	Oncology Education, Quality and Research

Improvements in cancer treatment have increased survival rates, and with more patients being diagnosed with cancer, complexity of disease state, and treatment toxicity, it can be challenging to identify an appropriate care delivery model.

 Care delivery—especially in complex, multidisciplinary programs&mdash;requires a well-conceptualized model to guide practice.

Nurses are the frontline providers and a crucial component in delivering high-quality patient care.

 Nursing care delivery models provide an infrastructure and organization for the care provided to patients and their families.

 The primary nursing model emphasizes one-to-one nurse—patient relationships and the importance of continuity of care.

At the Mount Sinai Hospital (MSH), our care delivery model is incorporated within the MSH Relationship Centered Care (MSHRCC) professional practice model.

 MSHRCC is an interdisciplinary model that extends the scope of the Relationship Based Care (RBC) model that focuses on relationships with patient/family, colleagues, and self.

 The MSHRCC includes all of the same relationships as the RBC model but extends the relationship to the entire healthcare team, as well as local and global communities. It contains six critical dimensions: leadership, teamwork, professional nursing practice, patient care delivery system, resource-driven practice, and outcomes measurement.

The expected outcomes are to increase patient and staff satisfaction, establish efficiency in the workplace, and improve patient safety.

 Modified primary nursing (MPN) is the care delivery model for the MSHRCC. It provides an explanation for the manner in which care is planned and delivered, the required skill sets, and expected outcomes. The tenets of MPN are nurse— patient relationship, accountability, autonomy, continuity, and collaboration.

Implementation strategies have been developed to provide structure and consistency throughout all units at Mount Sinai Hospital. These strategies include welcoming patients/families, shift report, back-to-basics care, developing patient relationships, RN/MD teams, and monitoring outcomes.

The majority of cancer patients receive their treatment in the ambulatory setting. The Derald H. Ruttenberg Treatment Center of the Tisch Cancer Institute at Mount Sinai offers a wide range of outpatient services for patients diagnosed with solid tumors and hematologic malignancies.

Cancer patients have access to a range of treatments, including chemotherapy, biologic therapy, bone marrow transplant (BMT), and clinical trials. Thirty medical oncologists, 20 nurse practitioners and physician assistants, and 57 RNs provide care to patients at the Ruttenberg Treatment Center.

Oncology nursing plays a critical role in ensuring patient safety and quality care to patients, and to improve our patient and staff satisfaction, we adapted the MSHRCC model and MPN to assist our patient population.

The main focus of MPN is to provide continuity of care to patients. Patients entering the Ruttenberg Treatment Center are immediately greeted by staff. Each infusion room is equipped with a TV, call bell, and iPad. A patient care board is located in each room, and RNs add their name and title.

When patients meet with their RN, they review their plan of care, medications, symptoms, and psychosocial issues. Nurses are expected to have a 5-minute “sit-down” with each patient to discuss family, career, coping, and fears.

Patients are assigned to one of three specific infusion areas, or “pods” (Hematologic Malignancy, BMT, and Solid Tumor). Nurses were given the option to identify in which area they preferred to practice. In addition, an electronic patient tracker system was implemented which tracks the location of patients during their visit. Nurses are also able to self-assign themselves to recurring patients, thus providing continuity of nursing care to patients and their families.

Three months after implementation of the new staffing structure and patient tracker, staff identified increased confidence in their skills and disease- specific knowledge and an enhanced ability to develop effective nurse—patient relationships.

Oncology RNs were engaged in the process of implementing the MSHRCC and modified primary nursing models, and staff recommendations assisted in the successful transition into this new nursing care practice. Assessment is gathered through patient and RN satisfaction scores and onsite observation. Patient satisfaction scores also are tracked on a monthly basis.

During the transition phase, we came across some challenges: (1) nursing staff were concerned about losing their skills to work with a wide variety of cancer diagnoses if they are assigned to disease-focused pods; (2) the patient tracker system needed many modifications in order for the tool to be effective in tracking current/ future patient visits; and (3) ancillary staff needed to be educated on the tenets of MSHRCC.

The implementation of MSHRCC and modified nursing was challenging; however, nursing staff have demonstrated job satisfaction and, in turn, the model has yielded high RN retention rates as well as an improvement in patient satisfaction scores. Moving forward, our goal is to continue to improve our patient satisfaction scores, communication among staff, and workplace efficiency.

			Lee CT, Fitzgerald B, Downey S, Malcomb M. Models of care in outpatient cancer centers. Nurs Econ. 2012;30(2):108-116.

			Jost SG, Bonnell M, Chacko SJ, Parkinson DL. Integrated primary nursing: a care delivery model for the 21st-century knowledge worker. Nurs Adm Q. 2010;34(3):208-216.

