Theresa Brown, PhD, BSN, RN, began her professional career as an English professor, but changed direction when she returned to school to study nursing. It did not take too long for Brown to find a home in oncology nursing practice, honing a particular interest in palliative care and supporting patients and families at the end of life. Brown has penned many articles and blog posts about life as a nurse and her current practice focus on hospice care, offering insightful and thought-provoking perspectives on healthcare today. She is a frequent contributor to the 

, Critical Care: A New Nurse Faces Death, Life, and Everything in Between 

The Shift: One Nurse, Twelve Hours, Four Patients' Lives 

 follows Brown as she cares for her patients during a 12-hour shift on an oncology ward. Any nurse who has worked in a hospital can identify with the many challenges Brown faces, the decisions she must make, and how she struggles to keep her day on track. Oncology nurses can identify with the issues unique to caring for patients with cancer, their families, and the spirit of hope and healing that underpins it all. 

 spoke recently with Brown about the challenges—and the rewards&mdash;that define her occupation.

How did you decide to specialize in oncology, and specifically palliative and hospice care?

There's a lot of cancer in my mom's family, so I always had an interest, fascination, and then fear of oncology. When I first went into nursing, there was no way I ever thought I would choose oncology. But by the end of school, it just felt like absolutely the right fit. It's such an interesting field. You always have to be paying attention to everything that's going on with your patients, and I really like that. There are always new developments and new things to learn. It's very sad at times, too, but it wasn't the sadness that drew me to it, obviously. It was the positive aspects.           

I think hospice is an extension of oncology. I feel like the two fields really should be seen as connected. I really wanted to see some better endings and be in that space with people and their families. I found out I was able to do that. It's hard, but it didn't make me uncomfortable. I didn't feel like I had to run away, and it's such a privilege to be there with people and acknowledge that someone's life is ending, and how hard that is and what it brings up. It's really an opportunity.

What are your thoughts on both the challenges and the rewards of practicing in oncology and palliative care? 

I think when people die is the hardest thing any of us will ever face, whether it's our own death or the death of someone we love, because death is the only thing in life that really is final. You can't reverse it. You can't change it. You have to deal with it because it's so concrete and that's what makes it hard, but it makes the time surrounding someone's death so incredibly rich.

Yet, emotionally, there's so much opportunity to really validate what people have done in their lives and also to validate the caregivers. Most of the people I see are in home hospice, and someone in their family, often more than one person, is taking care of that dying person. In this role, we have the chance to tell them, "Look at what you're doing. It's amazing.” I think people in that situation take their own caregiving for granted, so I love being able to say to them, "You just get a gold star as a human being for doing this amazing work." Our society doesn't really thank people for doing that work, and we should.

There's so much promise, and yet there is still so much disease that we can't cure, so that's really frustrating. We've gotten so much better at treating some diseases. But even among those that we're so amazing at treating, sometimes people just get a really bad form of the disease and we can't help them. That's very hard. 

 A second challenge is that there's always so much to learn. This is exciting, but it can also feel overwhelming—new drugs, new treatments, new ways to treat symptoms of chemotherapy, and new protocols for giving chemotherapy.

I guess the biggest challenge is that there are just some really sad times because people are often long-term patients. You get to know them well, and then it's hard when things end badly.

How can we as nurses help each other meet these challenges? 

First, supporting the idea of ourselves as trained professionals and underscoring that we need to always keep learning. Oncology nurses could really lead the way on that really support new nurses in that learning process.     

When we’re dealing with the sad parts, such as the promise and the frustration when treatment doesn't work, what's most helpful is having an emotionally open environment. That's what really helped me. If I was feeling sad about a death on the floor, I knew I could go talk to one of the nurses I worked with. My colleagues would just get it, and they would acknowledge that. There were times when it seemed like death would sometimes come in waves, and it was really hard on all of us, but everybody acknowledged that. I think acknowledging this part of our work is so important for not burning out and holding onto your humanity and what got you into the field in the first place.

In your book you talk a lot about the nurse/doctor relationship. What is your take on the relationship? For example, if we feel a patient needs more pain medication but the doctor doesn't agree, how do nurses navigate this and get the patients the support that we feel they need?

