Leaders should look no farther than health and safety to gain a vision of what a successful equity, diversity, and inclusion (EDI) framework should look like within oncology nursing, explains Aliènne Salleroli, MS, BSN, RN, OCN.

Salleroli, an assistant patient services manager at Yale-New Haven Health Smilow Cancer Hospital, and co-chair of the Yale New Haven Hospital Diversity, Equity, and Inclusion Nursing Task Force, recently presented at the 47th Annual Oncology Nursing Society Congress on how racial diversity within oncology leadership is linked with positive outcomes.

®, Salleroli explains how EDI should be at the back of every oncology nurse’s mind throughout any potential interventions similar to health and safety. She further explains that although both entities may require a specific task force to oversee protocols and keep an institution up to date, it is essential that the information is rolled out and implemented throughout clinical practice.

The framework for establishing equity, diversity, and inclusion throughout oncology nursing already exists within the standard for health and safety, explains Aliènne Salleroli, MS, BSN, RN, OCN.

Aliènne Salleroli on Establishing Equity, Diversity, and Inclusion Throughout Oncology Practice

Aliènne Salleroli, MS, BSN, RN, OCN.

Childhood cancer survivors may face different challenges than adult or geriatric patients, according to Michelle Mollica, PhD, MPH, RN, OCN, of the National Cancer Institute (NCI).

Mollica, who is a senior advisor in the NCI Office of Cancer Survivorship and is consequently responsible for developing, supporting, and promoting research efforts focused on cancer survivorship, gave a talk on individualized survivorship care plans at the 47th Annual Oncology Nursing Society Congress. 

 Mollica discusses tailoring different plans to fit the needs of different populations.

Michelle Mollica, PhD, MPH, RN, OCN, of the National Cancer Institute, discusses how childhood cancer survivors may face different challenges than adult or geriatric patients.

Michelle Mollica on Individualizing Care Plans for Cancer Survivors

Michelle Mollica, PhD, MPH, RN, OCN

During end-of-life care, nearly half of patients with agitated delirium were not receiving the level of sedation pre-described by their caregiver as their personalized sedation goal, according to 

®, David Hui, MD, MSc, discusses the implications of these findings, and the need for future research to find better ways to help patients with cancer manage their restlessness during end-of-life care.

“This is an important observation because, as clinicians, we often worry that we are overly sedating patients. [But] it seems that based on the data that is collected, we are not able to hit the hit the targets adequately, and [there] may be some unnecessary restlessness that could be managed a little bit better. We certainly need better research and more new agents to see how we can help control this condition a little bit more, given that it is one of the most distressing manifestations in the last days of life.”

Hui also highlighted the importance of incorporating oncology nurses into any research involving the sedation of patients in this setting.

“This is a study where nurses have a very important role; the nurses are the ones who helped us design the study together with the palliative care team, as an interdisciplinary teamwork… They are the ones who give the study medications. They are the ones who do the monitoring, of the patient's restlessness level, and they are the ones who also fill out their work their perception for how the person is doing in their personalization goal as well. By investing their time in this, they are also helping us to move the field forward.”

Hui D, De La Rosa A, Urbauer D, Nguyen T, Bruera E. Personalized sedation goal for agitated delirium in p0atients with cancer: balancing comfort and communication. 

. 2021;127(54)L4694-4701. doi:10.1002/cncr.33876

David Hui, MD, MSc, from The University of Texas MD Anderson Cancer Center, discusses findings indicating that patients with agitated delirium may be under-sedated, in accordance with their personalized sedation goal. 

Many Patients Are Under-Sedated During End-of-Life Cancer Care 

 revealed that during end-of-life care, caregivers were more likely to prefer a lighter sedation than nurses for their loved ones, despite previous responses to 6 different vignettes.

In an interview with Oncology Nursing News®, David Hui, MD, MSc, explained how distress is typically connected with a desire for deeper sedation, but in the case of caring for a patient with cancer experiencing agitated delirium, caregivers may often value communication more than they originally realized.

