A 2020 Gallup poll showed that nurses were — once again –  ranked as the most trusted profession in the United States. Now, in the era of the Internet, nurses can use social media to make their wisdom more broadly heard and ensure that their voice is heard.

“There are almost 4 million nurses in the United states — more than any health care profession – and there is great power and change that can occur when we use our voices,” said Lisa Kennedy Sheldon, PhD, APRN. AOCNP, FAAN, clinical and scientific affairs liaison at the Oncology Nursing Society (ONS), during a presentation at the 2020 ONS Bridge virtual conference.

Sheldon said that the first step in creating a professional social media presence is to find followers with like interests — this can be other nurses or health care providers, hospitals, clinics, research institutions, and more.

Next, nurses should craft their profile. It should include a professional headshot and a biography, which states who they are as a professional and what make them interesting and unique. Nurses should consider how their voice can be valuable to their colleagues and followers, and be sure that their profile and content fits the social media platform that they are using.

“LinkedIn is really a professional networking site designed to help people make business connections and share their experiences and resumes, maybe find jobs, or seek or share information,” Sheldon said.

“Twitter is considered a micro-blogging platform, because each entry that you put in there is only 140 characters. So you are limited in the amount of information that you can put in a tweet, but it is the fastest-growing social media platform because of its versatility.”

Sheldon emphasized that nurses must be careful on what they put out on social media, where patients might want to follow them. Nurses must be conscious of privacy of patients and images of institutions.  

Additionally, nurses must be sure that they are sharing reliable information on social media.

“If you’re going to be sharing information, you want to make sure you pick high-quality, evidence-based pieces. If you’re brining yourself forward in your branding as a thought leader, you want to make sure that you’re picking policy pieces that come from reputable sources,” Sheldon said.

Nurses looking to build their professional social media presence should be consistent and frequent in their posting, and take advantage of the use of hashtags and appropriate images to have content seen by even more people.

“You want to be frequent enough with relevant information that when people see your name, they say, ‘I wonder what she’s posting about today.’”

Sheldon recommended engaging with followers and with others who share valuable information, but again, be mindful of your health care institution’s policies regarding media.

Ultimately, nurses have been — and continue to be – trusted voices in the world of health care, both in the clinic and online. “We want to use social media to network with other nurses throughout the world to share information and ideas,” Sheldon said.

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A professional social media presence can be beneficial for oncology nurses and their followers, but there are a few guidelines that nurses should keep in mind.
 

Social Media: A Meaningful Tool to Share Nurses' Voices

Hospital-acquired infections can negatively affect outcomes in patients with cancer, so it is imperative that oncology nurses are vigilant about preventing them. After seeing a spike in Clostridium difficile infection (C. diff) a few years ago, nurse researchers at City of Hope National Medical Center conducted a root-cause analysis and then created an intervention plan to stop the spread.

The results were presented by Karen Wohlgezogen, BSN, RN, CPHON, clinical nurse manager at City of Hope, during the 2020 ONS Bridge Virtual Conference.

“C. diff is a spore-forming [bacterium] that is very resilient, and difficult to kill,” Wohlgezogen said. “It causes life-threatening diarrhea and colitis.”

In their initial analysis, the researchers realized that C. diff infections were occurring in adjacent rooms during the same time frame, which likely was a result of staff spreading the infection, Wohlgezogen explained, noting that some staff members were also unable to correctly answer questions about shared equipment being cleaned adequately. They also noticed family members of patients in isolation rooms not washing their hands when they left the room.

“Anytime you’re cleaning anything having to do with C. diff, you definitely have to use bleach, so it’ll kill the spores. Alcohol gel and alcohol wipes don’t do it,” Wohlgezogen said. “But we had complaints from staff, patients, and families about using bleach. They didn’t like the strong smell, it seemed to stain the clothes of the staff using it.”

Fixing the issue began with patient and staff education. In addition, nurses were in charge of getting patients and families any items they may have wanted or needed, such as coffee or snacks, so that they could be sure that things were cleaned appropriately before and after use.

Next, they realized the importance of patients bathing daily, either by shower or bath, to decrease the bacteria count on the body. Then the team identified that bedside commodes likely were not being cleaned as thoroughly as they should be—particularly the heavy-duty bucket underneath that catches the waste. Therefore, City of Hope started to use single-use patient items.

“Once we did the bedside commode buckets as a single-use, we definitely saw a decrease [in C. diff],” Wohlgezogen said.

When it came to vital sign machines, the team ensured that there were enough so that oncology patients in isolation could keep theirs in their room for the duration of the stay, and it would not have to be shared with other patients. Similarly, they made sure that the computers on wheels were also kept in isolation patients’ rooms, when possible.

“Our recommendation is to maintain a high focus on [C. diff] infection prevention, and that the education just continues with the nursing [and medical] staff, patient families, and all the people who touch the patients,” Wohlgezogen said.