That is a great question, and the answer of course varies depending on what kind of doctor you're dealing with. If it's a new intern or a resident, they may just not know or they may have been cautioned against overmedicating patients. Or they've never been in oncology and they don't know how painful cancer is and how freely we give people narcotics because they need them. That can be a process of educating them and saying: “This is a standard dose. This is what we do,” and then trying to work with them. If they say, "I need to talk to my resident," if there's time to let that play out, let that play out.

If it's a fellow or an attending being kind of stubborn for reasons that aren't clear, that's when I tend to be more assertive and say, "We really need to treat this pain. This patient is really uncomfortable. Here's what we've been giving. Here's how they've been responding to it. It just seems like it's really not working," and then have a proposal, for example, "What if we put them on patient-controlled analgesia, or what if we scheduled regular Dilaudid instead of having them ask for it?"            

I've found even with some attending physicians, who can be brusque, if I spell out a problem like that, it usually gets their attention and they'll do something. Physicians are so busy themselves that sometimes they really have to be pressed to make that extra diagnostic and prescribing effort. That's my experience with most of them. It's not that they don't care or they're indifferent, they're just in too much of a hurry.

If you could make one change, what do you think could make the biggest difference in improving life among patients on the oncology ward right now? 

The first thing that comes to mind is staffing. Have more nurses. Just have more nurses so that every patient could have the level of attention they really need. Then our documentation could also get done the way that it's supposed to get done. I visited MD Anderson Cancer Center a few years ago, and their ratios are 2 to 1 on the bone marrow transplant floor—amazing. The nurses were still busy, they just weren't frantic. I think we could then really perform to the full scope of our practice because we wouldn't have to be always thinking, "How can I get this all done?"

That's something that really comes through in your book—that you're mentally revising your “to-do list” all the time. Has technology made the job easier?

I find that charting takes us away from patients. I've been wondering if one aspect of it is just computers and med carts. I wonder if we could chart on iPads, because then you could really sit in a room and look at the patient and talk to them. It would be just like writing, which really doesn't feel that intrusive. If in the old days I'm talking to my primary care provider and he's writing things down, I never felt like that was alienating in the way I do now when he's on the laptop.

I think if we could make software that was easier to use it would help: less use of point-and-click and dropdown menus. Those things are just complete time-wasters and destroyers of concentration. If documentation could really flow, that would make a huge difference. They say we can chart in the room with the patient, but my experience is that people don't like to talk to you when you're looking at a computer screen, and I don't like to talk to people when I'm looking at a computer screen.

Sometimes we hear other nurses discouraging people from entering the profession. What can we do amongst our own to help nurses feel better about their role?

What I tell people is, "It's a great job—it just doesn't get the respect that it deserves." I think we really need a nurse self-esteem movement where we're proud of ourselves and proud of what we do. Physicians, they internalize this message. There's hazing in their education, and they're tired, and there's all this hard stuff, but I think they're reminded a lot that they're going to be doctors and they're going to be important, and nurses are not good at that. I really think that we should be. You can be hard on people and get them to learn and make them feel like they are fabulous at the same time. I really would like all nurses to have that feeling, more like, "This is a great job. People don't always see that, but that doesn't change the truth."

Your book does a great job of going through a nurse’s day, but if you had to give a quick answer to the question, “What do nurses do,” what would it be? 

I would say the nurse is in that middle place between the doctor and the patient. I would also say that the nurse is the human face of the hospital.

Marijke Vroomen Durning, RN, is a freelance writer who specializes in patient education and health and wellness topics. 

Articles

Theresa Brown, PhD, BSN, RN, began her professional career as an English professor, but changed direction when she returned to school to study nursing.

Hope, Healing and the 12-Hour Shift: Talking With Oncology Nurse Theresa Brown

Compassion fatigue ... burnout … job-related stress. Whatever the term used to describe it, most oncology nurses will have experienced the feeling themselves or witnessed it in their colleagues, and more than likely, both.

Burnout is a word that many people use to describe what they feel when they can no longer work effectively. It is a reaction to external forces, such as overwork, difficult working conditions, or conflicts with bosses or coworkers, and results in a breakdown in the ability to stay focused and on task.

People from all walks of life and all professions can experience burnout, but it can go deeper among people who work in caring and giving professions like nursing. These professionals can also develop compassion fatigue (CF).

