Pain management is essential in cancer care, especially in surgical oncology settings. Oncology RNs may administer narcotic pain killers to their patients on either a prn (“pro re nata” or as needed basis) or a scheduled basis. Unfortunately, this also opens the door to nurse abuse of high-risk medications, and other issues. Although the popular Netflix series 

 has brought attention to a specific nurse intending to cause harm, there are statistics which suggest that innappropriate handling of high-risk medications is a relevant problem for many institutions.

The rate of substance abuse in the United States is 6% to 8%.

According to the American Nurses Association, this figure has held true for the past 3 decades, and the percentage rate is comparative to the substance abuse rate in the country overall.

However, the general population does not typically have access to the same medications that nurses have access to.

RNs must chart on the electronic medication administration record, MAR, that the medication was given to their patient. However, it is possible to pretend to give an intravenous (IV) push medicine by trading it for saline or sterile water. The liquid pain medication can be extracted with a needle and compatible flushes and vials are readily available in the hospital. This scenario happens despite the advent of the computerized drug dispensers, known as the Pyxis or Omnicell. 

Drug diversion is defined as when a drug, in this case a narcotic, does not reach the patient. It is then used by the nurse, or may even be sold by the health care professional. Drug diversion includes drug theft, or tampering (adulteration or substitution). 

 Moreover, it is a felony that can result in a nurse’s criminal prosecution and loss of license.

What happens when a nurse tampers with narcotics? First of all, the patient suffers. Their pain is not controlled. The patients on the floor or unit experience what is described as “inadequate care from impaired health care workers.”

 Patients may also be at risk of infections from contaminated syringes.”

 The hospital or health care setting does not escape unscathed neither. They can accrue fines and may lose Medicare funding. The nurse with substance abuse disorder may also experience hardship as he or she could find themselves facing both legal and medical consequences of their addiction.

I work in surgical oncology and sometimes a dose is ordered that is less than what is dispensed. There are cameras in the med room to document what has transpired. Despite this safeguard, drug diversion continues.

 When a nurse signs off on a waste that was not witnessed, a note in the system can be added and an incident report can be created as a prompt for patient safety concerns not as a punitive measure.

 One potential solution to this problem may lay with pharmacy—if wider dose ranges are available it may become more difficult to make excuses for differences between ordered and administered doses.

 Having a designated bin where all witnessed narcotic waste is discarded is another potential strategy. In any case, unapproved Environmental Protection Agency methods of disposing drugs—such as discarding meds down a sink or in a sharps container—must be avoided.

I am in Florida, and there is a mandatory reporting law in this state for nurses with substance abuse problems. Different states have individual reporting requirements, so these processes can depend on where you are employed, but in Florida, hospital or medical facilities should report nurses suspected of experiencing substance abuse disorder to the Department of Health or Intervention Project for Nurses (IPN). The IPN was created in 1983 with the purpose of protecting the public by helping nurses with substance abuse disorders. The IPN gives them the tools to cope with substance abuse.

The IPN is contracted by the Florida Department of Health to help nurses through “state-wide education, support and monitoring to nurses with impairing conditions such as substance use disorders.”

 Florida statute 456.076 is the legal basis for this project.

, streaming on Netflix, based on the book by Charles Graeber tells the story of convicted serial killer Charles Cullen, RN.6He repeatedly took out Digoxin and Insulin and spiked IV bags with these high-risk medications. Cullen would also take out medication and then cancel the removal before closing the Pyxis. A nurse on the unit, one of his coworkers and friends, risked her safety to pull all his Pyxis and Cerner records—which showed his documentation—to bring him to justice. He is now serving multiple life sentences.

These issues and the buzz around this series, 

, suggest that inappropriate handling of high-risk medications is an issue which is not going away soon. This has been the topic of the day in many nurses’ stations nationwide. The oncology nurse should be aware of the issues regarding impairment to effectively function in the healthcare setting.

Pavlovich-Danis SJ. The nurse with substance use disorder: moving past the “impaired” nurse label. June 18,2019

https://cedirect.continuingeducation.com/Aspx/CourseContent.aspx?uniqueid=38817892&topicid=601&page=1&IsAnthology=1

Webster A. Drug and alcohol rehab for nurses near you. American Addition Centers. September 14, 2022. Accessed December 5, 2022. 

Alunni-Kinkle S. Identifying substance use disorder in nursing. 

. 2015;46(12):53-54. doi:10.1097/01.NUMA.0000473512.38679.ca

Nyhaus, J. Drug diversion in healthcare: prevention and detection for nurses. 

About us. IPN: Intervention Project for Nurses. March 2022. Accessed November 28, 2022. 

Nicholson A.‘The Good Nurse’ review: Bad medicine. 

. October 27, 2022. Accessed November 28, 2022. https://nyti.ms/3VMSzMS



Articles

Sometimes nurses inappropriately handle high-risk medications. It is important that other nurses, especially those who work in pain management, hold colleagues accountable to promote patient safety. 

