I was recently at my physician’s office and observed a patient recording himself and a family member in the waiting room. He continued recording as he walked down the practice hallway and entered the examination room. It was clear that the patient had not only recorded himself, but also had captured other patients in the room and their names being called. He even potentially captured conversations between patients and health care providers.

Yet no one from the practice told him to stop filming, questioned his activities, or otherwise reacted.

Has this happened in your practice? If it did, how would you react?

The above scenario is hardly surprising in the age of social media, although it was a first for me. And while most health care providers and medical practitioners are aware of the significant limitations HIPAA places on their activities, they are less clear how to react when it’s the patient who wants to record the physician, which could potentially expose protected health information of other patients.

Practices should address the issue of patients recording themselves and others by planning ahead. A practice should develop a policy for handling such activity and prepare the necessary paperwork for patients to acknowledge the policy. If a practice chooses to allow such recordings, then the policy must set the appropriate parameters for recording at the practice, such as where filming can occur, whether permission must be requested, and other necessary requirements.

Sometimes patients ask their physicians directly to record an encounter for arguably legitimate reasons, such as to help remember medical information or instructions or to share the details of the visit with caretakers or loved ones. A practice should have a separate approach for physician recordings and tailor it to physician preferences.

What happens if a patient does not ask permission and records the physician without his or her knowledge? It may not only violate the practice’s policies, but also expose the practice to liability and impact its reputation. What information was in plain sight and recorded that presented a HIPAA issue? Could the practice be liable for anything else related to the recording? How did its staff behave? Practices should be aware at all times that recordings may take place without their knowledge, so appropriate HIPAA precautions and patient interactions should be the norm throughout training and put into daily practice.

Finally, practices should be aware that patients have the right in most states to record interactions with third parties where the law only requires 1 party to consent to the recording. This means a patient does not need to inform the physician that he or she is recording at all. Other states, such as Illinois, require that both parties are aware of the recording. In these states, this means that a patient who records a physician or staff interaction without permission has actually violated the law.

I recommend exploring these issues with legal counsel to assure that your practice is properly protected and that any plan is tailored specifically to your practice’s needs. For example, the approach may be different for an internal medicine practice compared with one that focuses on cancer or communicable diseases. Knowledgeable legal counsel can assist in understanding your practice’s legal risks and potential vulnerabilities.

Ericka L. Adler has practiced in the area of regulatory and transactional health care law for more than 20 years

®, a sister publication of Oncology Nursing News®.

Articles

Updates

While most health care providers and medical practitioners are aware of the significant limitations HIPAA places on their activities, they are less clear how to react when it’s the patient who wants to record the physician, which could potentially expose protected health information of other patients.

How to Handle Patients Who Want to Record Medical Conversations

For many oncology nurses, caring for patients with cancer is the driving force inspiring them to come in to work, day after day. But issues with hospital or clinic administration plus the global coronavirus 2019 disease (COVID-19) pandemic are causing health care professionals to experience burnout or compassion fatigue. Thankfully, research on burnout has come a long way in recent years. In 

 we explore this research and analyze how COVID-19 is affecting stressors put on oncology nurses. A special callout in the story lists steps that nurses can take to prevent or lessen the impact of burnout.

Another anxiety-inducing factor that some oncology nurses face is the financial burden of paying back student loans from nursing school and/or higher nursing education. Our feature story sheds light on this issue, while also providing resources for eligible nurses to reduce—or eliminate&mdash;their debt. We will hear from a nurse who found value in furthering her education, even though it came with a hefty price tag.

” column, seasoned nurses as well as patients offer advice to new oncology nurses who are just starting their careers. Words of wisdom focus on making connections with patients and their families, taking the time to explain medications and their adverse events, and finding time to disconnect from work.

Finally, head over to our continuing education (CE) section, which highlights 5 articles from the 2020 American Society for Clinical Oncology Virtual Program. Do not forget to go online and take the quiz for 1 CE credit hour.