Charles Figley, PhD, now the director of the Tulane University Traumatology Institute, formally defined 

 in 1995 as a combination of burnout and secondary traumatic stress, the type of stress experienced by people who care for others who are traumatized or are suffering.

Compassion fatigue affects 16% to 39% of registered nurses. And although all nurses can experience it no matter where they practice, those at highest risk are nurses working in emergency, oncology, hospice, and pediatric settings.

“In general terms, burnout is more of a personal experience, whereas compassion fatigue is a relational experience,” Jillian Kenney, BSN, RN, OCN, explained. “While some of the symptoms may be the same, the motivation behind those symptoms is the biggest difference.

“Someone suffering from professional burnout may feel that they don’t have adequate resources, they don’t have adequate compensation, and that leads to a dislike of their place in their company or business, whereas compassion fatigue results from the perceived lack of ability to attain a shared goal.”

That goal is the well-being of the patients. “If your patient isn’t doing well, there’s almost a subconscious sense of failure on the part of the nurse,” continued Kenney, a clinical nurse in oncology at the UCLA Medical Center in Santa Monica, California.

Compassion is a vital part of a nurse’s role, and compassion satisfaction is the positive side of being in a helping profession.

 When compassion satisfaction rates remain high, this is positive for both nurses and their patients. Patients who feel satisfied with the care they received reported better overall satisfaction with their hospital experience. But the flip side of compassion satisfaction is CF, and when satisfaction drops, risk of CF follows, as does the risk of lower quality patient care.

Inpatient oncology units often follow the mixed-model setting. In the course of one shift, nurses may provide care to patients who are receiving active curative treatment, while at the same time helping patients who are receiving palliative or end-of life care, depending on their assigned patient load.

By moving continuously from one situation to another, if a nurse does not feel in control or supported, he or she is at risk for CF. Patricia Jakel, RN, MN, AOCN, a clinical nurse specialist also at UCLA Santa Monica Medical Center, shared this story:

“One of my young nurses came to me. He’s a great nurse. He said to me, “The patient dies. I do what I have to do with the family, but then I have to go next door and begin the chemo on a newly diagnosed lymphoma patient, and I have to put on my happy face.” That’s really hard in a fast-paced environment. You can take 10 minutes at work, but most of us cry in our cars on the way home.”

Nurses who experience CF usually dread going to work, may have difficulty concentrating, feel nervous, anxious, or pessimistic, and have low self-esteem. Anger towards coworkers is not unusual. At first, the signs may be brushed off as having a bad shift or not feeling up to par, but as the feelings continue or intensify, this could point to CF.

The Professional Quality of Life Measurement (ProQoL) tool was developed and made available for free from ProQoL.org, to help professionals analyze their feelings, and measure how they rate on scales for burnout and secondary traumatic stress.

 This measurement has been in use since 1995, and has been used extensively in CF research. Any person or facility may download and use the tool, which can be used as a starting point determining CF.

Before every plane takes off, passengers are reminded of emergency procedures, which include instructions regarding the oxygen masks. If passengers are traveling with a child or someone who needs assistance, they are instructed to put on their own oxygen mask first, so they are able to help their companion. Nurses must take that same approach. They must take care of themselves, so they can take care of their patients and the others who need them. In her research into CF, Patricia Potter, RN, PhD, FAAN, and her colleagues determined that there were five approaches or strategies to self-care that nurses could employ, which they named compassion fatigue “antibodies.”

	Learning how to relax or achieve a feeling of peace

	Learning how to regulate thinking and perception

	Writing a covenant and choosing how to live and work

	Healthy living, participating in hobbies, etc

Self-care approaches provide nurses with a variety of options, from keeping gratitude journals to taking regularly scheduled vacations. Becca Hawkins, MSN, ARNP, ACHPCN, the Director of Compassionate Care at Providence Health & Services in Pendleton, Oregon, likes to promote mindfulness as a part of self-care. She has done extensive research and teaching about mindfulness and meditation for nurses. She uses this approach as self-care because it can be done anywhere any time—literally in the moment.

Jon Kabat-Zinn, founder of the Mindfulness-Base Stress Reduction (MBSR) program described mindfulness as an “awareness that arises through paying attention, on purpose, in the present moment, nonjudgmentally.”

“We’ve been working a lot throughout our healthcare system with mindfulness. We’ve been starting with self-compassion, and paying attention to when you’re really hard on yourself, and beating yourself up over a situation or just being negative,” Hawkins said. “When this happens, you’re not able to see the positive things.”

