Diversity, inclusion, and equity are values central to advancing the mission of the American Association of Colleges of Nursing (AACN); an organization recognized as the collective voice of academic nursing.

We hear these terms all of the time; however, what do they really mean? To eliminate any bias per se, let us review the literature to expound on the value of these concepts as it pertains to professional organizations, especially where people hold leadership positions.

While this topic can be viewed as controversial by some; it is important to address to ensure that everyone’s opinion is recognized. Inclusion provides support to obtaining a better understanding of one’s personal and social values; this can reduce bias, discrimination, and prejudice.

However, inclusivity does not mean conforming to the social norm of the majority, it means that someone might be a little different, but you accept that and meet them where they are.

Diversity embraces a wide range of variation; factors such as, age, gender identity, race, ethnicity, culture, religion, sexual orientation, disability, language, or socioeconomic status are just a few aspects of the term diversity.

We have all heard the term, “having skin in the game,” well this is equity, the ability to recognize the differences in the resources or knowledge needed to allow individuals to lend their full participation.

In order for the nursing profession to continue to evolve, change is needed; we can all make a start by embedding these concepts into our minds and giving deliberate attention to everything that we do. Leadership sustainability includes every component of diversity, it is imperative that leaders who are serving today be appropriately prepared, and that they mirror the behaviors that they want their followers to demonstrate.

These are all interpersonal concepts that require cultural competence and respect being paramount during assimilation to continue to advance the nursing profession. 

New perspectives, new faces of leadership, new leadership styles, all can create new opportunities with more voices being heard.

Having all stakeholders involved can reduce assumptions, challenge opinions, widen perspectives, and encourage socialization across all groups. This can result in innovation and overall improvement in the foundation of the nursing profession, which will allow nurses to treat a wider range of patients more effectively.

AACN position statement on diversity, inclusion, & equity in academic nursing (2017). Journal of Professional Nursing, 33;173—174.

Woody, R. (2017). Expanding diversity: Noncategorical inclusion and equity. 

Articles

New perspectives, new faces of leadership, new leadership styles, all can create new opportunities with more voices being heard.
 

Diversity and Inclusion Should be Valued in Leadership Roles

As palliative care becomes a bigger part of a patient’s treatment journey, oncology nurses need to understand the realities and benefits of palliative care and help make their patients understand these as well.

Which is why in this month’s episode of the “

 Talks Cancer Podcast: Nursing Edition,” we had the chance to talk with 

, director of the Division of Nursing Research and Education at City of Hope, and discuss the important differences between palliative care and end of life care and how nurses can advocate for proper palliative care for their patients.

In this month’s episode of the "CURE Talks Cancer Podcast: Nursing Edition," we had the chance to talk with Betty Ferrell, FAACN, FCPN, MA, PhD, director of the Division of Nursing Research and Education at City of Hope, and discuss the important differences between palliative care and end of life care.

Using Education to Understand the Realities of Palliative Care

Treating patients with cancer is more than just providing a patient with their medication. It’s also vital to address a 

 and connect them to resources for support, which oncology nurses are leading the way on, according to Sally Werner, RN, BSN, MSHA.

Oncology nurses can provide a patient with a trained eye on what support measures that may work best for them, including support groups. Werner, the senior vice president for affiliate relations at the Cancer Support Community headquarters, had the chance to sit down with 

 and discuss why oncology nurses are referring patients to support groups and how they can help patients in ways an oncology nurse might not have time for.

I think your nurses are your first line of defense when it comes to your psychosocial care, and a lot of times an oncology nurse can help break down that barrier and encourage patients to find a support group. I think that oncology nurses are in a unique position to know what's available in their own community and what resources are out there [for patients].

In today's day and age, an oncology nurse doesn't have nearly enough time at the bedside as they would like to have whether it's at the infusion center, the doctor's office, the hospital, you name it, they don't get to spend the amount of time with patients that they want to. So, they really like to have some confidence in their community resources and have some other tools in their toolkit to share with patients and family members. Most of us, me included being an oncology nurse, really take the time to know what's available and where to refer patients to.

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Oncology nurses are the first line of defense when it comes to a patient's psychosocial needs, but they don't often have the time to directly attend to them. Which is where support groups can come in to help.

Referring Patients to the Right Support Group

A recent study in the American Cancer Society Journal confirmed that “cancer survivors appear to have a high prevalence of chronic pain, which is associated with worse mental, functional and employment outcomes.”

Through years of serving as a surgical nurse and patient advocate who talks to cancer survivors, I have seen this tragic reality up close.