Opinion: The Good Nurse Brings Safe Narcotic Handling to the Forefront of Nursing Minds

In addition to worrying about the staffing needs in oncology units, RNs are facing workplace violence concerns at increasing rates. Workplace violence events can mean violence between staff membors or with visitors. As COVID-19 restrictions are relaxing and more hopsitals are welcoming visitors, safety considerations have become more relevant.

As of January 1, 2022, an official statement from the Joint Commission, the hospital accreditation agency, now includes a broader definition for workplace violence, which is defined as follows: “An act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors.”

 Unfortunately, in the past decade, the incidence of violence-related health care worker injuries has steadily increased and, as of 2018, health care and social service workers are 5 times more likely to experience a workplace violence event compared with other American workers. Even though workplace volence is often underreported, these events are not occurring unnoticed. In fact, the Joint Commission has recently instituted Workplace Violence Prevention Standards as of January 2022

with the goal of identifiying threats, educating staff, and using social media to improve data collection.

The incidence rate of violent events toward RNs, specifically, is “approximately 3 times greater than the rate of violent events for all occupations (3.8 cases per 10,000 workers).”

Building this case, a look at the Bureau of Labor Statistics shows that in general, health care workers experienced an increase of 63% in violence directed toward them between 2011 and 2018.

These statistics can be misleading because not all events are reported. The result is that these events can “can impair effective patient care and lead to psychological distress, job dissatisfaction, absenteeism, high turnover, and higher costs.”

Looking at data from 2018 also shows that health care and social service personnel, which would include RNs and social workers in oncology units were 5 times more at risk than other workers to be exposed to these types of incidents.

 The bottom line is that this accounts for almost 73% of “all nonfatal workplace injuries and illnesses requiring days away from work.”

The reasons for the uptick in violence by visitors vary. Some have to do with a family member receiving a troubling diagnosis and the visitors’ reaction to it, others may be related to trying to navigate the health care system in general—which can be frustrating. Nursing shortages can also play a role in this; with fewer nurses to offer families a social support system, and with fewer nurses to adequately attend to individual patients, families may become overwhelmed quicker. According to the US Bureau of Labor Statistiucs, mental health disorders, political and social issues, and gender and race discrimination can also play a role.

 Interviews with security personnel at hospitals, known as safety directors, revealed that the COVID-19 pandemic has exacerbated this reality. In fact, the National Nurses United Union, which is the largest union for RNs in the United States, report that almost half of 2000 RNs have experienced an “increase in workplace violence—more than double the percentage from a year earlier.”

A new legislation will come before Congress which will be called the Safety from Violence for Healthcare Act.

 The aim of this act is to establish consequences for those who want to hurt health care workers. In addition, an amendment put forth by Representative Kathrine Clark (D-Mass) will earmark $5 million for Health and Human Services to provide grants aimed to improve safety and security guidelines in health care.

The new Joint Commission standards of care regarding workplace violence are now being implemented. In order to remain accredited, hospitals must comply with creating systems to promote policies and procedures to decrease workplace violence. This may include improved reporting systems, data collection and analysis, postincident strategies, training and education.

In oncology settings, where unfortunately nurses and social workers are dealing with the aftermath of a terminal diagnosis such as metastatic cancer, recognition of workplace violence and solutions impacts us every day when we swipe in at the clock for our shift. I hope these new efforts will improve the level of safety for all healthcare professionals.

Workplace violence prevention standards. Requirement, rational, reference. The Joint Commission. June 18, 2021. Accessed November 16, 2022. 

Boyle P. Threats against health care workers are rising. here’s how hospitals are protecting their staffs. AAMC. August 18, 2022. Accessed November 16, 2022. 

National nurse survey reveals significant increases in unsafe staffing, workplace violence, and moral distress. News release. National Nurses United. April 14, 2022. Accessed November 16, 2022. 

House appropriators aapprove FY23 health funding increases in Labor-HHS Bill. AAMC. July 1, 2022. Accessed November 16, 2022. 

In addition to worrying about the staffing needs in oncology units, RNs are facing workplace violence concerns at increasing rates. 

Opinion: The Return of the Hospital Visitors Merits Conversation About Workplace Violence

Ask any patient with breast cancer and they’ll likely you tell you that the initial days following a diagnosis are a blur of appointments as treatments and surgeries are planned. Patients are often overwhelmed with the number of decisions that must be made amid their initial shock. Staying alive and getting the cancer out of their body is their top priority. Patients often don’t know what questions to ask or what to expect during their recovery.

That’s where oncology nurses come in. These nurses are in a unique position to help patients process the vast amount of information being given to them. Among that information are the adverse effects of mastectomy—and how those adverse effects, such as chest numbness, might affect their quality of life in the future.

I share this from my experience not only as a nurse of 20 years, but also as a breast cancer survivor. I was diagnosed with stage III breast cancer 5 years ago at the age of 39. My first concern was getting all the cancer out of my body. I was fortunate to be able to use my medical background to know what questions to ask during the initial flurry of appointments. Within 2 weeks, I started the first of 6 rounds of chemotherapy and scheduled a double mastectomy.


Thanks to my medical background, I knew that my nerves would be cut when my surgeon removed the breast tissue during my mastectomy. Without further intervention, the severing of nerves would interrupt the connection between the skin over my breasts and my brain—and that could lead to numbness across my chest area. It’s like the numbness that you feel after a dental procedure, but more widespread.