Wohlgezogen K. Decreasing C.difficile Infection Rates: the Bundle Approach. Presented at: 2020 ONS Bridge Annual Conference Sept. 8, 10, 22, and 24, 2020. Accessed Sept.22, 2020.

Repeated education and other protocols can decrease the spread of this deadly infection.

Prevent the Spread of C. Diff on Oncology Units

Women who underwent laparoscopic surgery for gynecologic cancer may not need opioids to manage their pain after the procedure, according to recent research conducted at the University of Rochester James P. Wilmont Cancer Center.

“There's been such an increased focus on the opioid crisis. And we all can play such an important part in helping to control this crisis,” said Karen Kugel, BSN, RN, OCN, assistant nurse manager of the gynecologic cancer division at the Wilmot Cancer Center.

Kugel and her team conducted a study analyzing the outcomes of non-opioid pain management for women treated with laparoscopic surgery. She recently sat down with 

: Talk a little bit about your research on non-opioid management of gynecologic cancer pain, and why this is an important topic. 

 There's a group called ERAS which stands for Enhanced Recovery After Surgery, which was developed over 10 years ago, internationally, that has used evidence-based practice and research to develop better recovery protocols for post-op patients. So, keeping their recommendations in mind, our hospital decided to adopt a non-opioid pain regimen for post-operative pain consisting of Tylenol and ibuprofen, and we were recommending this and prescribing this to patients.

The nurses had often talked to the patients about their post-op regimens and decided to do a pain audit of performance improvement project that, first of all looked at the effectiveness of the Tylenol and ibuprofen regimen. And a secondary end point was to really look at how many patients were actually being discharged with opioids, which would be an interesting piece.

So we looked at both pieces. And we really found out some interesting information that was really helpful to our practice and improve the outcomes for our patients. And it really ultimately led us to form a team of providers in nursing. And the providers would include the attending nurse practitioner, myself, and we put together this based on the rest protocols, post stuff, not only pain regimen, but a whole pathway for our post-operative patients. So we used a team approach — inpatient and outpatient – to develop this protocol. And we've adopted our own ERAS protocol, and we have rewritten our pre- post-op instructions for patients based on our findings in this research study.

Postoperatively, the nurses would call and do a phone interview with our patients. And they would ask what they were prescribed, the effectiveness of it, whether or not they were prescribed an opioid in addition. And with that research, we found that, for laparoscopic procedures, upwards of over 75% of the patients had obtained substantial relief with Tylenol and ibuprofen regimen. We also found that there were several that were sent home with an opioid, just a prescription that never filled it, because they didn't need it. There were also patients who didn't even need any analgesic at all postoperatively.

But the interesting finding was this: What we were looking to see is what we were prescribing to patients, because we went from a total opioid prescribing practice postoperatively to a non-opioid approach. So, we were really curious and wanted to assure our ourselves that this was definitely something that was going to improve the patient's post-op outcome. So based on those findings, we continue to prescribe and put that as part of our pathway.

How did patients respond to the non-opioid pain management regimen? 

The reception has been extremely positive. Opioids, as many people know, come with other [adverse events]. And what we have found that in many cases, [opioids] actually slowed down our patients’ post-op recovery. It slows down your body function, it makes you lethargic. So because our patients go home in such a short period of time now with the laparoscopic procedure, it's important for them to be as independent as possible when they get home by prescribing the non-opioids.

We did find that their recovery, with many patients a day or two after surgery say that they just feel great. Their bowel function returns very quickly. They're eating a full diet. They're ambulating and it's much different than it was many years ago when we just automatically would prescribe narcotics postoperatively.

Oncology Professionals Can Affect the Opioid Epidemic

Women who were prescribed non-opioid pain management after their gynecologic cancer procedure tended to have quick recoveries.
 

Opioid-Free Regimen Is Feasible After Laparoscopic Surgery

Patients with cancer can experience immense pain, and it is crucial that oncology nurses know how to effectively — and safely – manage that pain.

“Pain management is both an art and a science. You really have to see how the patient is doing. How are they tolerating the opioids?” said Jeannine Brant, PhD, APRN, AOCN, FAAN, oncology clinical nurse specialist, director and lead scientist at the Billings Clinic, Collaborative Science and Innovation. Brant recently led a presentation on opioid use at the 2020 ONS Bridge virtual conference.

Brant said that morphine is really, “the gold standard for comparison for all opioids,” because it is inexpensive and can be given orally, rectally, as an immediate release or controlled release liquid, and can even be administered directly into the spine.

Morphine has 2 metabolites (byproducts of the body breaking down the drug) — m3G and m6G. Nurses should be aware that for patients with kidney issues, m3G and m6G accumulate in the body and can cause adverse events (AEs) such as neurotoxicity, nightmares, hallucinations, or over sedation.