My organization, The Mesothelioma Center, specializes in helping people diagnosed with 

, a rare form of cancer that often constricts the lungs and invades the chest wall. Because of spinal nerves being closely intertwined where this type of cancer presents, it is known to be very painful for patients.

Add to that a harsh reaction to chemotherapy or a long recovery from surgery, and it is easy to understand that pain management is not an afterthought in cancer care but is one of the most vital types of treatment that cancer patients need.

Unfortunately, policy restrictions have created a climate where many patients trying to manage debilitating pain feel left behind. The examples of opioids and medical marijuana illustrate this problem well.

Opioids and Medical Marijuana Have Uncertain Status in US

Not so long ago, our nation’s authorities assured us that prescription opioids were respectable remedies, whereas medical marijuana was merely a party drug masquerading as medicine.

Now the pendulum is swinging the opposite way.

Consumers and lawmakers have filed legal actions against pharmaceutical giants, alleging their aggressive opioid marketing has contributed to the national drug abuse epidemic. Meanwhile, medical marijuana is now legal in 33 states.

I’m glad to see new research dispelling old myths about opioids and marijuana. But I worry that without rational policy reform, fresh misconceptions will sink in and continue to make life more painful for cancer patients. Health care providers need improved guidelines for opioid prescribing, as well as the federal government’s go-ahead to conduct research on medical marijuana.

When it comes to opioids — even with their considerable risks of addiction and overdose &mdash; these drugs remain an essential resource for cancer survivors.

Powerful opioid drugs, such as morphine, oxycodone, and fentanyl, can provide life-changing benefits when used appropriately. They should not be the first thing a patient is prescribed, but they should certainly be available as an option of last resort.

I recall one gentleman’s case that shows this nuance perfectly. He was one of the lucky ones whose cancer went into remission after surgery, but it came at the cost of nerve damage that caused him chronic, debilitating pain. He struggled with post-surgery pain management for years, until finally switching to fentanyl. Fentanyl has earned a grim association with thousands of drug overdose deaths. But at low, controlled doses this drug can also allow cancer survivors to lead relatively normal lives when other options for pain relief have failed them.

A tragic consequence of the nationwide crackdown on fentanyl is that many cancer survivors with a legitimate need have 

 The lesson here is that solving the opioid epidemic is not as simple as forcing our nation to quit drugs cold turkey.

Descheduling Medical Marijuana Will Allow the Research Data Doctors Need

Many experts have pointed to medical marijuana as a potentially safer alternative to opioid pain management. Decades of research have suggested that medical marijuana can help with cancer symptoms, treatment side effects and related conditions such as anxiety and insomnia.

More research needs to be done on the risks and side effects of medical marijuana, but there is a broad consensus that cannabinoids are not as addictive or life-threatening as opioids.

Rather, the rise of medical marijuana presents a different type of hazard: misinformation. People with terminal cancers are particularly vulnerable to buying into claims of miracle cures, and a quick internet search will show you that cannabis plant derivatives have become the folk cure-all of our time.

As with opioids, this issue is not black and white. In fact, my colleagues and I have heard several firsthand accounts from cancer survivors who were certain that medical marijuana products helped them control their pain and increase their quality of life.

The cancer treatment community needs the federal government to deschedule cannabis from the Schedule 1 category, which would remove marijuana from the federal controlled substances list in the Controlled Substances Act. When that happens, doctors will be able to run proper large-scale clinical trials for medical marijuana. If doctors could legally study the medicinal uses of cannabis, then they could determine how to integrate cannabinoids into cancer treatment plans and use medical marijuana to manage pain and reduce the number of opioid prescriptions given out.

Policymakers Must Act to Improve Pain Management

The American Cancer Society Journal article emphasizes that “screening and management of chronic pain should be addressed by policymakers to improve cancer survivorship care.”

Oncology nurses can play a vital role in screening for chronic pain, but all too often, medical professionals do not have a full toolkit for pain management. The controversies around opioids and medical marijuana in the U.S. today are holding back effective pain management for cancer patients.

I believe our country is taking steps in the right direction by reigning in our system’s dependence on opioids and increasing access to medical marijuana. But we still do not have enough leadership from policymakers on these issues.

Legislators and health care system administrators must reassess the role of opioids and medical marijuana with a cool head, an open mind, and a critical eye to ensure cancer patients get the care they need.

 Sanford NN, Sher DJ, Butler SS, et al. Prevalence of chronic pain among cancer survivors in the United States, 2010&#8208;2017. 

Hoffman J, Walsh MW. Purdue Pharma, Maker of OxyContin, Files for Bankruptcy. 