Before my mastectomy, I asked my doctor a question many patients wouldn’t know to ask: Am I ever going to feel sensation in my chest again? I knew that post-mastectomy sensation loss could be permanent. Many patients, however, are not aware of this adverse effect. If their surgeon did mention sensation loss, it was likely one of the many adverse effects that were quickly covered.

What I didn’t know was the impact that chest numbness would have on my quality of life. Until my sensation started to return, I felt nothing. That numbness also compounded the physical and mental toll cancer survivorship had taken on me. A hug didn’t have the same effect, and I didn’t feel connected to my own body. This had a tremendous effect on my body image and self-esteem. Chest numbness can also impact safety; for instance, knowing if you’re being burned while cooking, sunbathing, or showering.

I also didn’t know that it was possible to restore chest sensation as a part of breast reconstruction. I was fortunate that my surgeon performed breast neurotization—surgically reconnecting nerves with the goal of restoring sensation. If the nerve connection is repaired, it’s possible to get feeling back over time. As a result, I eventually regained much of the feeling in my chest.


During my breast reconstruction procedure, my surgeon used nerve allografts (donated human tissue) to reconnect the nerves that had been cut during my mastectomy. This procedure enables nerves to regenerate over time, potentially restoring sensation. This technique can be performed during breast reconstruction, including immediate reconstruction, delayed reconstruction, and some revision surgeries.

Nerves regenerate slowly—at a rate of approximately 1 mm per day. I started to notice some signs of nerve regeneration after 3 months, and the sensation continued to progressively improve over the next 18 months.



Oncology nursing continues to evolve with advancements in breast cancer treatment, and the way we talk about chest numbness must evolve, too. Oncology care teams should be proactively talking with their patients about the realities of chest numbness, including the emotionally devastating, isolating and disorienting feelings that may also occur.

Not every patient will be a candidate for breast neurotization, but patients need to know that it may be an option. You don’t need to have personal experience with sensation loss to educate your patients on the potential quality of life impacts of chest numbness and treatment options. This topic isn’t talked about nearly enough in the pre-operative stage but using your voice to advocate for your patients will change lives.

I’m fortunate to now live cancer-free and feel like my old self, but I know that if my chest numbness had been permanent, it would have had a tremendously negative impact on my life. Many patients feel guilty for being burdened by chest numbness—they think they should just be grateful to be alive. But it’s normal and valid to want to feel completely whole again. And it’s possible—I’m living proof.

Mitchell S, Gass J, Hanna M. How well informed do patients feel about their breast cancer surgery options? Findings from a nationwide survey of women after lumpectomy and/or mastectomy. 

. 2018;226(2):134-146.e3. doi:10.1016/j.jamcollsurg.2017.10.022

Habibi K, Delay E, Sarfati I, Duteille F, Clough KB, Atlan M. Lessons learned from twenty-eight cases of burns following breast reconstruction: an underestimated complication requiring inclusion in consent information. 

. 2021;41(7):NP773-NP779. doi:10.1093/asj/sjab027

Oncology nurses are in a unique position to educate patients with breast cancer about post-mastectomy chest numbness.

Opinion: Post-Mastectomy Chest Numbness: Oncology Nurses Are Key to Patient Education

Teddi Mellencamp, celebrity known for her appearance on the

, is currently battling stage 2 melanoma. She discovered this at her 3-month checkup after an initial melanoma surgery. Right now, Mellencamp is using her celebrity platform to stress the importance of returning for checkups as instructed to do that by a physician.

I live in Florida which has been ranked second in the nation for new melanoma cases.

In 2018, there were 7940 cases of melanoma diagnosed in Florida, and it is estimated that nearly 1 out of every 10 Floridians receive a skin cancer diagnosis in their lifetime. Although I have seen many cases of metastatic melanoma in the hospital where I work, melanoma awareness should extend beyond Florida. It is a common disease which affects individuals all over the country.

In 2022, the American Cancer Society estimated that there were 99,780 new cases of melanoma and approximately 7650 cases are expected to be fatal.

At the very least, 3-month checkups after an initial diagnosis are required, which is why Mellencamp returned to the dermatologist. The American Society of Clinical Oncology recommends that physical and skin examinations be performed every 3 to 6 months for the first 2 to 3 years following surgery and annually thereafter.

 For some patients, a chest x-ray, CT scan, MRI, and/or PET-CT scan may also be recommended.

Mellencamp originally received a diagnosis of stage 0 melanoma, also known as in situ, in March 2022. This was not her first 3-month checkup and it was during the most recent appointment that new findings near the original spot were discovered. In addition, a PET scan revealed lymph node involvement1. At the time of writing, she is currently scheduled to receive genetic testing.

Mellencamp has a huge Instagram following of 1 million fans and she is posting her photos and updates about her treatment plan. Her hope is that other patients with melanoma will take her lead and return to the doctor in a timely fashion. Many times, in the hospital setting, patients become what is known as “lost to follow-up.” I have seen this more times than I can count. For RNs and social workers, the risk of patients not returning to their oncologist or primary care doctor for screenings or later check-ups is a serious reality. Patient education and discharge instructions are something that we are all familiar with and that cannot be stressed enough to patients. 