“We know from the vignettes that more distress is usually associated with the desire for deeper sedation. So that makes a lot of sense, right? If [a] patient has been up and about and yelling and screaming, they generally prefer more sedation,” he said. “But the very interesting observation in this study is [that], despite caregivers feeling more distress from the agitation than the nurses, they still prefer lighter sedation.”

“…That communication piece may be one of the factors. We do feel the ability to still communicate is rated quite high by caregivers. And so if they feel that it's okay to sacrifice a little bit of that sedation, and as long as they can still communicate, but that's again, important to find that balance and really monitor the preference over time, because the caregivers may or may not have different perceptions as the patient's condition evolves as well,” he added. “So it's not a static kind of outcome. Their preferences may also change, [and] the patient's ability to communicate may also change. It’s important to have a continuous dialogue, monitor, titrate in, and ask again.”

. 2021;10.1002/cncr.33876. doi:10.1002/cncr.33876

David Hui, MD, MSc, from The University of Texas MD Anderson Cancer Center, discusses how caregivers may prioritize communication when making end-of-life sedation decisions for loved ones with agitated delirium.

Ability to Communicate Is a Key Factor in Personalized Sedation Goals

David Hui, MD, MSc

Brianna Lutz, MSN, RN, OCN, Smilow Cancer Hospital at Yale New Haven, discusses a flowchart built within EPIC that allows nurses on an oncology unit to view the workflow across the unit and better identify which patients require attention via targeted rounding.

Lutz recently presented on the topic at the 47th Annual Oncology Nursing Society Congress. In an interview with 

®, she explains how her team developed and rolled out the system, and how it improves workflow across the unit.

Lutz and her team collaborated to identify a series of data points that already exist within the nurse’s workflow, such as vital signs, pain assessment intake/output, fall risk interventions, activity, ambulation, hygiene, positioning and Medical Administration Record documentation. Every time a nurse documents one of these items, their patient’s dot automatically turns green within the system; signaling to colleagues that this patient has been attended to within the past hour. If a patient has a red dot, then this signals that he or she has not been checked on within the hour and a nurse, or personal care assistant, should make a targeted round to care for that patient.

Brianna Lutz, MSN, RN, OCN, discusses a red-and-green dot hourly column that shows which patients with cancer have been attended to in the past hour. 

Brianna Lutz on How to Improve Nurse Responsiveness on an Inpatient Oncology Unit

Brianna Lutz, MSN, RN, OCN

Managing nausea and monitoring complete blood counts (CBC) for drops in hemoglobin are crucial when administering olaparib (Lynparza) to patients with germline 

-mutated, HER2-negative, high-risk early breast cancer, according to Charles E. Geyer, MD, FACP.

 as a treatment for patients with this disease type and who have already undergone chemotherapy before or after surgery, after 

 demonstrated that the oral PARP inhibitor resulted in a 42% improvement in invasive disease-free survival compared with placebo.

®, Geyer, who is chief scientific officer of the National Surgical Adjuvant Breast and Bowel Project (NSABP) Foundation, and an investigator in the OlympiA trial, 

 to discuss dosing strategies and adverse event management with olaparib.

The starting dose in OlympiA was 300 milligrams twice a day, Geyer explained. “The medication comes in tablets, there are 150 milligram tablets that are a greenish color, and 100 milligram tablets, which are yellow. Patients start out by taking 2 green tablets twice a day.”

Furthermore, because olaparib is taken twice a day and can cause nausea (particularly in the first month), nurses should stress the importance of taking the agent with food.

“Doctors on the study found that sometimes patients do not hear how important it is to take [olaparib] with food,” noted Geyer. “It can be a light meal [or] a snack, but we do [stress the importance of] taking it with food. That is a hugely important message.”

Another important consideration when treating patients with olaparib is anemia, he continued. He emphasized the importance of adjusting dosage if a patient’s hemoglobin begins to drop, adding that since patients will need to take the agent for 1 year, it is important to find a dose that is manageable.