. https://www.nytimes.com/2019/09/15/health/purdue-pharma-bankruptcy-opioids-settlement.html. Published September 17, 2019. Accessed October 23, 2019.

New Data: Some Measures Meant to Address Opioid Abuse Are Having Adverse Impact on Access to Legitimate Pain Care For Patients. American Cancer Society Cancer Action Network. https://www.fightcancer.org/releases/new-data-some-measures-meant-address-opioid-abuse-are-having-adverse-impact-access. Published October 10, 2019. Accessed October 23, 2019.

Achenbach J, Bernstein L. Opioid crackdown forces pain patients to taper off drugs they say they need. 

. https://www.washingtonpost.com/health/opioid-crackdown-forces-pain-patients-to-taper-off-drugs-they-say-they-need/2019/09/10/3920f220-c8da-11e9-a4f3-c081a126de70_story.html. Published September 10, 2019. Accessed October 23, 2019.

Grinspoon P. Access to medical marijuana reduces opioid prescriptions. Harvard Health Blog. https://www.health.harvard.edu/blog/access-to-medical-marijuana-reduces-opioid-prescriptions-2018050914509. Published June 25, 2019. Accessed October 23, 2019.

Patients with cancer are faced with chronic pain that nurses often cannot manage properly due to outdated restrictions and practices.

Chronic Pain and Policy Restrictions: Controversies Holding Back Effective Pain Management

Caregiving for a person with cancer, while they go through chemotherapy and radiation, presents numerous challenges. However, when a person with cancer is given the treatment option of stem cell transplant, caregiving becomes more complex and challenging. Stem cell transplants impact not only the person with cancer but their loved ones as well, who are required to be more involved throughout the transplant process.

Perhaps no practice on the medical team knows more than nurses that the treatment and recovery are complex and put extreme social strain on patients and caregivers. About 20-30% of people with cancer will relapse after a stem cell transplant. In addition, 30% of people with cancer will have lingering treatment-related complications such as Graft vs. Host Disease.

Due to the significant morbidity and mortality, caregivers experience high-stress levels related to the physical and emotional care that the person with cancer needs before, during and after the transplant procedure. Similarly, most caregivers are new at caregiving through a complex treatment such as a stem cell transplant. This may leave caregivers unprepared for the toll it takes on them emotionally and physically. 

Additionally, caregivers may feel responsible for the outcome of the transplant. Studies show how well the person with cancer does in the treatment determines how the caregiver will respond to being a caregiver. If the transplant recipient has complications and side effects that are not able to be managed, caregivers may feel especially strained which can lead to an increase of frustration, anxiety, and depression.

The caregiver’s new role can make them feel as if their whole world has been turned upside down.  For example, instead of working full time at home or a job, caregivers are now required to spend long periods of time with their loved one, assisting them at doctor appointments, preparing food and helping to manage side effects of the transplant process. Most caregivers have other responsibilities as well such as helping care for other family members. Although caregivers are willing to help their loved ones and are willing to be involved, it’s a lifestyle change that can be overwhelming and unfamiliar.

With the increased amount of stress, caregivers sometimes become hesitant to seek help for themselves, feeling they do not want to distract the medical team from the needs of the patient. Many hospitals use the Hospital Anxiety and Depression Scale (HADS) to measure the patient’s psychological stress, which is effective in detecting depression, anxiety, and distress. However, there is no testing to screen distress in caregivers. Findings suggest that distress can increase when there are practical or unexpected problems throughout the journey of a stem cell transplant. Currently, the experience of the patient is routinely assessed, but there is no formal approach at this time to address concerns of caregivers, physically or emotionally. 

Some concerns caregivers have include managing their own emotional and physical stress, finding time for themselves and balancing work and family responsibilities. Many caregivers are responsible for juggling multiple roles all at once as their loved one begins a transplant. For example, a female may become a caregiver, spouse, and mother. 

Because of the intimate nature of transplants, nurses meet families through the treatment process and are in a perfect position to recognize the multiple stressors playing out on caregivers. For example, federally mandated Family and Medical Leave (FMLA) covers only 12 weeks of unpaid leave, and transplant patients can take up to a year or longer to recover from the procedure. 

Even with 12 weeks of protected leave, caregivers often need many more weeks to continue to care for their loved ones. 

 Nurses can refer caregivers to other team members such as social workers, patient navigators, behavioral health and billing specialists for help locating financial resources throughout the transplant and recovery process.