Celebrities can be huge in raising awareness. For instance, celebrity shows like Stand Up To Cancer have a huge impact.

 Every 2 years, Stand Up To Cancer (SU2C) produces a roadblock televised fundraising special, supporting urgently needed research and new treatments for cancer. The last program aired in 2021 during the middle of the Covid-19 pandemic. The program highlighted all the research this organization has completed in the past decade and featured performances by noted Hollywood stars. The show is coproduced by Reese Witherspoon and her husband, Jim Toth, who is a talent agent as well. The program also showcased survivor stories. The mission statement of this program is “collaborative, multidisciplinary, multi-institutional scientific cancer research.”

Working on surgical oncology floors at night, I frequently see patients watching TV and movies all night in between getting pain medications. I think that the RN working in oncology should have an awareness of the importance of everyday heroes like our favorite TV and movie stars who have survived cancer. I know that nurses and social workers unwind with things other than journals, and this is a good opportunity to blend the 2.

Mccarthy A. I feel blessed!’ ‘ROBH’ star Teddi Mellencamp, 40, celebrates ‘good news’ after her frightening close call with cancer. Survivornet. March 24, 2022. Accessed November 3, 2022. 

Melanoma by the state: Florida. Aim At Melanoma Foundation. Accessed November 3, 2022. 

Key statistics for melanoma skin cancer. American Cancer Society. Accessed November 3, 2022. 

Melanoma: follow-up care. Cancer.net. December 2021. Accessed November 3, 2022. 

What we do. Stand Up To Cancer. Accessed November 3, 2022. 

Celebrated reality star Teddi Mellencamp is using her Instagram as a platform to stress the importance of follow-up visits for patients with melanoma.

Opinion: Oncology Nurses Should Know the Celebrity Stars Raising Cancer Awareness

Rebecca Kronk, PhD, MSN, CRNP, ANEF, FAAN, CNE

According to the World Health Organization

 there are over 1 billion individuals living with a disability, representing approximately 15% of the world’s population. In the United States, the Center for Disease Control reports that 1 in 4 adults have some type of disability.

Individuals with disabilities can be described as the largest minority group in the world; disability intersects across all demographics and rates of disability are increasing. Almost everyone will experience either a temporary or permanent disabling condition along their life span.

Early cancer detection saves lives, whereas delayed detection results in late-stage diagnoses and higher mortality. Compared with women without disabilities, women with disabilities have lower rates of breast and cervical cancer screenings. According to a study based on the 2013 National Health Interview Survey, prevalence of Papanicolaou tests among women with disabilities between ages 21 and 65 years ranged from 66% to 80%, compared with women without disabilities (81%).

 Prevalence of mammograms among women with disabilities between ages 50 and 74 years was 61% to 68% compared with women without disabilities (73%). Women with mobility limitations had the lowest prevalence of receiving a Papanicolaou test, and women with cognitive impairment had the lowest prevalence for mammograms. Among adults with disabilities ages 50 and 75 years, screening for colorectal cancer ranged from 49% to 65% and was 57% among adults without disabilities. Individuals with disabilities experience disparities in cancer screenings and are at higher risk for late-stage diagnoses.

A mixed methods systematic review investigated the barriers and facilitators of access to cancer services for people with physical disabilities.

 Five themes emerged from eighteen studies including: reasons for not engaging in preventive health care behaviors; interactions with health care providers (HCPs); external factors; accessibility of facilities; and positioning for procedures. Barriers to care included a lack of knowledge, personal beliefs systems, time constraints, and competing priorities. HCPs with poor attitudes, lack of knowledge and sensitivity, or failure to give needed referrals or information also were viewed as barriers. Receiving letters, post cards, or phone calls as reminders were viewed as facilitators as well as treating the person with a disability as an expert in their own care.

Women with disabilities were more likely to return for repeat mammograms when initially treated with sensitivity. External factors such as finances, transportation and accessible facilities could be improved with reliable transportation, and disabled parking spaces. Referrals to clinics with accessible equipment, ramps, and allotting additional time for appointments to allow for personal needs such as dressing or undressing were seen as facilitators. Regarding positioning, having a second technician to assist with safety, handrails, or being able to sit for a mammogram were suggested.

Resources for Evidenced-Based Care for People With Disabilities

To be part of the solution, nurses and other HCPs need the right tools to gain the competencies as well as the confidence to advocate for change for indivduals with disabilities. 

Alliance for Disability in Health Care Education

offers a set of core competencies that define standards and care for interprofessional teams to address health care disparities and improve outcomes for individuals with disabilities.

It is never too early to introduce nursing competences specific to the care of people with disabilities within prelicensure curriculum. A set of 12 simple, yet flexible, competencies distinctly specific to disability culture and care were developed by this author and colleagues. These competences were divided into 4 dimensions—environment and care, communication, culture, and referral—and are adaptable to any nursing curricula (

National League for Nurses (NLN) has developed the Advancing Care Excellence for Persons with Disabilities Program

 to support nursing education so that high quality care is delivered by nurses who are both knowledgeable and sensitive to the needs of individuals with disabilities. This online resource provides case studies, teaching strategies, and other resources to expand nurses’ abilities.