A good place to start with mindfulness is when nurses are washing their hands. After all, how many times a shift do nurses wash their hands, Hawkins asked. “As you’re using the hand sanitizer, you just really feel your hands, listen to your heart, feel your breath, feel whatever practices you do and it brings you back here, instead of thinking, “I’m walking into this room and I’m going to have to break bad news,” she explained.

With mindfulness, there is no looking back at what happened or forward at what might happen.  

Most nurses do already know what they should do in order to prevent CF, but knowing what to do and actually doing it are two different things.

Kenney and Jakel learned of an app that would help nurses remember to use these strategies. They initiated a study to evaluate the use of the Provider Resilience Mobile App among oncology nurses. Originally designed by the Department of Defense for those who cared for Iraqi war veterans, the app was adapted for nurses for the study. Kenney described the app as something that would remind nurses to do the small pieces of daily self-care.

“From there, it offers various resilience builders, and also helps you with your resilience killers,” Kenney explained. “It helps you see some of the negative coping strategies that you might be using and not realize you’re using. It also offers very simple resilience builders that you can do throughout the day.” The app asks when the provider last did a positive act, but it also asks things like when was the last time the user ate junk food, sat for too long, and so on, to help identify unhealthy behaviors as well.

Also included in the app is a version of the ProQoL so users can do an initial assessment, and it measures compassion satisfaction and possible levels of burnout or potential secondary traumatic stress.

Jakel pointed out that there is no one-size-fits-all approach to preventing or dealing with CF. “I think it’s a combination, be it self-care, or meditation,” she said. “I really liked that the app had daily affirmations that you could read through. The app was easy because it was there, and it was one measurement, one thing, one intervention that people could do to build their resilience.”

 Practicing gratitude and setting intentions is another form of self-care. Gratitude journals can help nurses focus on themselves and the positive things that are in their life. Hawkins believes that the act of physically writing down three gratitudes at night sets the stage for your brain to relax, allowing  you to wake up with a positive mindset. This is followed by starting your day with your intention. “This is the day I’m going to….”

The issue of CF cannot be dealt with by the nurses alone. According to Hawkins, part of the problem in dealing with CF among nurses starts with acknowledging that it is happening. “Half the workforce is burned out,” she said. “It’s interesting, because what other industry allows people to participate in the job when they’re impaired [from burnout]? It’s been shown over and over again in the literature that when you’re burned out, there’s a higher risk for errors, there’s more sickness, etcetera.”

Now that we know that CF is a problem, we have to start taking care of ourselves and each other. “That means we have to acknowledge what is hard in healthcare,” Hawkins explained.

“What is hard about oncology nursing? What do we do with all of the suffering we have born witness to? Where do we put that?” The leadership needs to put programs into place that allow the nurses to express their feelings and to help them deal with them. The leadership needs to hear what the nurses are saying without getting defensive, Hawkins said. Those in charge have to be able to listen when their nurses are talking, without thinking that the nurses are being disloyal or disgruntled.

There is a school of thought that says that you cannot develop compassion fatigue if you take care of yourself and practice mindfulness.

In a personal reflection piece published in the 

, palliative care physician Lisa Marr asks, “Can compassion fatigue?” According to Marr, in order for there to be compassion fatigue, there must be a finite amount of compassion in the first place. When this finite amount runs out, it needs to be replenished, and it starts over again.

“I believe that if we are truly engaged in that moment, not focusing on ourselves or worrying about where I should or could be at that moment, but truly engaged in the interaction with the other person, then compassion cannot fatigue, and frankly, burnout is less likely to occur.”

This brings us back to mindfulness: “If we are wholeheartedly engaged in each moment, responding to what is in front of us, not judging or labeling ourselves or others, then I believe compassion cannot fatigue. Compassion can arise anew in each situation, each moment, since it is a response to what is in front of us. It’s what we do, not who we are,” Marr concluded.

Compassion fatigue (CF) is estimated to affect 16% to 39% of registered nurses, and especially affects those practicing in emergency, oncology, and hospice settings.

Moving continuously from one situation to another can increase risk for CF.

The Professional Quality of Life Measurement (ProQoL) is available online and can help assess for CF.