It is important for nurses to recognize the needs of caregivers during and post-treatment because, without support, many caregivers may burn out, which can lead to their own health problems, and put the health of the person with cancer at risk. Reminding caregivers of the many and diverse professionals in the medical team and their roles who can help them with issues such as dividing caregiving responsibilities using an app like 

, finding resources and getting emotional support from organizations such as Cancer

, locating financial and medical supply resources and other issues as they arise.  

As medical providers, nurses are first-hand witnesses to the struggles of caregiving. Most importantly, checking in with caregivers to get a better sense of how they are doing can be one of the most helpful interventions. Caregivers play a critical role in the transplant process and, even more importantly, in the patient’s life and recovery.   

Eldredge DH, Nail LM, Maziarz RT, et al. Explaining family caregiver role strain following autologous blood and marrow transplantation. J Psychosoc Oncol 2006;24:53-74

. Gaston-Johansson F, Lachica EM, Fall-Dickson JM, et al.Psychological distress, fatigue, burden of care, and quality of life in primary caregivers of patients with breast cancer undergoing autologous bone marrow transplantation. Oncol Nurs Forum2004;31:1161-1169

Cooke, L., Gemmill, R., Kravits, K., & Grant, M. (2009). Psychological Issues of Stem Cell Transplant. Seminars in Oncology Nursing, 25(2), 139—150. doi: 10.1016/j.soncn.2009.0008

Bevans, M., Wehrlen, L., Prachenko, O., Soeken, K., Zabora, J., & Wallen, G. R. (2011). Distress screening in allogeneic hematopoietic stem cell (HSCT) caregivers and patients. Psycho-Oncology, 20(6), 615—622. doi: 10.1002/pon.1906

Family and Medical Leave (FMLA). (n.d.). Retrieved October 10, 2019, from https://www.dol.gov/general/topic/benefits-leave/fmla.

Any patient with cancer needs a caregiver through the treatment journey, but it's even more vital for patients with cancer undergoing the stem cell transplant process.

The Importance of Caregivers During the Stem Cell Transplant Process

 and identify patients that needed a nutritional intervention at the start of their treatment. Learn more about it in this story.

4. What Are Your Patients’ Needs After Treatment?

Healthcare teams can promote autonomy and improve their patients’ quality of life through 

. This piece takes a closer look at how care plans, telemedicine, support staff and more can all play a role in post-treatment care.

3. Addressing a Significant Cognitive Issue

 affects many survivors of the disease, but researchers are still not quite sure if it is the disease itself or other factors that contribute to this decline. We spoke with an expert on the topic in this piece.

Here, a palliative care nurse shares 6 areas that nurses can focus on to 

 and keep burnout and compassion fatigue at bay. 

While the opioid crisis sweeps the nation, we take a closer look at how nurses can be key players in the 

 to patients with cancer, in the cover story of our October issue.

Here are the top 5 Oncology Nursing News® stories for October 2019.

ONN's Top 5 Stories: October 2019

Nursing involves truly unique stressors, that if left unmanaged, can lead to equally unique negative outcomes. These include Burnout (A state of physical, emotional, and mental exhaustion caused by a depletion of the ability to cope with one’s environment, particularly the work environment)

 and Compassion Fatigue (Physical, emotional, and spiritual exhaustion resulting from caring for patients and witnessing pain and suffering).

 The principles of Stress Management are the same regardless of one’s job but can provide a very helpful framework for nurses to decrease job stress and improve health outcomes for themselves and their patients 

Stress Awareness involves identifying one’s personal 

 of stress (stressors) as well as identifying one’s personal 

 to stress.  There are six work domains relevant to a nurses’ stress levels. 

 involves the amount of work required, the frequency of unexpected events and the suffering acuity of patients.

refers to participation in work decisions, quality of management leadership, and patient outcomes.

 describes recognition for achievements as well as opportunities for bonuses and raises.

 includes the frequency of supportive work interactions and the closeness of personal friendships at work.

 refers to the administration’s dedication to equal consideration for everyone and clear procedures for allocating rewards and promotions.

involve the confidence that one’s personal and organizational mission is meaningful and that there is the potential to contribute to the greater good.

Nurses can go through these domains to identify their own stressors and think about how they are reacting physiologically (e.g., headaches), psychologically (e.g., anxiety or depression), and behaviorally (e.g., missing work, or getting angry with colleagues).

Once aware, one can recognize when suffering from stress and can begin to implement a number of practical management techniques. First, try to eliminate or modify the severity of the stressor via problem-solving.  Relax and focus on nothing but the issue at hand. Identify the real problem.  Brainstorm for possible solutions. Select one possible solution and implement it. If it works, celebrate! If it not, go back to brainstorming and trying different solutions.