Caring for People with Disabilities: The Nurse Practitioner Tool Kit

to help prepare nurse practitioner (NP) students and practicing NPs as frontline workers to be part of the solution and fill a significant gap in NP training.

To summarize, it is imperative that nurses and other HCPs not only recognize the disparities in preventive screenings, but also to be part of the solution. Early detection and cancer treatment must be accessible and will save lives.

Disability and health. World Health Organization. November 24, 2021. Accessed October 26, 2022. 

Disability and health overview. Centers for Disease Control and Prevention. Updated September 16, 2020. Accessed October 26, 2022. 

Steele CB, Townsend JS, Courtney-Long EA, Young M. Prevalence of cancer screening among adults with disabilities, United States, 2013. 

 2017;14:160312. doi:10.5888/pcd14.160312

Edwards D J, Sakellariou D, Anstey S. Barriers to, and facilitators of, access to cancer services and experiences of cancer care for adults with a physical disability: a mixed methods systematic review.

2020;13(1):100844. doi:10.1016/j.dhjo.2019.100844

Teaching and learning resources. Alliance for Disability in Health Care Education. Accessed October 26, 2022. 

Advancing care excellence for persons with disabilities. National League for Nursing. Accessed October 26, 2022.

Caring for people with disabilities: the nurse practitioner tool kit. Villanova University M. Louise Fitzpatrick College of Nursing. Accessed October 26, 2022. 

Kronk R, Colbert AM, Smeltzer SC, Blunt E. Development of prelicensure nursing competencies in caring for people with disabilities through Delphi methodology. 

2020;45(3):E21-E25. doi:10.1097/NNE.0000000000000712

Development of Prelicensure Nursing Competencies in Caring for People With Disabilities Through Delphi Methodology; Nurse Educator45(3):E21-E25, May/June 2020.

It is imperative that nurses and other health care professionals not only recognize the disparities in preventive screenings but become part of the solution. Early detection and cancer treatment must be accessible for those with disabilities, as it can help save lives.     

Improvements in Accessibility to Cancer Screenings Are Needed for Individuals With Disabilities

Electronic health record (EHR) optimization is about to get more challenging, but there are ways for organizations to prepare. With a looming economic downturn, a labor shortage in professional services, and continued supply chain disruptions, it may feel daunting to overhaul, enhance, or implement an EHR system. Optimizing these systems is critical for creating operational efficiencies, reducing high administrative costs, and improving financial stability. Here are some ways to optimize your EHR system during a time of continued disruption.

It is important to understand the functionality and benefits of the tools your organization has already implemented but may not yet be adopted by your department or other departments. It is also crucial to know how updates or available features of your current EHR or a new system could affect overall business goals and drive value. Knowing the capabilities of an EHR system may reduce the need for a third-party system, decrease overall application and training costs, and lessen complexities for staff members working in multiple systems.

An optimized EHR system can improve workflows, catalyze queues of denials or referral responses, and improve scheduling templates to open access. Improving workflows through EHR optimization also creates an opportunity to reduce open encounters and lag charge times by enhancing clinical documentation tools and templates.

With continued labor shortages of frontline workers and back-office staff, it is more important than ever to ensure that digital solutions are integrated and implemented to reduce administrative burdens and increase provider and patient satisfaction. EHR systems can be updated with dashboards that include analytics for key metrics such as denials or provider efficiency metrics. By taking advantage of automated workflows and activities and ensuring the system provides support to both the provider organization and providers themselves, you may lessen the impact of labor shortages.

Right now, improving the patient experience is crucial across all provider organizations. Many patients are increasingly dissatisfied with their care and some may even choose to defer care altogether. Results of a recent Associated Press–NORC Center for Public Affairs Research poll showed that 8 in 10 Americans are at least moderately concerned about getting access to quality health care when they need it. Ease of access to telehealth and urgent care services and increased consumerization of health care continue to affect patient loyalty. An optimized EHR system can help enhance the patient's experience by simplifying the referral process.

Optimizing your EHR system also can boost the efficient use of the patient portal and empower patients or their caregivers to take the lead on managing care. A developed patient portal facilitates online appointment self-scheduling, allows patients to update their medical information, and offers the option to revise medications. Mature patient portals can simplify online check-in and arrival, online bill pay, and the patient’s ability to obtain their records and visit notes. An optimized EHR system and patient portal create real-time access to patient data for patients, their caregivers, and other providers in a way that was not possible before digital transformation. The ability for provider organizations and health care workers to share patient data more effectively may lead to better, more personalized treatment.

If a complete overhaul of your organization’s EHR system is out of the question, you can still make measurable, meaningful changes. Building and reestablishing relationships with patients should be top of mind for all provider organizations, so a good starting point is to optimize the patient portal. Make the most of the reports, dashboards, and other functionalities that the current EHR system offers, and use the technology you have to its fullest potential. EHR systems have the tools to generate documentation and ordering efficiencies for a high revenue-generating specialty—or you can use these tools to take a struggling specialty and improve its documentation and reporting.