“Sometimes hemoglobin can drop quick enough [that] patients get symptomatic and might require transfusions; about 6% of the patients required a blood transfusion, but only 2% required more than 1 transfusion,” said Geyer. “It is important [to monitor] complete blood counts carefully, and [understand] that it is okay to hold the drug.”

“Sometimes patients feel, ‘I need to take it, I can take it, and I don't feel bad enough to stop it.’ However, you don't want the hemoglobin to drop: [the treatment] is a marathon—[they take it] for a whole year, so we want to work to find the correct dose. That will be important to keep in mind,” he concluded.

Charles E. Geyer, MD, FACP, discusses dosing strategies and adverse event management with olaparib.

Dr. Geyer Highlights Optimal Dosing Strategies for New Olaparib Indication in Breast Cancer

Charles E. Geyer, MD, FACP

Janelle Wagner, RN, OCN, has been an oncology nurse for almost 20 years and an oncology nurse navigator for 5 years.

®, Wagner, Senior Manager of Patient Navigation Program for Community Sites, Seattle Cancer Alliance, discusses some of the more difficult components associated with the role. Among them, she mentions the struggle to define clear boundaries, navigate the health care system without trying to fix it, and understanding that patients are now a part of your team.

“Setting boundaries [is difficult],” Wagner explained. “Oncology nurse navigation is a newer field, and there are many different opinions on what the job entails. Being able to set those boundaries and kind of sticking with your standard work to be able to best serve the patient [is crucial]. The challenge is understanding [that] our health care system is so complex, and that you really need to be the point person for that patient to navigate through that system [rather than] trying to fix the system.”

She added that, “If somebody is going to go into this field, they need [to] make sure that they have good leadership, and good pathways for the position. It is really questioning [the following]: what does standard work look like? Who is my team? When you are navigating a patient through the whole continuum of care, it could be across many different organizations. [You need to understand] who that team is and how to utilize [your] skills to help the patient go through the system.”

Janelle Wagner, RN, OCN, Senior Manager of Patient Navigation Program for Community Sites, highlights some challenges commonly associated with nurse navigation, and how nurses can overcome them. 

Setting Boundaries Can Be a Challenge for Nurse Navigators

Confidence and oncology knowledge are crucial skills for effective nurse navigators, according to Janelle Wagner, RN, OCN.

®, Wagner, senior manager of Patient Navigation Program for Community Sites, Seattle Cancer Care Alliance, explained what skills are necessary for an oncology nurse to become an effective nurse navigator and offered advice for any prospective navigators seeking a career shift.

“Being a nurse navigator requires somebody who has a broad understanding of oncology care. [This is someone] who has worked in many different aspects of oncology, from inpatient to infusion to the clinic, [experience with] radiation oncology is helpful, [as well as] surgical oncology. Someone who understands the bigger picture of how all aspects of care happen—rather than just one discipline.”

“In terms of implementation, it's really bringing a full team together. When looking at oncology care, you're looking at multiple disciplines: surgical oncology, medical oncology, radiation oncology, etc. It’s really [about] bringing that whole team together to see what the current state is. How do the patients currently flow through the system? Is it working? Where are the gaps; where does the patient get kind of lost in the system? How can the nurse navigator be that person to help? Again, it's working with the existing system to hold that patient's hand and get them in to the right places and the right timeframe.”

An expert from Seattle Cancer Care Alliance highlights key skills in nurse navigation. 

Confidence Is Key in Oncology Nurse Navigation 

Janelle Wagner, RN, OCN

Patients who undergo radiation therapy may experience a host of long-term side effects that their radiation team would be best equipped to deal with, explains Kate Sandstrom MSN, APRN-BC, AOCN.

Sandstrom currently works as a full-time nurse practitioner in the Department of Radiation Oncology at Seidman Cancer Center, University Hospitals Case Comprehensive Cancer Center, and recently gave a presentation on late side effects at the 47th Annual Oncology Nursing Society Congress.