The six nursing work domains can be a framework for brainstorming ideas. Talk with co-workers to see who may have some of the same concerns and think of ways to make changes among yourselves. Then, approach the administration as a group to ask for help with larger issues, which can also enhance the credibility of the problem if a number of your colleagues echo the same issues.

Next, one can try changing one’s attitude toward or cognitive appraisal of the stressor.  There are a number of ways to do this that are quite relevant to nurses. First, a nurse must be clear about the scope of their professional role.  A nurse cannot always cure a patient’s illness or disease or solve all problems, however, a nurse can always do 

 to make a patient, family member, caregiver and/or colleague feel better. A nurse must be absolutely, positively convinced about the incredible value of every nursing intervention performed!

Hope related to health status is a prime example of how nurses can change their cognitive appraisal. There is no such thing as “false hope.” However, what is hoped for, probably will change over time. What is first hoped for in the face of illness or disease is cure or return to full physical and mental health. What is next hoped for is a positive adaptation to partial physical and/or mental health with a good quality of life. This can be a long trajectory with diminishing yet important and valuable hopes.  What is finally hoped for is an end of life with all instrumental and emotional business completed in a dignified, pain-free manner, and in the presence of people who care/matter.

Fears and perceptions about the End of Life, both for oneself and one’s patients, are major stressors for nurses. First, our fears about the process of dying that include loss of dignity, pain, and sadness about leaving loved ones. Palliative and Hospice Care are major resources that can significantly mitigate these issues. Next, are fears about being dead. One way to cognitively approach this is the “Two Option Plan.” Option 1 is that there is an Afterlife/Heaven. Most references describe this as beautiful, peaceful, and joyful. There is no pain, suffering, or sadness. The deceased will join ones who have died earlier and in a blink of celestial time, loved ones left behind will also arrive. Option 2 is there is no Afterlife, everything just ends, there is nothing. However, there is no pain, suffering, or sadness. There is no consciousness at all.  This is akin to the best night’s sleep one ever had, one just doesn’t wake up. The bottom line is that this is not bad! Everyone has their own personal beliefs about what comes next, and it’s important to not only be conscious of your own but also your patient’s.

The final stress management technique is learning how to change one’s physiological reaction to a stressor from negative to positive by shutting off the chronic release of stress hormones and turning on positive neuro-endocrine-Immune responses such as endogenous opioids. These are naturally occurring opiate-like substances and are pain killers. They are also anti-depressants and enhance the immune system. Fortunately, there are a number of mechanisms that serve both functions. These include exercise, laughter, music (listening to, singing, playing), pets, aromatherapy, meditation, and much more. Allowing you a wide variety of options to find the best technique that fits you.

Stress and its management, particularly for nurses, are complex issues but ones that can be successfully managed. For more information on Stress Management go to 

1. Maslach C. (1982) Burnout-The cost of caring. Englewood Cliffs, NJ;Spectrum.

2. Aycock, N, Boyle, D. (2009) Interventions to manage compassion fatigue in oncology nursing 

3. Fawzy FI, Fawzy NW, Pasnau RO. (1991) Burnout in the health professions.  In Judd, Burrows, Lipsitt (eds.), 

Handbook of Studies on General Hospital Psychiatry

, Elsevier Science Publishers B.V.:New York, 119-130.

4. Figley, CR. Treating compassion fatigue. New York,NY: Brunner-Routledge

5. Henry BJ. (2014) Nursing burnout interventions: What is being done? 

6. Houck, D. (2014) Helping nurses cope with grief and compassion fatigue: An educational intervention. 

Stress management is vital for any profession, but for oncology nurses, stress management is crucial to not only helping themselves but also helping their patients.

Stress Management for Nurses

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Incorporating Palliative Practices Into Critical Care

In this month’s episode of CURE Talks Cancer Podcast: Nursing Edition, we had the chance to follow up with Chasity M. Washington, MPH, CHES, director of the Center for Cancer Health Equity at The Ohio State University Comprehensive Cancer Center, after sitting down with her at the 

to discuss her presentation on health equity. In this episode, we were able to talk more in-depth on how the social determinants of health affect patients with cancer and how nurses can not only advocate for their patients but their fellow nurses as well.

For more on the impact of the social determinants of health in cancer care read on here: 

https://www.oncnursingnews.com/conference-coverage/sono-2019/better-understanding-your-patients-situation

In this month’s episode of CURE Talks Cancer Podcast: Nursing Edition, we had the chance to speak with Chasity M. Washington, MPH, CHES, on how the diversity in the workplace is important to cancer care.

Championing Diversity in Nursing and Oncology

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

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

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

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

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

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

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

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

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

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