I hope you find the information in this magazine informative and helpful. As always, thanks for reading.

From the Chairman

For many oncology nurses, caring for patients with cancer is the driving force inspiring them to come in to work, day after day. But issues with hospital or clinic administration plus the global coronavirus 2019 disease (COVID-19) pandemic are causing health care professionals to experience burnout or compassion fatigue.

Nurses Prevail Over Stressors Like Burnout, Educational Costs

Although nursing can be a fulfilling career, many new nurses graduate nursing school with tens of thousands of dollars of debt. According to a study by the American Association of Colleges of Nursing, the majority of nurses with a master’s degree or a doctor of nursing practice degree have student loans (71% and 67%, respectively), and nearly half (48%) of nurses with their PhD have loans as well.

Monica Mikhael MSN, RN, a nurse at UCLA who graduated with her master’s degree in nursing in 2018, is one of those nurses. “I have accrued—if I just have to estimate&mdash;almost $200,000 in student loans,” she told 

. For Mikhael, the debt is worth it, since it leads to a meaningful career in the field she loves—so much so that she plans on going back to school to become a nurse practitioner, which she expects will put her debt into the $300,000 range. She realizes, however, that others are more apprehensive to continue their education.

“I do think [high costs] prevent a lot of people from furthering their education if they want to,” Mikhael said. “In talking to some of my colleagues, they said their biggest concern is how much the program is going to cost.”

Programs exist to reduce the financial burden of education for nurses and other health care professionals. They include the following:

• Public Service Loan Forgiveness Program: This is for health care providers who work for a federal, state, local, or tribal government or a nonprofit organization. Qualifying individuals have the remaining balance of their loans forgiven after they make 120 monthly payments.

• Nurse Corps Loan Repayment Program: Qualifying nurses who work 32 hours or more in underserved communities or designated critical shortage facilities can receive up to 60% of their loans paid off over 2 years.

• Federal Perkins Loan cancelation or discharge: Nurses with Federal Perkins Loans may have 100% of their loans canceled if they work 5 or more years for a qualifying organization. Under certain conditions, a Perkins Loan also may be discharged.

Other programs also exist within hospitals or health care institutions, and Mikhael said that it is worth it for nurses to inquire with their employers.

“I know some hospitals do pay for like at least half,” she said. “So I would really encourage new nurses or [more experienced] nurses who want to go back to school to see what their hospital offers.”

Carolyn Maloney, a US representative for New York, recently introduced the Student Loan Forgiveness for Frontline Health Workers Act into the House of Representatives. If passed, the bill would forgive federal and private loans of eligible frontline health care professionals who are providing coronavirus disease 2019 (COVID- 19)—related care. This could apply to oncology nurses who have been reassigned or are treating patients with both cancer and COVID-19.

“Heath care professionals—especially through this pandemic&mdash;definitely deserve something,” Mikhael said.

As the demand for nurses continues to grow, Mikheal noted that nurses should not shy away from continuing their education solely because of cost.

“I hope that more people look to advance their degree and won’t be afraid of student loans—even though that [does play into the decision],” she said. “But know that there are so many options to help you pay, if furthering your degree is something you truly want to do.”

Feature Story

Many nurses are apprehensive about continuing their schooling because of the cost. But programs do exist to reduce the financial burden.

A High Price to Pay: Student Debt vs Furthering Nursing Education

A job in oncology nursing is both stressful and rewarding—whether you have been working in the profession for 10 days or 10 years. We recently asked our readers and cancer survivors what advice they would give to new oncology nurses. What follows is just some of the advice shared.

"Always remember that you are caring for the whole family. They, too, are suffering."

"Take the time to explain each medication, what it is for, how it might affect [patients]. Encourage patients to take advantage of palliative measures and not suffer needlessly."

"Being able to create a connection with your patients is important. I’m a relatively young cancer patient, and I remember the nurses who have conversations with me and are generally interested in how I’m doing. I keep up with all my favorites!"