			Friese CR, Himes-Ferris L. Nursing practice environments and job outcomes in ambulatory oncology settings. J Nurs Adm. 2013;43(3):149-154.

			Person C. Patient care delivery. In: Koloroutis M, ed. Relationship-Based Care. A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management; 2004:159-182.

			Manthey M, Ciske K, Robertson P, Harris I. Primary nursing. Nurs Forum. 1970;9(1):64-83.

			The Mount Sinai Hospital Department of Nursing. Mount Sinai Hospital Relationship Centered Care. 2013.

			The Mount Sinai Hospital Department of Nursing. Care Delivery Model: Modified Primary Nursing. 2013.

Articles

Partner Perspectives

Implementation of Modified Primary Nursing in an Ambulatory Cancer Center

		Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

		Louisiana State Health Sciences Center in New Orleans, Louisiana

Back in 2005, the Surgeon General issued a health advisory about radon, the second leading cause of lung cancer in the United States and called it a completely preventable health threat. Like many oncology nurses, I was relatively uninformed about radon until I took care of a patient whose lung cancer was attributed to radon exposure. I’ve started paying closer attention to those patients who have never smoked (“not even a single cigarette!” exclaimed one patient) and are now baffled by a diagnosis of lung cancer.

While deaths caused by drunk driving (17,400 per year) receive considerable media attention, radon-related health hazards have not received much attention at all. Radon is estimated to cause 21,000 lung cancer deaths per year, according to the Environmental Protection Agency (EPA). Although quite a bit of information is available on the EPA’s website (www.epa. gov/radon), most nurses I’ve talked to are unaware of resources like this and lack knowledge about radon exposure and lung cancer.

Radon is a radioactive gas that cannot be seen, smelled, or tasted. The breakdown of uranium in soil, rock, and water produces radon, which becomes airborne. Less commonly, radon gas can enter a building through well water and is released into the air when water is used for showering and other uses. Research suggests that swallowing water with high radon levels may pose risks, too, although risks from swallowing water containing radon are believed to be much lower than those from breathing air containing radon.

Found all over the United States, radon may be present in any type of building (eg, buildings built on slabs and those with basements). Local geology, construction materials, and how the building was built are among the factors that affect radon levels.

The likelihood of developing radon-induced lung cancer is dependent on levels of the chemical at home and work, the amount of time spent in buildings with high radon levels, and smoking history. A smoker who is also exposed to radon has a much higher risk of lung cancer than nonsmokers; however, radon is the number one cause of lung cancer in nonsmokers.

Testing for radon is the only way to determine radon risk. Both the EPA and Surgeon General recommend testing all homes and schools below the third floor for radon. The amount of radon in the air is measured in picocuries per liter of air, or “pCi/L.” A radon level of 20 pCi/L in a smoker’s home, for instance, represents a high risk for developing lung cancer (26% chance). A radon level of 20 pCi/L in a nonsmoker’s home represents about a 4% risk for developing lung cancer. The EPA recommends that buildings with radon levels of 4 pCi/L or higher be fixed to reduce or eliminate radon exposure, and ideally, radon levels should be less than 2 pCi/L.

In many states, radon testing is a requirement of real estate transactions. Testing may be performed by a radon testing professional or via do-it-yourself radon test kits that are sold in home improvement stores and available by mail. Each state maintains a list of qualified testers, and the list is available on the EPA’s website at 

http://www.epa.gov/radon/whereyoulive.html

Basic radon test kits cost approximately $15 to $20. Simply sealing foundation cracks and openings is not enough to reduce radon risk. Reliable and durable techniques for reducing radon exposure include active soil depressurization, which collects radon from the soil beneath the building. A fan system draws the radon-laden soil gas from beneath the foundation of the building and exhausts it outside the building, far enough away from windows and other openings so that it will not reenter.

All buildings should be retested for radon no sooner than 24 hours later, or later than 30 days after installation to verify radon reduction. The buildings also should continue to be tested every 2 years.

The cost of a radon mitigation system varies depending on the size of the building, foundation, local climate, and other factors. The national average is $1200, with a range of $800-$1500. It’s estimated that one out of every 15 homes in the United States has an elevated indoor radon level that should be lowered. Oncology nurses are in the forefront of cancer prevention, and should include a discussion of radon exposure in terms of lung cancer risk in their patient and public education efforts.

Nurse's Notes

Back in 2005, the Surgeon General issued a health advisory about radon, the second leading cause of lung cancer in the United States and called it a completely preventable health threat. 