To avoid CF, practice self-care and self-compassion, eg, gratitude journals, taking regularly-scheduled vacations, and mindfulness “in the moment”.

“Acknowledge what is hard in healthcare”—engage institutional leadership to improve the culture and support nurses.

US Library of Medicine. PubMedHealth. Depression: What is burnout syndrome?  

Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized

Potter P, Deshields T, Berger JA, et al. Evaluation of a compassion fatigue resiliency program for oncology nurses. 

Stamm BH. Compassion Satisfaction and Compassion Fatigue. April 26, 2012. 

Potter P. Compassion Fatigue: Prevalence Among Oncology Nurses. Presented at: Missouri Oncology Society Spring 2015 Membership Meeting; April 14, 2015. 

Professional Quality of Life Scale (PROQOL). Compassion Satisfaction and Compassion Fatigue. http://bit.ly/1OWPcb. Accessed April 2, 2016.

Compassion Fatigue: How Nurses Can Care for Themselves

More people than ever are using complementary and integrative therapies (CIT) to manage their illnesses in addition to conventional treatments. A study published in 2011 found that about 53% of American adults used CIT at some point in their lifetime, and 42% said they used it within the past year. People with cancer reported even higher use: 65% of cancer survivors used CIT at some point, and 43% used it within the past year.

The five modalities of complementary therapies include mind-body, manipulative and body-based, biologically-based, energy, and alternative medical systems. According to Gwen Wyatt, PhD, RN, FAAN, the most common types of CIT oncology nurses hear about from their patients are those of the mind-body modality. These therapies, such as meditation, mindfulness, and yoga, are often helpful for the patient and have very low risk, Wyatt, a professor at the College of Nursing at Michigan State University in East Lansing, explained. Manipulative and body-based therapies, such as reflexology and acupressure, are also considered fairly low risk, Wyatt noted. “We have increasing evidence of their efficacy,” but, she added, assessments should be made regarding how appropriate each therapy would be for individual patients.

When speaking with patients about possible therapies, nurses must weigh the potential benefits versus the potential risks. For example, while yoga may help a patient with relaxation or flexibility, a deep tissue massage could be harmful if that patient had low platelets.

From the patients’ perspective, their preference for mind-body modalities is likely because these therapies are noninvasive, Rebecca Lehto, PhD, RN, said. “They don’t involve ingesting substances, such as herbs, vitamins, or supplements, and they don’t involve needles.” In addition, if the patients are receiving treatment at a cancer center that offers integrative healthcare or has an integrative health department, these are the types of therapies predominantly offered. In addition to supporting oncology patients, many of these departments are also involved in CIT clinical research.

Mind—body therapies such as meditation are very portable. As the patients learn the techniques and how to use them, they can be practiced while sitting in treatment waiting rooms, for example, Lehto explained. “Patients can experience real benefits over time.” Lehto is an associate professor at the College of Nursing at Michigan State.

Identifying the Patients’ Therapy Goals

Patients often depend on their nurses for information about available treatments and therapies, including complementary therapies. This fits in well with the nursing focus on a holistic approach to patient care, Lehto said.

“We want to integrate the whole person into nursing care. One thing about integrative modalities is that they’re framed to address quality-of-life issues and perhaps improve emotional symptoms that a patient might be experiencing, as well as to potentially impact patient function,” she continued. “These kinds of parameters are so essential to a patient’s well-being, as well as for personal empowerment.” Just as not all patients receive the same medical treatment, their approaches to and needs for complementary therapies differ. By discussing the issues with their patients, nurses can determine what types of therapies might be of benefit to them.

To start, it’s vital to determine if their patients’ goals are realistic. “If they’re looking for something that is going to cure their cancer, we don’t have any complementary therapies that have shown the same type of efficacy as conventional treatment,” Lynda G. Balneaves, PhD, RN, said.

Are they looking for relief of physical issues, such as fatigue, nausea, or pain? Or are they trying to deal with depression or anxiety? Or both? Determining if they have used complementary therapies in the past and the outcome is also helpful. Balneaves is the Director for the Center for Integrative Medicine at the University of Toronto in Canada.

Balneaves also pointed out that a difficulty faced by many nurses is finding the time to speak to their patients about these issues. “To me, the biggest challenge is time, and for nurses, being able to find time in their busy practices to actually sit down with the patients and ask them about their beliefs and values, and what they’re most interested in learning about.”