"Show an interest in their life outside of their illness. Ask about their ambitions and what they enjoy. Befriend them. Understand that everyone is different and that some patients might not want to chat. Don’t take it personally. Stay upbeat. And learn the side effects of each drug given.”

"Having the ability to leave home at home and work at work is important. We all have a lot on our plates, but our patients with cancer expect us to walk into their room with a smile and ask about their life. It’s not only about meds and chemo!”

— Hamza Abid, clinical nurse specialist

The Social Nurse

A job in oncology nursing is both stressful and rewarding&mdash;whether you have been working in the profession for 10 days or 10 years. We recently asked our readers and cancer survivors what advice they would give to new oncology nurses. What follows is just some of the advice shared.

Patients and Fellow Providers Offer Advice for Oncology Nurses

Nurses have always faced difficult and challenging situations—ethical issues, futile treatment, patient suffering, staff suffering&mdash;but never have we faced a worldwide pandemic like the coronavirus disease 2019 (COVID-19). As a nurse leader, my priority is to encourage nurses to develop their resiliency muscle through education and promotion of nursing self-care. The World Health Organization designated 2020 as the Year of the Nurse and Nurse Midwife, and we should make the development of nurse resilience a priority for all health care systems and professional organizations. It should be integral to every nurse’s professional development.

Since the start of the pandemic, nurses have experienced burgeoning moral distress and burnout. They are concerned for their safety, their patients’ safety, and the safety and care of their own families. They must provide care that seems unconventional and often not fair. There are changing personal protective equipment (PPE) guidelines, and general information overload. We nurses are experiencing unprecedented anxiety. The human brain has limits on its ability to absorb change, and if nurses fail to address these issues or nurses’ leaders fail to coach and support, we may witness a mass exodus from our profession.

This summer, I have the privilege of coaching 5 new graduate residents who are starting their nursing careers on COVID-19 medical/surgical unit. These nurses interviewed for and accepted positions in an oncology unit, but in the interim, the oncology patients were consolidated and a COVID-19 unit was formed. Keeping the new nurses focused and less anxious, while all of us are working in full PPE, will be among the biggest challenges in my 35-plus years of nursing. I will provide them with support and education, and I hope that in the near future I will have the opportunity to help develop them into stellar oncology nurses. I will teach them the power of resiliency and self-care, the most important lessons of their nursing future.

Resilience allows a person to adapt well in the face of adversity, trauma, tragedy, threats, or significant sources of stress. The characteristics of resiliency include adaptability, self-control, self-sufficiency, creativity, optimism, persistence, and humor.

 Resilience can be learned and further developed. Factors that can promote resiliency include individual temperaments, family bonds, and external support systems, while personal resiliencebuilding qualities include the ability to ask others for support, optimism, faith, and the belief that stress makes you stronger. Working toward personal goals also is important.1 Innovative educational programs can help cultivate resilience in both new and experienced nurses.

In response to the moral distress and burnout clearly conveyed in many accounts from the epicenters of the virus, the CDC published recommendations for nurses on how to decrease stress and increase resiliency during these trying times.

• Communicate clearly about job-related stress.

• Identify and accept the things over which you have no control.

• Realize the crucial role you are playing in the COVID-19 pandemic, especially with limited resources.

• Keep a daily routine to maintain a sense of control, including getting adequate sleep.

• Know how to step away from work at the end of the shift, as well as take breaks from social media and other potential sources of negativity.

As a nurse, recognize that developing or improving your resilience is not only one that is ethically necessary to care for patients in difficult situations, but a crucial personal journey. Research results clearly show that nurses with high levels of resilience have are less likely to experience posttraumatic stress disorder, burnout syndrome, anxiety, and depression.2

We need you to care for yourselves and other nurses as we find our way out; we don’t want to lose nurses during this difficult journey. Keep yourself safe and always listen to your heart and body.