Educating Patients About Radon Exposure and Lung Cancer Risk

Susan C. McMillan, PhD, ARNP, FAAN, has conducted extensive research on treatment-related constipation, which, she noted, is the most common side effect of all of the opioid medications, and one that is “very amenable to nurse intervention.” When ONS asked her to be on the concentration team to explore the topic for its Putting Evidence Into Practice (PEP) series, she discovered after an exhaustive literature review that there were no clinical trials testing interventions for this side effect in cancer patients.

This led McMillan to design a clinical trial for cancer patients. She stressed that this complication not only threatens quality of life, but it can also result in death when patients who are prescribed opioids are not educated about opioid-induced constipation and the associated risks for bowel obstruction/perforation. In fact, she said, adding specific examples to her grant application, describing how patients on opioids had died after requiring surgery for bowel obstructions, helped to persuade the NCI to fund her trial.

Phase I data from the trial have been analyzed and published.

 The Constipation Assessment Scale was used to evaluate 400 patients with cancer who were receiving treatment with opioids, vinca alkaloids, or both.

Most patients experienced enduring constipation that ranged from mild to severe, causing them symptom distress. McMillan did note that she expected to find the results to be worse, but anecdotally discovered that several nurse practitioners at the Moffitt Cancer Center where the trial was conducted had been trained at the USF School of Nursing, and were thus aware of the importance of managing constipation.

Researchers concluded that practitioners were not sufficiently managing cancer patients’ medication-induced constipation, nor were they providing the education for them to manage it themselves.

			McMillan SC, Tofthagen C, Small B, et al. Trajectory of medication-induced constipation in patients with cancer. Oncol Nurs Forum. 2013;40(3):E92-E100.

Conference Highlights

Susan C. McMillan, PhD, ARNP, FAAN has conducted extensive research on treatment-related constipation, which, she noted, is the most common side effect of all of the opioid medications, and one that is "very amenable to nurse intervention."

Medication-Induced Constipation Is Poorly Managed

	Rebecca Lehto is an assistant professor at the Michigan State University College of Nursing in East Lansing.

Many cancer patients use complementary therapies for symptom management in conjunction with their standard medical treatment.

 Mindfulness-based practices, classified in the mind—body category by the National Center for Complementary and Alternative Medicine (NCCAM),

 are a group of complementary therapies that have gained increased popularity among cancer patients over the past two decades.

The uses of mindfulness-based therapies are rooted in ancient eastern contemplative practices and involve a combination of formal and informal meditation and gentle yoga, to cultivate an accepting, non-judgmental attitude of internal and external experiences.

 Mindfulness practices can lead to improved attention, increased awareness of mental and physical events, improvement in perceptions of wellbeing, and enhanced capacity to manage stressors.

Mindfulness-based stress reduction (MBSR), a program developed by Kabat-Zinn to treat pain and to reduce emotional distress in chronic conditions, is the most common format and incorporates eight weekly group sessions with a meditation retreat and daily home practice.

 Other popular programs include mindfulness-based cognitive therapy, which combines cognitive therapy with the MBSR components to treat conditions such as depression and chronic worry,

 and acceptance and commitment therapy (ACT), used in the treatment of behavioral disorders.

The number of studies that integrate mindfulness- based therapies in cancer care are increasing and showing promise in modifying psychological distress and improving health-related quality of life.

 Much of this research has focused on women with breast cancer,

 and patients who are either posttreatment or well into the survivorship trajectory. 

Many of the cancer-related studies have incorporated variations of the Kabat-Zinn MBSR intervention.

 Studies involving cancer patients report that training in meditative practices resulted in significant improvements in mood, anxiety, depression, fatigue, health-related quality of life, stress, coping, and sleep quality.

Although research demonstrates strong potential for the efficacy of mindfulness-based therapies for patients with cancer, further studies are needed due to methodological variation, limited use of comparison groups, small sample sizes, incomplete intervention fidelity information, limited research in wider cancer populations, and inadequate information on sustained effects over time.

 Further, there is minimal testing of mindfulness interventions during active treatment, a time when symptom management and quality of life are particularly challenged. While the mechanism of action behind mindfulness meditation practices for improving problematic symptoms is not yet substantiated,

 evidence from MRI brain scans indicates that mindfulness practice over a 8-week period resulted in changes in brain areas that are engaged in emotion regulation, attention, learning, and memory function.

Other research has demonstrated that meditative practices result in increased parasympathetic and decreased sympathetic nervous system activity contributing to relaxation and reduced stress.

Although more research is needed, studies suggest that meditative practices also positively influence neurogenic modulation of immune system responsiveness.

Mindfulness-based therapies represent a range of options within the NCCAM mind—body category that are widely utilized and have been shown to promote illness adjustment, reduce psychological distress, and improve health-related quality of life.10,11 Mindfulness-based therapies, emphasizing meditative practices, are economically delivered and once learned, are feasible for patients to use on their own. Further, such nontoxic strategies could be a reasonable option for symptom management that patients may elect to use during active treatment.