In an interview ahead of her presentation with 

®, Sandstrom discusses resources available to patients who have undergone radiation therapy, and the importance of emphasizing to the patient that they continue to follow up with the radiation oncology team.

Kate Sandstrom, MSN, APRN-BC, AOCN, discusses the importance of including the radiation oncology team in a patient’s long-term care plan.

Kate Sandstrom on Ensuring Patient Follow-Up With Radiation Oncology Teams

Kate Sandstrom, MSN, APRN-BC, AOCN

The language used to describe patients in electronic health records (EHR) may be perpetuating racial bias and other negative stereotypes in health care, according to a study recently published in 

 A multi- disciplinary team of investigators from the University of Chicago used machine learning techniques to analyze potentially stigmatizing language across more than 40,000 history and physical notes in EHRs made up of 18,459 adult patients and 33,142 unique encounters at an academic medical center in Chicago, Illinois, between January 2019 and October 2020. They determined Black patients were 2.54 times more likely than White patients to be described in negative terms (95% CI, 1.99-3.24). Negative terms included refused (n = 1461), (not) adherent (n = 605), (not) compliant (n = 561), and agitated (n = 409). Findings were adjusted for sociodemographic and health characteristics.

Moreover, the differences were not solely based on race. For example, Medicare and Medicaid beneficiaries were more likely to have negative descriptors applied to them than were patients with commercial- or employer-based insurance (Medicare: adjusted odds ratio [AOR], 2.08; 95% CI, 1.57-2.75) (Medicaid: AOR, 2.66; 95% CI, 2.08-3.40), as were unmarried patients (AOR, 2.12; 95% CI, 1.70-2.65) compared with patients who were married.

Evaluable patients were patients with at least 1 charted history or physical note in their EHR when they were admitted to an inpatient setting or emergency department or visited an outpatient setting. These notes are designed to document the patient’s reason for seeking medical care; provide a summary of medical, family, and social history; and lay out the prescribed care plan to address the medical problem. The investigators chose to center their research on the history and physical note because it is designed to create a comprehensive narrative of the patient’s experience, which will be used by other health care professionals. If a patient had multiple history and physical notes, all available notes were extracted and included for analysis.

The findings are especially troubling, given that other studies have found that less than 20% of text in inpatient progress notes are original,

 with most of the rest being imported from prior documentation. As a result, “subsequent providers may read, be affected by, and perpetuate the negative descriptors, reinforcing stigma to other health care teams,” the authors wrote. “Negative descriptors written in the admission history and physical may be likely to
be copied into subsequent notes, recommunicating and amplifying potential biases. This practice underscores the responsibility of providers who document the initial patient encounter to do so in an aware and sensitive manner.”

Furthermore, the investigators found that notes written for outpatient visits were less likely to have negative descriptors included in the patient’s EHR than inpatient encoun- ters (31% vs 68%). They theorize that this may result from inpatient settings being inherently more stressful, thereby increasing the risk of doctors using stereotypes as “cognitive shortcuts.” They also found that race-based differences in the use of negative descriptors narrowed after March 1, 2020.

Nevertheless, the authors agreed that fixing the problem will require medical 

institutions to better address the issue of implicit racial bias among providers. They cite the example of 1 physician’s use of the term “aggressive” as reflecting the physi- cian’s personal bias regarding Black men. Once such a negative label becomes part of the patient’s record, “it potentially affects the perceptions and decisions of future providers, regardless of whether future providers hold a bias about Black men being aggressive,” they wrote.

Regulatory bodies, such as the Accreditation Council for Graduate Medical Education, might also develop specific recommendations for the use of nonstigmatizing, patient-centered language to prevent the transmission of bias, they suggest. The study concludes that the need is especially important in light of the OpenNotes policies that medical institutions are adopting, which allow patients full access to their EHRs, including chart notes. Without paying attention to the language used to describe patients, providers risk “harming the patient-provider relationship, with downstream effects on patient satisfaction, trust, and even potential litigation.”

Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: documenting racial bias in the electronic health record.