When asked for referrals, nurses may find themselves unsure of how to proceed, particularly if they work in smaller communities with limited resources.

“When I consult with health agencies, I encourage them to do an investigation of the local practitioners and to have a list within the facility of the ones who have been checked out in terms of their credentials and their ability to work with patients with various conditions,” Wyatt said.

“I’m always looking for those that are sensitive to cancer diagnosis, because some work only with patients who have arthritis, for example. So you have to have practitioners who are familiar with patients who have the diagnosis, and who have certification or a license if it is available in that therapy. These are the types of things that need to be considered.”

Unfortunately, this type of information is not always available. “It’s time-consuming and expensive to do a full community assessment of which therapists and practitioners in the community are really providing the services that they market, and that they are qualified to provide the services,” Wyatt acknowledged.

There is a good bit of information on integrative health available online, as several websites are dedicated to the topic. However, it’s vital that nurses know which sites are safe for their patients and which should be avoided.

Websites like the National Center for Complementary and Integrative Health and the Complementary and Integrative Medicine section of MedlinePlus, which are federal government sites, are safe sites for patients to explore, as are major hospital and healthcare system sites.

Nurses may want to suggest to their patients that they download a workbook made available through the National Cancer Institute: 

Talking about Complementary and Alternative Medicine with Health Care Providers: A Workbook and Tips

. This workbook contains documents that your patients can use to keep track of their CIT use and their providers, as well as their conventional medical therapy. There is also a glossary and cancer CIT resources. The workbook reviews types of questions patients should ask their healthcare providers and gives the reader other resources. A document like this can give nurses and patients a foundation on which to base their discussions.

There is some secrecy involved in CIT use on behalf of many oncology patients. A 2012 study looked at 305 patients who were receiving radiation therapy. A total of 43.6% of the study participants reported using CIT, but only 12.1% of the patients said that they had discussed their CIT use with their radiation oncologist, and only 11.1% mentioned it to their medical oncologist.

Nurses must support disclosure, Balneaves said. “Nurses are in a really great position of trust. Patients will often open up to us, so we have to make sure that we don’t shut down that dialogue. It’s important that we start acknowledging complementary therapies as a reality in many patients’ lives and ensuring that we’re considering their whole care plan.”

Wyatt said that the best thing is to be straightforward with the patients who are reluctant to discuss CIT use with their physician. “Some of the therapies can actually interfere with the medical treatments. So if the medical practitioner understands what else the patients are doing, then they can adjust or give them advice so that the patients can see that it’s to their advantage to inform their health providers of what they’re doing.”

It is for this reason that nursing assessments of oncology patients should include more than the standard overview. “We have to get to the point that the assessments we do on patients when they come into the clinic are not just about blood pressure and pulse, but also about what therapies they are using,” Wyatt said. If such discussions become part of the regular routine, patients may feel more comfortable talking about CIT.

Keeping up to date on CIT research is another part of working with oncology patients. There are several resources online for nurses that review the use of integrative therapies in supportive care. In 2014, the 

 published clinical practice guidelines regarding integrative therapy for patients who have breast cancer.

 While the researchers concluded that more well-designed controlled trials were needed regarding CIT and its benefits, they found that therapies such as meditation, yoga, and massage, were appropriate for patients who were seeking to manage stress, anxiety, depression, and fatigue.

A year earlier, the American College of Chest Physicians published evidence-based clinical practice guidelines on complementary therapies and lung cancer.4 The researchers also concluded that certain types of complementary therapies, such as acupuncture, mind-body therapies, exercise, and massage, should be integrated with standard oncology care, and that such therapies could help patients manage symptoms such as anxiety, mood disturbances, pain, quality of life, and treatment-related side effects.

Nurses are also encouraged to do their own research to match their patients’ requests and interests. The NCI has a database, where nurses can find links to sites for research articles on CIT in scientific journals, the Cochrane Library, a directory of health organizations and research resources, and information on ongoing clinical trials. The site also has a link to CIT therapies, from A to Z, which offers an exhaustive list of therapies, some which nurses may never have heard of.

Barriers to use of integrative medicine among some healthcare professionals persist, however.

Wyatt encourages nurses to have an open mind to complementary therapies. “There are oftentimes barriers to professional thinking about complementary therapies, because they are not all well integrated into nursing programs, and certainly not into all medical programs,” she said.