The adoption and optimization of EHR systems not only have the potential to create operational efficiencies and lead to better outcomes for provider organizations, but they also may improve patient care with faster, safer, and more cost-effective decision-making. By optimizing your EHR system now, your organization will be better equipped to address future challenges in health care, the workforce, and the economy.

Julie McGuire, MSN, RN, is a managing director at The BDO Center for Healthcare Excellence & Innovation. She has more than 25 years of experience in health care and 15 years of experience collaborating with operational and clinical partners on delivering and transforming technology to new and existing facilities and services. BDO USA delivers assurance, tax, and financial advisory services to clients throughout the US and around the globe and is a member of BDO International, the world’s fifth-largest accounting network.

8 ways to get the most out of your EHR system. BDO. August 2022. Accessed October 12, 2022. 

Healthcare stability outlook report: 2022 and 2023. BDO. September 2022. Accessed October 12, 2022. 

Support for greater government role in health care for older adults. The Associated Press-NORC Center for Public Affairs Research. August 2022. Accessed October 12, 2022. 

Buying one for your practice or enhancing the one you have will help you cut costs and boost your financial stability.  

Opinion: Now Is the Time to Optimize Electronic Health Record Systems

The COVID-19 pandemic turned 2020 and then 2021 into the deadliest years in United States history.

In this time, the deaths caused by the coronavirus, an increase in deaths from heart disease and cancer, and the almost doubling of overdose fatalities has left the country living and working through unprecedented loss.

Health care professionals, and specifically those who manage the day to day care of patients such as nurses, have lived through a collective traumatic pandemic with little to no training on how to manage loss – their own, their patients’, and that of the families of their patients.

Although the pandemic has brought loss and trauma to the forefront, historically, most individuals in the United States die in hospital or nursing homes. Stanford School of medicine calculates that about 80% of all deaths happen in institutions.

By default, nurses become the first line of support for grieving family members. When engaging with a family member of a patient who has died, nurses should consider using immediate interventions aimed at supporting the loved ones who are in shock and in pain following their loss.

Given the devastating loss of the past two years, as a nurse, it is necessary to take a moment to understand and process your own experiences. When working with end of life and bereaved individuals, it is helpful to identity your own triggers, acknowledge and process your own losses, and find compassion for yourself and your experiences. Understanding yourself will allow you to better understand and support others.

Hospitals and hospice institutions have traditionally offered bereavement support through educational materials, referrals to services, individual counseling, and support groups, which typically begin weeks after the death. These services are necessary and provide a map for bereaved individuals as they move through their grief. But what happens at the moment of death? What interventions can you use to support people as they are witnessing their loved one die and immediately afterwards?

Immediate interventions at the time of loss:

1. Be present and hold the space: Although death is inevitable, most of us are not comfortable seeing, talking, or thinking about death – our own or someone else’s. To be a good support for a grieving family member, you must identify, acknowledge, and accept your own feelings. Perhaps you are feeling scared, frustrated, impatient, numb, or simply sad.Be aware of your own emotions so that you may be able to provide the emotional space needed for your patient’s grieving loved ones.

2. Emotional safety first: Always assess family and friends present. Are they able to feel and sustain the emotions they are experiencing? Are they physically able to stand and be present in the room? Do you need to offer a chair or a drink of water to those present? Should you offer psychiatric or bereavement resources?

3. Acknowledge and normalize: Regardless of how long their loved one was sick or how expected or unexpected the death is, almost everyone’s initial reaction will be shock or numbness. Your best approach is to use concrete and clear language to communicate and normalize what has happened (I am sorry that your loved one has died, I cannot imagine your feelings right now, etc). Remember, you cannot make things worse by using accurate and precise language.

4. Say no to platitudes: You can make things worse by using platitudes. Never make assumptions about people’s feelings or experiences. Even though you may believe that the death is a relief from the patient’s pain, the griever may not be ready to see it at that moment.Statements such as ‘he is in a better place’ or ‘at least she is no longer suffering,’ will not help the loved one see the loss in a different way. But such comments will make the griever feel guilty about the yearning for more time with their loved ones.

5. Always use the name of the deceased: “I am sorry Peter has died” or “I know you loved Mary very much.” Most of us wrongly believe that using the proper name will elicit painful reactions from their grieving friends and family. On the contrary, hearing the loved one’s name brings comfort.

6. Validate: Allow the person to feel exactly what they are feeling and confirm for them that that is exactly what they should be feeling. As nurses, you are trained to cure or alleviate pain. When supporting a griever, nobody can fix or take away their pain.The grieving person must experience the intense emotions that come with the death of a loved one.

7. Psychoeducation: Share with the grieving family and friends that grief is an emotional, behavioral, and a physical experience. Review with them the basic symptoms of grief.Emotionally, they might feel sadness, anger, guilty, anxiety, loneliness, etc. Physically, they might feel exhausted, unable to sleep/sleeping too much, change in eating habits, tightness in throat, shortness of breath, general distress. And their behavior is likely to change as well: forgetfulness, excessive worrying, withdrawal from normal activities.