1. Palmiter D, Alvord M, Dorlen R, et al. Building your resilience. American Psychological Association. February 1, 2020. Accessed July 6, 2020. https://www.apa.org/topics/resilience

2. Centers for Disease Control and Prevention. Healthcare Personnel and First Responders: How to Cope with Stress and Build Resilience During the COVID-19 Pandemic. May 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/mental-health-healthcare.html

Nurse's Notes

If nurses fail to address these issues or nurses’ leaders fail to coach and support, we may witness a mass exodus from nursing.

Build Your Resilience Muscle, Stat

When Betty Ferrell, PhD, FAAN, FPCN, began her nursing career in 1977, the concept of burnout was relatively new. As oncology units, like the one Ferrell worked on, were just getting started, the challenging nature of providing care solely for patients with cancer soon became apparent. Ferrell started hearing more about burnout, which at the time was being attributed to the work itself—an idea she had trouble reconciling with what she was experiencing. As a new nurse, Ferrell found herself questioning whether caring for this population was truly the root cause of burnout, as many seemed to believe. She realized that for her and many of her colleagues, caring for sick, complicated patients was not the problem. On the contrary, it was the patients who kept her coming back day after day. It was the patients who kept her going. She could learn how to care for and comfort the seriously ill and dying, but dealing with an administration that made her job more difficult was another matter.

®, Ferrell, a professor and director of nursing research at the City of Hope National Medical Center, shared her insights about burnout and resiliency, and the important role of compassion, particularly during this trying time with the coronavirus disease 2019 (COVID-19) pandemic. Recalling her early years of nursing, Ferrell reflected, “What made me the craziest was that I could not give the care I wanted to give. I remember thinking that when it came to the concept of burnout, it was not just about the patient. The organization has a big role to play as well.”

The issue of burnout is now a well-known and well-researched phenomenon.

 Oncology nurses are at high risk for suffering from its effects, but they are also learning that even amid a pandemic, there is reason to hope, lessons to learn, and strength to be found.

Unlike burnout, which is defined as workload stress, compassion fatigue is secondary stress from exposure to suffering, and it is unique to caring professions.

 If not addressed, compassion fatigue can lead to burnout.

Courtney Sullivan, MSN, RN, CPNPAC, CPHON, project coordinator of global nursing, and Belinda Mandrell, PhD, RN, PNP, director of nursing research, both with St Jude Children’s Research Hospital, recently completed work on an evidence-based compassion fatigue quality-improvement program on a subspecialty pediatric oncology unit at St Jude.

® about their work and shared what nurses and organizations can do to address the issue of compassion fatigue.

Sullivan and Mandrell first identified the existence of compassion fatigue as a true problem through validated staff surveys. They also measured resiliency. What they learned was that while nurses experienced much reward from their work, they also experienced much stress. The emotional toll of caring for patients with cancer may be offset by the rewards of the work, but the risk for compassion fatigue remains high.

Having a mechanism for hearing the voice and concerns of staff and a plan for improving resiliency are crucial for preventing/reducing compassion fatigue and, ultimately, burnout. Sullivan noted that shared governance, unit-based councils, and a healthy work environment committee are important structures for nurses to share their concerns with nurse leadership, who can then act upon them and help support nurses with the self-care needs they have.

Their organization created spaces on each newly constructed unit only for nurses, including a lounge with a kitchen and a respite room. Leadership makes a point to come to the unit to let staff know they care.

They also have Resilience in Stressful Events (RISE) responders who are trained, interpro-fessional volunteers who are available 24/7 to provide staff with needed support during stressful events or for mental, emotional, and moral distress.

A new support tool called Code Lavender started at their organization in July. When a Code Lavender is called, a RISE responder comes to the unit with a self-care cart of interventions, such as journaling materials and aromatherapy. Mandrell noted that, “We mustn’t forget that compassion fatigue trickles throughout the orga-nization. [Environmental services], nutrition, registration personnel—everyone is affected by patients and their stories.”