“There always tends to be a bit of fear around something that people don’t understand well. I would encourage nurses to really enjoy the literature that’s out there and available about evidence-based practice in the area of complementary therapies, so they become better informed themselves and they can better answer their patients’ questions.”

National Center for Complementary and Integrative Health

Medline Plus: Complementary and Integrative Medicine

Office of Cancer Complementary and Alternative Medicine (OCCAM)

https://cam.cancer.gov/health_information/talking_about_cam.htm

https://cam.cancer.gov/health_information/cam_therapies_a-z.htm

Marijke Vroomen Durning, RN, is a freelance writer who specializes in patient education, and health and wellness topics. 

1. Mao JJ, Palmer CS, Healy KE, et al. Complementary and alternative medicine use among cancer survivors: a population-based study. 

2. Ge J, Fishman J, Vapiwala N, et al. Patient-physician communication about complementary and alternative medicine in a radiation oncology setting. 

3. Greenlee H, Balneaves L, Carlson LE, et al. Clinical practice guide- lines on the use of integrative therapies as supportive care in patients treated for breast cancer. 

4. Deng GE, Rausch SM, Jones LW, et al. Complementary therapies and integrative medicine in lung cancer: diagnosis and management of lung cancer. 

More people than ever are using complementary and integrative therapies (CIT) to manage their illnesses in addition to conventional treatments.

Integrative Healthcare: Caring for the Whole Patient

New research has found that young black women have a higher prevalence of 

 mutations compared with non-Hispanic white women, a finding which adds even more heft to the need for greater access to genetic services in underserved communities to address disparities in cancer care.

Researchers from Moffitt Cancer Center in Tampa, Florida, undertook the largest population-based study to date among black patients with breast cancer to examine the frequency of 

Among 396 young black women who were diagnosed with breast cancer before the age of 50 years, 12.4% of the study participants had either BRCA1 or BRCA2 mutations.

The results were unexpected, said study leader Tuya Pal, MD, a clinical geneticist at Moffitt, in an interview. “This was more than double than what has been found among white women.” In addition, over 40% of women with BRCA mutations had no close relatives with either ovarian or breast cancer.

“Even though the overall breast cancer incidence is lower among black women than white women, the frequencies among young black women is actually higher,” Pal added. “Inherited gene mutations may account for part of this discrepancy. 

 mutations greatly increase the risk of both breast and ovarian cancer.”

Genetic testing is increasingly common for certain diseases like breast cancer and ovarian cancer; however, not all groups of women are receiving genetic testing and counseling in equal numbers.

Underserved communities often do not have access to these services. However, while it is known that education and socioeconomic status may play a role in access, the researchers pointed to their published report earlier this year in Breast Cancer and Treatment to evaluate access to genetic services among the same population-based cohort.

The findings showed that only half of study participants were referred for or accessed genetic services, yet all met national criteria to be referred to these services. Women with private insurance at time of diagnosis and a household income of more than $35,000 per year were more likely to access genetic services, but the strongest factor in moving forward with testing or counseling was the healthcare provider referral. This indicates that healthcare providers need to better identify high-risk women and provide them with access to genetic services, Pal suggested.

Genetic testing for women who may have the 

 mutations can help them make decisions about breast cancer screening through MRIs and mammograms or preventative surgical procedures, such as mastectomies or oophorectomies, allowing them to be proactive about their health. In addition, women who know they have the mutations can pass this information on to family members who may also be at risk and who may want testing.

“We need to better understand the reasons for disparities in access to genetic services and testing so we can intervene,” Pal said. “What we don’t want is for these tremendous technological advances to widen the existing disparities among blacks. By quantifying them, it’s a step to trying to figure out why they exist and what we can do about them.”

1.   Pal T, et al. (2015), A high frequency of BRCA mutations in young black women with breast cancer residing in Florida [published online ahead of print August 19, 2015]. 

2.   Cragun D, Bonner D, Kim J, et al. Factors associated with genetic counseling and BRCA testing in a population-based sample of young black women with breast cancer. 

Young black women have a higher prevalence of BRCA mutations compared with that previously reported among non-Hispanic white women, placing these women at a higher risk for breast and ovarian cancer. 

Marijke Vroomen Durning, RN

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