skills nurses need to assess patients’ symptoms and know the difference between a simple case of diarrhea and a possible bowel obstruction; or what may appear to be a non-emergent, low-grade fever but could actually be signs of septic shock from undergoing oncology treatment.

As technology is advancing, fast-track educational programs with more online courses and fewer classrooms are becoming a reality. However, nursing leadership should ensure novice nurses entering oncology are paired with experienced nurses. As a clinical nurse educator who onboards nurses new to the oncology field, I recognize a great need for strong preceptor programs specific to oncology that should be the foundation to build competencies and enable nurses to obtain certifications and continuing education units (CEUs), foster professional relationships, and encourage participation in professional organizations such as the Oncology Nursing Society (ONS).

Preceptor programs are not a new concept in nursing. These programs have long been developed to transition new graduates from the classroom to the patient’s room. However, the same attention and dedication should be implemented for nurses entering the oncology field even with years of experience in general nursing and advanced practice nursing. Oncology advanced practice nurses (APNs) often serve as preceptors for those new to the cancer space because many graduate nursing programs do not have robust oncology-specific offerings.

Oncology preceptors would be able to provide the inexperienced nurse with knowledge, skills, and focused assessments that can help them increase their competence. Preceptors not only provide practical clinical education but also support a novice nurse as their mentor and coach.

I have found, when precepting nurses, that the more exposure they are given to learn the higher level of care, the more they will be able to provide such care to their patients. An infusion nurse who cares for patients with breast cancer may benefit from opportunities to shadow experienced nurses in areas such as mammography, radiation oncology, surgical procedures, or new patient consults.

Preceptor programs also benefit organizations, improving staff retention and increasing satisfaction with new employees’ orientation. According to 

, a publication of the Association of periOperative Registered Nurses, “the partnership between a preceptor and an orientee sets the foundation not only for the nurse’s success in that organization but also for the nurse’s overall success in the nursing profession.”

Ultimately, the success of an oncology preceptor program will benefit patients who have cancer, ensuring that they receive care from a highly skilled, competent oncology nurse.

Robitaille, P. Preceptor-based orientation programs for new nurse graduates. 

Bazzell, A, Jones, T, Dains, J, Champion, J. Assessing the needs of oncology APRN preceptors. 

 2018;14(4):296-301. doi: 10.1016/j.nurpra.2017.12.008.

A strong preceptor program specific to oncology is needed to help train nurses new to working in the field.
 

From Novice to Expert Through Preceptorship Programs

Karen Harris is a clinical nurse educator at Robert H. Lurie Comprehensive Cancer Center (RHLCCC), Northwestern Medicine in Chicago. Karen transitioned to nurse educator after many years of working as an infusion nurse. Her strong desire to teach led her to her current role, educating and mentoring new nurses entering the oncology field. Karen was instrumental in the development of the first preceptorship program at RHLCCC to develop high-level oncology nurses. Karen also chairs RHLCCC’s Best Practice committee, ensuring evidence-based practice across the cancer center.

Karen Harris, MSN, RN