. 2022;41(2):203-211. doi:10.1377/hlthaff.2021.01423

Wang MD, Khanna R, Najafi N. Characterizing the source of text in electronic health record progress notes. 

 2017;177(8):1212-1213. doi:10.1001/jamainternmed.2017.1548

Fixing the problem will involve holding medical institutions accountable for addressing implicit bias among providers.

Electronic Health Record Notes May Be Perpetuating Biases

 Jeffrey Bendix 

Although the majority of nurses and advanced practice providers (APPs) agreed that implicit bias is a problem which affects many health care professionals, most fail to acknowledge their own personal bias, according to a recent survey published in the 

, Kathy Burns, MS, APRN-CNS, AGCNS-BC, a benign hematology clinical nurse specialist at James Cancer Hospital, and study co-author, explains the importance of self-awareness and how oncology nurses can improve patient interactions by recognizing their own bias–particularly when prescribing medications for patients with substance abuse disorders.

“The number one thing is awareness, being aware of your own implicit bias, being aware of your personal triggers,” she said. “Reflecting on your own behavior and how others react to that behavior, reaching out to those you trust [to be] honest and help guide you.”

She acknowledged that with recent events in the pandemic, there is a plethora of resources available both within and outside of oncology institutions. She encouraged nurses and APPs to take advantage of these resources, to push themselves beyond their comfort zone, to interact with different people, and lastly, to seek ways to build their multicultural perspectives.

“In the last 12 months, the CDC has reported from March 2020 to March 2021, [over] 96,000 people died of an overdose

,” she added. “[Be] very mindful of what's going on in the world, how we react to that, and know that the needs of people are just going to shift and change.”

Burns K, McNally GA. Implicit bias training: improving outcomes for patients with cancer who have substance use disorders. 

. 2021;25(5):595-599. doi:10.1188/21.CJON.595-599

Provisional Monthly National and State-Level Drug Overdose Death Counts. CDC. November 7, 2021. Accessed Decembers 10, 2021. https://bit.ly/3rZb0SS

Kathy Burns, MS, APRN-CNS, AGCNS-BC, of the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, comments on the importance of self-awareness as an oncology nurse when working to overcome one’s implicit bias.

Self-Awareness Is Critical in Treating Prescribing Patients With Cancer and Substance Abuse Disorders

A recent survey completed by nurses and APPs revealed that many health care professionals may be blind to their own implicit biases.

In an interview with Oncology Nursing News, Kathy Burns, MS, APRN-CNS, AGCNS-BC, a benign hematology clinical nurse specialist at James Cancer Hospital, and study co-author, explains the meaning of implicit bias and how oncology nurses can improve patient interactions by becoming more aware of how the issue impacts them.

“I think it's very important to understand: What is implicit bias? There's many components to it from a scientific standpoint, but from a basic standpoint, is 

, it's unintentional. And it's a way our brain has evolved over many years for survival status to process our environment,” said Burns. “So consciously, as health care providers, [through] medical school and nursing school, we are taught not to be prejudiced, we're not taught to treat all people equal. And I think we consciously come in with that with great intentions. But it's the unconscious, the unintentional interactions that a patient may pick up during an interview process communication, [or] in an assessment.”

“In understanding a lot going on in the world—pandemic, opioid crisis, all these things—how is that changing our perception of the patients who care for? How has all that changed them and their needs? How [can we] interact, reach out. and be able to meet their needs, from that standpoint, too?” she added.

Kathy Burns, MS, APRN-CNS, AGCNS-BC, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, comments on the importance of being mindful about one’s implicit bias in the treatment of patients with cancer who have substance use disorders.

Clinical Nurse Specialist Explains Meaning and Impact of Implicit Bias on Patients

Kathy Burns, MS, APRN-CNS, AGCNS-BC

Mindfulness has been studied and proven to have a number of benefits on our physical and mental health. Mindfulness is the act of being present and aware of our surroundings while having a neutral response.