For any intervention program to be successful, someone must own it and make it available. “Unless someone has ownership of the program/project,” said Mandrell, “it will just sit there.”

Sullivan stresses the importance of adminis-trative support. “Through healthy work environment committees and unit councils, that’s where you have your stethoscope to the voice of the unit, the heartbeat of those nurses, your finger on the pulse of what’s going on.”

When it comes to burnout, nurses are making a difference. They have learned more about what burnout is and what can be done to offset and even prevent it. By looking at work environ-ments and studying leadership strengths and weaknesses, nurse scientists like Ferrell have a better understanding of why nurses stay and why they leave.

“When you can’t provide the care your patients deserve, that’s a big part of burnout. Saying burnout is from working too many hours is a shallow interpretation. A deeper reflection is to think about what is really creating the burnout and consider the concept of moral injury and distress,” Ferrell said. “We’ve learned a lot. Great people have done important work. Ethics committees, nurse ethicists, and palliative care have become part of our practice. Reducing the moral distress that stems from violating personal values and beliefs regarding what constitutes good patient care can greatly impact the level of burnout experienced by nurses working in oncology.”

With COVID-19, the intensity of being a nurse is escalated on many levels.

 Nurses worry they will get sick and expose their families to risk. Working during the pandemic may mean longer hours, reductions in staff, and added concern for patient safety. Nurses may find themselves caring for patients, but without the proper protective equipment. Going beyond equipment shortages, nurses have also had to abandon the basic princi-ples of oncology nursing that they hold dear. COVID-19 has challenged the core beliefs of hands-on care, human touch, and close human connection. Ferrell leads the End of Life Nursing Education Consortium (ELNEC) project which has developed many resources for nurses including topics such as self care.

“We’ve spent our entire career focusing on patient- and family-centered care. We want families at the bedside. We believe that no one should die alone. [But] we are now told we can’t let anyone at the bedside, even when someone is dying,” Ferrell said. The moral injury nurses feel when they tell a family member over the phone that they cannot visit can contribute to burnout. “These big, important things affect how we do what we do,” Ferrell acknowledged.

Ferrell advises nurses and nurse leaders to step back, have a moment of compassion and grace, and tell each other that they are doing the best they can. There will come a time when they are through this. She hopes oncology organizations will then take the time to talk about what happened. Although orga-nizations may want to just move ahead, Ferrell believes that is not the answer. An important part of the healing will be talking about what it was like and employing debriefing as an opportunity to grow. “When it comes to burnout, self-care, and resiliency, the wise organization will be the one that takes the time to really deal with what happened and how that felt,” she said. She also encourages nurses and organizations to find reason to celebrate. “Part of self-care is to say, ‘What did we do really well? What went right?’”

Burn-out an “occupational phenomenon”: international classification of diseases. World Health Organization. May 28, 2019. Accessed July 5, 2020. 

https://www.who.int/mental_health/evidence/burn-out/en/

Nursing professionals pulse survey: 2020 pandemic. NurseGrid. Accessed July 5, 2020. 

https://nursegrid.com/help-nurses-now/survey-results/

Jarrad RA, Hammad S. Oncology nurses’ compassion fatigue, burn out and compassion satisfaction. 

Sullivan CE, King AR, Holdiness J, et al. Reducing compassion fatigue in inpatient pediatric oncology nurses. 

Cover Story

Burnout is no new phenomenon in the world of oncology nursing, but the recent COVID-19 pandemic has exacerbated these feelings. Thankfully, nurses are creating ways to help.

August 2020

How to Handle Patients Who Want to Record Medical Conversations

Nurses Prevail Over Stressors Like Burnout, Educational Costs

A High Price to Pay: Student Debt vs Furthering Nursing Education

Patients and Fellow Providers Offer Advice for Oncology Nurses

Build Your Resilience Muscle, Stat

Mitigating Compassion Fatigue and Nurse Burnout Amid COVID-19