Nursing is a profession that has always been defined by compassion, understanding, and empathy. Applying the traditional nursing skills, coupled with the immediate interventions mentioned in this article, will help the newly bereaved begin their grief journey in a supportive way.

Stobbe M. U.S. deaths in 2020 top 3 million. PBS. December 22, 2020. Accessed October 12, 2022. 

COVID-19 was third leading cause of death in the United States in both 2020 and 2021. National Institutes of Health. News release. July 5, 2022. Accessed October 12, 2022. 

Stobbe M. COVID helped make 2021 the deadliest year in U.S. history. April 12, 2022. Accessed October 12, 2022

Cavallo J. Determining the best place to die for patients with cancer. The ASCO Post. June 25, 2020. Accessed October 12, 2022. https://bit.ly/3CUdRlj

When engaging with a family member of a patient who has died, nurses should consider using immediate interventions aimed at supporting the loved ones who are in shock and in pain following their loss.

Immediate Interventions to Support The Newly Bereaved

My childhood experiences with my mother and grandmother, my family history, and my own personal experiences drove me to become a nurse, and most importantly, an 

 nurse. My passion for genetic testing comes not only from my clinical background, but also my personal experience. My sister Copelan and I pursued genetic testing after watching our mother and grandmother battle breast cancer. We both tested positive for the 

genetic mutation, putting us at a significantly increased risk for developing breast cancer and ovarian cancer at a young age.

genes produce proteins that repair damaged DNA—but when mutated, some variants increase the risk of developing cancer. After finding out we were carriers of this mutation, Copelan and I decided to act. She underwent a risk-reducing double mastectomy at 21 years old, and I did the same 3 years later when I turned 20 years old.

 carriers will develop breast cancer in their lifetime. In men, this rate is 1% to 5% and 5% to 10% for 

, respectively. During my 2 years in oncology nursing, I have met many patients who, like me, tested positive for a 

 variant. I try to share my story with patients, when appropriate, because it creates an immediate connection between us. From my perspective, this enhances the patient care experience and sparks their interest in learning more about genetic testing.

Some patients are unsure if they are candidates, and some—even if they have tested positive—are not always well-informed on the subject. I try to surface the subject, especially with patients who are 

, often known as a “breast cancer gene,” can be passed down from 

parent—it is not exclusive to female family members. I urge patients to familiarize themselves with their family history and, if they feel the need, to talk with their primary care physician about the possibilities of genetic testing. If a patient tests positive, I further encourage them to educate their children and grandchildren so they can take proper precautions and begin early surveillance of the breast and ovaries, and eventually have genetic testing done themselves. The hope is these preventive measures reduce their risk for cancer.

I feel incredibly fortunate I learned of this mutation at a young age and took the steps that were right for me, hopefully allowing our family to reduce the risk of cancer in future generations. I have served patients who were simply unaware of their genetic mutation and, if they had known sooner, may have been able to change course. This reality fuels my pursuit, as an oncology nurse, to spread awareness, knowledge and empowerment about genetic testing and help others take more control of their health.

During Breast Cancer Awareness Month and beyond, I encourage nurses to lean into conversation with patients about family history and genetic testing. As cornerstones of care and compassion, we may very well be the difference-makers in their journey.

Information for carriers of BRCA1 and BRCA2 gene mutations. Penn Medicine Abramson Cancer Center. Accessed October 20, 2022. 

Liz-Hunter Brack, RN, discusses how oncology nurses can play an important role in patient education surrounding genetic testing. 

Opinion: Nurses Need to Start Conversations About Genetic Testing

In the middle of Breast Cancer Awareness month, First Lady Jill Biden visited Miami, Florida, where I am based, to spotlight President Biden’s Cancer Moonshot initiative, which is designed to combat and end cancer. Biden and US Senator Debbie Wasserman Schulz, who is a breast cancer survivor, visited Sylvester Comprehensive Cancer Center for an event to spotlight the Moonshot initiative, Breast Cancer Awareness Month, and National Mammography week.

This month has been a revelation in terms of breast cancer awareness. Katie Couric, noted broadcast journalist, has once again shone the spotlight on a potentially lethal cancer. The University of Michigan coined the term “the Couric Effect” in the year 2000 when she advocated for colonoscopy screening after her husband from colon cancer in his 40s.

 There was a national jump in colonoscopy screening rates that year by approximately 20%. The same phenomena may be in the process of happening again.

Couric was in the middle of filming her 3D mammogram and ultrasound when her physician spotted a suspicious area. The camera was turned off. Katie found out that she needed a biopsy and then was given the diagnosis of stage IA HER2-negative breast cancer. She had a lumpectomy and 15 radiation therapy treatments this past summer. She received her diagnosis on June 21; on July 14 she had surgery, and on September 7, she began her first of 15 sessions of radiotion. Couric has shared that for the next 5 years she will be taking an oral aromataste inhibitor in order to decrease her estrogen level.

In addition to sharing various detrails about her diagnosis and treatment plan, Couric has also shared that she has dense breasts and that her diagnosis required a breast ultrasound. On TV, she has stressed the importance of this 2-step process. During an appearance at the TODAY show where she was a co-anchor for many years, Couric noted that only 70% of women who meet criteria for breast cancer screening complete this important step. The COVID-19 pandemic had an impact on women going for screening as well. Couric herself did not go for these annual tests since December 2020. In her personal blog, she wrote that the pandemic may have skewed her sense of time.