 Practicing mindfulness can offer the average person relief from a number of different life stressors. It can make a world of difference for caregivers of patients with cancer who are balancing their personal responsibilities with their loved one’s needs often with minimal support, which leads to caregiver stress and burnout.

Caregivers are often our unsung heroes of the cancer experience. Although not going through cancer treatment itself, caregivers walk alongside their loved one during a journey that can last anywhere between a few months to a lifetime. Studies show people caring for a loved one with cancer have a shorter yet more intense caregiving experience compared to people caring for a loved one with a different type of illness.

Within this intense experience, cancer caregivers can often find themselves physically and emotionally exhausted. Their lives do not stop just because they have become a caregiver, and so they need to adapt and find ways to navigate an even greater amount of responsibilities. Caregivers help their loved ones with activities of daily living, learn new medical tasks, and often coordinate services for their loved ones that do not leave much time left over to care for themselves.

This lack of time can lead to poor physical health for caregivers, and changes in sleeping or eating patterns, as well as increased feelings of anxiety and depression. Many caregivers do not notice these patterns until they feel completely run down and burnout.

Research has found mindfulness can have a great positive impact in many different areas of our lives. Mindfulness can help decrease feelings associated with burnout, such as anxiety and depression, as well as improving other symptoms such as lack of sleep or gastrointestinal issues.

 These benefits can all lead to a caregiver having a more positive outlook, which, in turn, can lead to better health outcomes for themselves and their loved ones.

Caregivers might share that they do not have the time to practice mindfulness or maybe feel like they don’t know where to start. If your caregivers are not talking about self-care, you may have to be the one to start the conversation. You can remind them that the idea of mindfulness can be intimidating when getting started but it is important to not let it discourage them.

You can start with encouraging your caregivers to set aside dedicated time to practice in a quiet space with no distractions. If it is hard to find time to set aside, that’s okay too, because they can be mindful anywhere. A person can be mindful on a walk home, while eating dinner or listening to music. Take a moment to remind caregivers before they make the decision to begin this practice that the goal is not to keep the mind from wandering, because this isn’t always possible for us as humans.

When they catch their mind wandering, encourage them to acknowledge it and bring focus back to the breath or whatever they chose to focus on.

There are so many different types of meditations we introduce caregivers to help them integrate mindfulness into their daily routines. Progressive muscle relaxation is a type of meditation where a person will focus on each part of their body, starting from their toes and going up to their head. During this exercise, the person will tense one muscle group at a time and then release the tension. Oftentimes, we don’t realize where we are holding tension in our bodies until we make ourselves release it.

When practicing this, one should focus only on one muscle group at a time and move slowly. Caregivers can go from their toes to their head or their head to their toes, as long as they include everything that is in between. They will tense their muscles on the inhale, pause for just a moment and then release the tension on the exhale. We should encourage caregivers to feel free to breathe out audibly, getting rid of anything they do not need.

Whether you practice progressive muscle relaxation, body scans, or journaling, you are living mindfully. We all have the ability to be mindful, we just need to give ourselves the space to practice it. We need to encourage our caregivers to take care of themselves by keeping up with their own physical and mental health to be able to better cope with stress and burnout. Introducing mindfulness is one way to address both.

What is mindfulness. Mindful. July 8, 2020. Accessed November 22, 2021. 

https://www.mindful.org/what-is-mindfulness/

National Alliance for Caregiving, National Cancer Institute and Cancer Support Community. 

Practicing mindfulness to relieve caregiver stress. Visiting Nurse Service of New York. Accessed November 22, 2021. 

https://www.vnsny.org/article/practicing-mindfulness-to-relieve-caregiver-stress/

Stoll, N. Three ways mindfulness can help caregivers

 Caring Across Generations. March 26, 2021. Accessed November 22, 2021. 

https://caringacross.org/blog-mindfulness-helps-caregivers/

Learning to relax. National Cancer Institute. March 23, 2021. Accessed November 22, 2021

https://www.cancer.gov/about-cancer/coping/feelings/relaxation

Within this intense experience, caregivers can often find themselves physically and emotionally exhausted

Authors