Theresa Brown, PhD, BSN, RN
The Shift follows Brown as she cares for her patients during a 12-hour shift on an oncology ward. Any nurse who has worked in a hospital can identify with the many challenges Brown faces, the decisions she must make, and how she struggles to keep her day on track. Oncology nurses can identify with the issues unique to caring for patients with cancer, their families, and the spirit of hope and healing that underpins it all. Oncology Nursing News spoke recently with Brown about the challenges—and the rewards—that define her occupation.
How did you decide to specialize in oncology, and specifically palliative and hospice care?There's a lot of cancer in my mom's family, so I always had an interest, fascination, and then fear of oncology. When I first went into nursing, there was no way I ever thought I would choose oncology. But by the end of school, it just felt like absolutely the right fit. It's such an interesting field. You always have to be paying attention to everything that's going on with your patients, and I really like that. There are always new developments and new things to learn. It's very sad at times, too, but it wasn't the sadness that drew me to it, obviously. It was the positive aspects.
I think hospice is an extension of oncology. I feel like the two fields really should be seen as connected. I really wanted to see some better endings and be in that space with people and their families. I found out I was able to do that. It's hard, but it didn't make me uncomfortable. I didn't feel like I had to run away, and it's such a privilege to be there with people and acknowledge that someone's life is ending, and how hard that is and what it brings up. It's really an opportunity.
What are your thoughts on both the challenges and the rewards of practicing in oncology and palliative care?I think when people die is the hardest thing any of us will ever face, whether it's our own death or the death of someone we love, because death is the only thing in life that really is final. You can't reverse it. You can't change it. You have to deal with it because it's so concrete and that's what makes it hard, but it makes the time surrounding someone's death so incredibly rich.
Yet, emotionally, there's so much opportunity to really validate what people have done in their lives and also to validate the caregivers. Most of the people I see are in home hospice, and someone in their family, often more than one person, is taking care of that dying person. In this role, we have the chance to tell them, "Look at what you're doing. It's amazing.” I think people in that situation take their own caregiving for granted, so I love being able to say to them, "You just get a gold star as a human being for doing this amazing work." Our society doesn't really thank people for doing that work, and we should.
There's so much promise, and yet there is still so much disease that we can't cure, so that's really frustrating. We've gotten so much better at treating some diseases. But even among those that we're so amazing at treating, sometimes people just get a really bad form of the disease and we can't help them. That's very hard. A second challenge is that there's always so much to learn. This is exciting, but it can also feel overwhelming—new drugs, new treatments, new ways to treat symptoms of chemotherapy, and new protocols for giving chemotherapy.
I guess the biggest challenge is that there are just some really sad times because people are often long-term patients. You get to know them well, and then it's hard when things end badly.
How can we as nurses help each other meet these challenges?First, supporting the idea of ourselves as trained professionals and underscoring that we need to always keep learning. Oncology nurses could really lead the way on that really support new nurses in that learning process.
When we’re dealing with the sad parts, such as the promise and the frustration when treatment doesn't work, what's most helpful is having an emotionally open environment. That's what really helped me. If I was feeling sad about a death on the floor, I knew I could go talk to one of the nurses I worked with. My colleagues would just get it, and they would acknowledge that. There were times when it seemed like death would sometimes come in waves, and it was really hard on all of us, but everybody acknowledged that. I think acknowledging this part of our work is so important for not burning out and holding onto your humanity and what got you into the field in the first place.
In your book you talk a lot about the nurse/doctor relationship. What is your take on the relationship? For example, if we feel a patient needs more pain medication but the doctor doesn't agree, how do nurses navigate this and get the patients the support that we feel they need?That is a great question, and the answer of course varies depending on what kind of doctor you're dealing with. If it's a new intern or a resident, they may just not know or they may have been cautioned against overmedicating patients. Or they've never been in oncology and they don't know how painful cancer is and how freely we give people narcotics because they need them. That can be a process of educating them and saying: “This is a standard dose. This is what we do,” and then trying to work with them. If they say, "I need to talk to my resident," if there's time to let that play out, let that play out.
If it's a fellow or an attending being kind of stubborn for reasons that aren't clear, that's when I tend to be more assertive and say, "We really need to treat this pain. This patient is really uncomfortable. Here's what we've been giving. Here's how they've been responding to it. It just seems like it's really not working," and then have a proposal, for example, "What if we put them on patient-controlled analgesia, or what if we scheduled regular Dilaudid instead of having them ask for it?"
I've found even with some attending physicians, who can be brusque, if I spell out a problem like that, it usually gets their attention and they'll do something. Physicians are so busy themselves that sometimes they really have to be pressed to make that extra diagnostic and prescribing effort. That's my experience with most of them. It's not that they don't care or they're indifferent, they're just in too much of a hurry.
If you could make one change, what do you think could make the biggest difference in improving life among patients on the oncology ward right now?The first thing that comes to mind is staffing. Have more nurses. Just have more nurses so that every patient could have the level of attention they really need. Then our documentation could also get done the way that it's supposed to get done. I visited MD Anderson Cancer Center a few years ago, and their ratios are 2 to 1 on the bone marrow transplant floor—amazing. The nurses were still busy, they just weren't frantic. I think we could then really perform to the full scope of our practice because we wouldn't have to be always thinking, "How can I get this all done?"
That's something that really comes through in your book—that you're mentally revising your “to-do list” all the time. Has technology made the job easier?I find that charting takes us away from patients. I've been wondering if one aspect of it is just computers and med carts. I wonder if we could chart on iPads, because then you could really sit in a room and look at the patient and talk to them. It would be just like writing, which really doesn't feel that intrusive. If in the old days I'm talking to my primary care provider and he's writing things down, I never felt like that was alienating in the way I do now when he's on the laptop. I think if we could make software that was easier to use it would help: less use of point-and-click and dropdown menus. Those things are just complete time-wasters and destroyers of concentration. If documentation could really flow, that would make a huge difference. They say we can chart in the room with the patient, but my experience is that people don't like to talk to you when you're looking at a computer screen, and I don't like to talk to people when I'm looking at a computer screen.
Sometimes we hear other nurses discouraging people from entering the profession. What can we do amongst our own to help nurses feel better about their role?What I tell people is, "It's a great job—it just doesn't get the respect that it deserves." I think we really need a nurse self-esteem movement where we're proud of ourselves and proud of what we do. Physicians, they internalize this message. There's hazing in their education, and they're tired, and there's all this hard stuff, but I think they're reminded a lot that they're going to be doctors and they're going to be important, and nurses are not good at that. I really think that we should be. You can be hard on people and get them to learn and make them feel like they are fabulous at the same time. I really would like all nurses to have that feeling, more like, "This is a great job. People don't always see that, but that doesn't change the truth."
Your book does a great job of going through a nurse’s day, but if you had to give a quick answer to the question, “What do nurses do,” what would it be?I would say the nurse is in that middle place between the doctor and the patient. I would also say that the nurse is the human face of the hospital.
Marijke Vroomen Durning, RN, is a freelance writer who specializes in patient education and health and wellness topics.