In addition to advocating for annual mammograms, Couric is educating the public about dense breasts and the importance of ultrasounds. Approximately 40% to 50% of women between the ages of 40 years to 74 years have dense breasts.

 Couric, at 65, also falls into this category.4 Patients with dense breasts may be at increased risk of developing breast cancer and it is recommended that they get routine mammaorgrams similar to other individuals. However, women with dense breasts may also benefit or a 3D mmammogram, or an ultrasound, as these screening devices may be able to better detect tumors in this population. There is also a new modality called SoftVue, which is a new form of ultrasound. It has received FDA approval and, when coupled with mammography, increases detection accuracy by approximately 20%.

Currently, 38 states, including Florida, New York, California, and New Jersey, as well as the District of Columbia have a requirement for “some level of breast density notification after a mammogram.”

 A federal national standard for reporting dense breast findings to women does not exist at the present time. Since 2019, there have been efforts for legislation on a federal level. In addition, the FDA has been trying to push for a standard covering reporting these findings.

I personally believe that there is a benefit to additional screenings for this patient population. I hope standard guidelines emerge in the coming years, and I believe that Katie Couric’s advocacy may be the incentive needed to get us there.

Last call for 10.11.22-A prime-time read of what's going down in Florida politics. Florida Politics. October 11, 2022.October 14, 2022. https://bit.ly/3EQ0AeS

Berman M. Katie Couric's Breast Cancer. MEDPAGE today. October 6, 2022. Accessed October 12, 2022. 

Weisholtz, D. TODAY. Exclusive; Katie Couric on telling daughters she has breast cancer: 'Hard to deliver that news'. October 3, 2022. Accessed October 12, 2022. https://on.today.com/3MOpyx1

Uda, R. Do you have dense breasts? Here's how to find out-and what to know about the cancer risks. Katie Couric Media. October 14, 2022. October 11, 2022. https://bit.ly/3So4ezS

State legislation map. Dense Breast Info. Accessed October 13, 2022. 

Katie Couric is educating the public about the importance of ultrasounds for women with dense breasts.

Opinion: The Couric Effect May Be Just What the Breast Cancer Community Needs

October is Breast Cancer Awareness month. This disease is relentless and again back in the news. This past week, TV journalist Katie Couric, revealed she had received a diagnosis of breast cancer in June. Couric, age 65, has been treated with radiation and a lumpectomy. She had her mammogram taped in real time to raise awareness about screening just as she had done to raise awareness with her colonoscopyafter her first husband died from colon cancer in his forties.

Breast cancer awareness has been in the media spotlight for many years now. At hospitals across the country, RNs and social workers wear pink to raise awareness of this cause. Branding is powerful. AIDS related causes use red, and organ donation goes with green. I was curious as to why breast cancer related causes had a pink theme. As ironic as it seems, this was not a Madison Avenue campaign from New York.

This was the brainchild of Charlotte Haley from Simi Valley California in 1991. Charlotte Haley was not in the public relations business. Her goal was to simply create some attention around breast cancer. At age 68, 3 of her close family members had gone through the battle with breast cancer. She began raising awareness in the grocery store by handing out postcards with 5 peach ribbons. Interestingly, by many accounts, peach was the first color recognized for breast cancer awareness. Peach eventually evolved into pink.

The postcards that Charlotte Haley handed out explained that only 5% of the National Cancer Institute’s annual budget out of $1.8 billion was earmarked to prevent cancer in general.

 The ribbon was supposed to create attention and it did; both through word-of-mouth and though catching the attention of major newspapers. Before Instagram, Tik Tok, and brand influencers, newspapers created a firestorm around causes. As Haley was handing out ribbons in 1991, by 1992, the 

 had dubbed the year as “The Year of the Ribbon,” on account of other ribbons gaining attention, such as the yellow ribbons associated with the First Gulf War in 1991 and the red AIDs awareness ribbons from that same year.

However, the grassroots efforts of Haley gained national attention once Alexandra Penney, 

magazine editor and Estee Lauder of the cosmetics firm, became involved. Penney wanted to use Haley’s ribbons as part of her second annual “Breast Cancer Awareness Issue.” Haley was uninterested, she felt they were too corporate and commercialized. However, Penney’s legal counsel advised her that if they changed the ribbon to a different color, they did not need Haley’s permission. Breast cancer ribbons were born. The peach color was left behind.

Coincidentally, the Susan G. Komen for the Cure® Foundation has been affiliated with the color pink since its start in 1982, although they did not begin handing out pink ribbons until 1991. From the mid-1980s to the early 1990s, their brand design used a pink ribbon with a woman running. Since 1990, pink was the color used to identify breast cancer survivors. When women ran in the Komen Race for the Cure in New York, pink ribbons were given to all runners and disease survivors alike. Again, Alexandra Penney of 

By certain accounts, the breast cancer awareness ribbon was actually peach before it was pink. 

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