The opioid is not completely off the table for patients with renal insufficiency, but clinicians should adjust the dose appropriately.

Oxycodone — which is primarily administered orally, sometimes combined with acetaminophen – is another common and versatile opioid option for patients with cancer.

Oftentimes, patients who experience AEs from morphine will switch over to oxycodone. However, clinicians should be cautious when they are combining oxycodone and acetaminophen.

“We have to be careful of [combining the drugs] because we should limit acetaminophen to even less than 4 [doses] a day. Oftentimes, the limits are lower,” Brant said. “So many times, giving pure oxycodone and acetaminophen on the side is some of the best ways to control pain, even though it has an active metabolite.”

While oxycodone is efficacious and has a tolerable AE profile, nurses and other providers should also remember that it may pose a greater risk for patients with substance use disorder.

Finally, fentanyl is a drug that has various mechanisms, depending on how it is administered.

For example, a transdermal patch can take up to 12 hours to start working, because the drug has to pass through the patient’s subcutaneous tissue and saturate the tissue. “Then it finally starts working 12 hours later, and lasts about 72 hours,” Brandt said. “For some patients, however, you have to apply it every 48 hours because they really drain that patch more quickly.”

Clinicians can also give fentanyl orally through the patient’s transmucosal membrane. That method had a quick onset — about 5 to 10 minutes, according to Brandt, who explained that fentanyl is absorbed through the fat or liquid membrane in the mouth.

Intravenous fentanyl also is quick to work, though nurses must remember that whichever fentanyl administration is chosen, it likely will take longer to have an analgesic effect in patients who are obese, because the drug has to saturate fat tissues.

Brant J. All about opioidsL calculations and conversions. Presented at: 2020 ONS Bridge Annual Conference Sept. 8, 10, 22, and 24, 2020. Accessed Sept.22, 2020.

Pain management is both an art and a science, according to Jeannine Brant, PhD, APRN, AOCN, FAAN

Opioid Overview: Know What to Use and When

Oncology nurses are faced with difficult decisions every day. And while tough situations are part of the job, there may be instances where they feel that they know what is right, but cannot act on it. This is called moral distress, and there are methods nurses can use to build their resilience and better face these challenging instances.

Natalie Correll-Yoder, MN, RN, CCRN, CCNS, a critical care clinical nurse specialist at NorthBay Healthcare recently presented on moral distress at the 2020 ONS Bridge virtual conference. Correll-Yoder cited research published in the 

 stating that nurses experience high levels of moral distress when they are treating patients who likely will not benefit.

“The stress was significantly correlated with years of nursing experience, speculating that 15 years of experience had a cumulative weight,” Correll-Yoder said. “[The researcher] found that nurses reported anger, anxiety, depression, powerlessness, and helplessness. Then there were physical symptoms, health-related symptoms, changes in their job satisfaction, their self-image and spirituality.”

After a nurse experiences repeated instances of moral distress, they might begin to experience moral residue, which builds, and may causes nurses to think to themselves, “here we go again,” the next time they face a difficult situation. Eventually, this may lead to moral outrage, which can present as anger toward physicians, other nurses or disciplines, administration, policymakers.

“We can become ungrounded and … not connected to our ethical self,” Correll-Yoders said.

Correll-Yoder cited Cynda H. Ruston, PhD, MSN, RN, FAAN, who described moral resiliency as, “a distinctive sense that life is meaningful under every condition.”

There are steps nurses can take to build their moral resiliency, including:

Learning to self-regulate and end negative thought patterns

Be flexible, especially if the situation is complex. For example, think about the patient and their family’s wishes, rather than what you think is right

Know when to speak up if you believe something is morally wrong

Seek meaning in what you are doing, such as honoring patient’s wishes, acknowledging what end-of-life care means to them, etc.

“It’s tough work that we do, trying to care for our patients and provide care that is, in the long run, trying to make them better, but also care that can be adjusted,” Correll-Yoders said.

Correll-Yoder N. Dealing with ethical issues at the bedside: the journey to moral resilience in oncology nursing. Presented at: ONS Bridge Virtual Conference. Sept. 8, 10, 22, and 24, 2020. Accessed Sept.22, 2020.

Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. 

Rushton CH. Moral resilience: a capacity for navigating moral distress in critical care. 2016 Feb;27(1):111-9. doi: 10.4037/aacnacc2016275.

What can nurses do when they feel powerless to make a morally just decision at work?

ONS Bridge

Social Media: A Meaningful Tool to Share Nurses' Voices

Prevent the Spread of C. Diff on Oncology Units

Opioid-Free Regimen Is Feasible After Laparoscopic Surgery

Opioid Overview: Know What to Use and When

Facing Moral Distress as an Oncology Nurse