			Boon HS, Olatunde F, Zick SM. Trends in complementary/alternative medicine use by breast cancer survivors: Comparing survey data from 1998 and 2005. 

http://www.biomedcentral.com/content/pdf/1472-6874-7-4.pdf

			National Institutes of Health, National Center for Complementary and Alternative Medicine. What is CAM? 

			Shapiro SFL, Carlson LE, Astin JA, Freedman B. Mechanisms of mindfulness. 

			Arch JJ, Craske MG. Mechanisms of mindfulness: Emotion regulation following a focused breathing induction. 

			Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. 

			Delgado LC, Guerra P, Perakakis P, et al. Treating chronic worry: psychological and physiological effects of a training programme based on mindfulness. 

			Kabat-Zinn J. Full Catastrophe Living: Using The Wisdom Of Your Body And Mind To Face Stress, Pain, and Illness. 15th ed. New York, NY: Delta Trade Paperbacks; 2009.

			Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression. New York: Guilford Press; 2002.

			Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy. New York: Guilford Press; 1999.

			Ledesma D, Kumano H. Mindfulness-based stress reduction and cancer: a meta-analysis. 

			Shennon C, Payne S, Fenlon D. What is the evidence for the use of mindfulness-based interventions in cancer care? A review. 

			Tacón AM, Caldera YM, Ronaghan C. Mindfulness-based stress reduction in women with breast cancer. 

			Witek-Janusek L, Albuquerque K, Chroniak KR, et al. Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. 

			Shapiro SL, Bootzin RR, Figueredo AJ, Lopez AM, Schwartz GE. The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: an exploratory study. 

			Lengacher CA, Johnson-Mallard V, Post-White J, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. 

			Matchim Y, Armer JM, Stewart BR. Mindfulness-based stress reduction among breast cancer survivors: A literature review and discussion. 

			Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients. 

			Bränström R, Kvillemo P, Brandberg Y, Moskowitz JT. Self-report mindfulness as a mediator of psychological well-being in a stress reduction for cancer patients—a randomized study. 

			Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS), and melatonin in breast and prostate cancer outpatients. 

			Carlson LE, Speca M, Faris P, Patel KD. One year pre-post intervention follow-up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-based stress reduction (MBSR) in breast and prostate cancer outpatients.  

			Garland SN, Carlson LE, Cook S, et al. A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients. 

			Wurtzen H, Dalton SO, Elsass P, et al. Mindfulness significantly reduces self-reported levels of anxiety and depression: results of a randomised controlled trial among 336 Danish women treated for stage I-III breast cancer. 

			Henderson VP, Clemow L, Massion AO, et al. The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: a randomized trial. 

			Andersen SR, Wurtzen H, Steding-Jessen M, et al. Effect of mindfulness-based stress reduction on sleep quality: results of a randomized trial among Danish breast cancer patients. 

			Lengacher CA, Kip KE, Barta M, et al. A pilot study evaluating the effect of mindfulness-based stress reduction on psychological status, physical status, salivary cortisol, and interleukin-6 among advanced-stage cancer patients and their caregivers

			Lengacher CA, Reich RR, Post-White J, et al. Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters. 

			Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. 

			Nesvold A, Fagerland, MW, Davanger S, et al. Increased heart rate variability during nondirective meditation. 

			Rosenkranz MA, Davidson RJ, MacCoon DG, et al. A comparison of mindfulness-based stress reduction and an active control in modulation of neurogenic inflammation. 

			Davidson JJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. 

Using Mindfulness-Based Therapies for Symptom Management in Cancer

 Researchers presenting findings at the 2014 ONS Congress reported that many oncologists who are treating patients with head and neck cancer are proactively starting these patients on enteral nutrition (EN) support to avert malnutrition in a population which is especially vulnerable to this complication of this diagnosis and treatment.

Noreen Luszcz, RD, MBS, CNSC, and Donna Ford, RN, BSN, of Walgreens Infusion Services in Deerfield, Illinois, conducted a randomized, retrospective review of medical records of 172 patients receiving EN and found that 50% of these patients had their gastrostomy tubes placed prior to beginning treatment for head or neck cancer.

Notably, only 8% of these patients had severe malnutrition at the start of therapy, whereas 17% had malnutrition classified as moderate and 55% mild. For 27% of patients, the goal was weight gain, and for 64%, weight maintenance. Of the 62 patients who completed EN (average length = 131 days), 46% met their initial goal, and of patients remaining on EN, 70% were progressing toward their goal.

The infusion clinicians stressed that “it is important to incorporate early nutrition screening into the care plans of cancer patients to identify and treat those who may be at risk for malnutrition.”

Researchers presenting findings at the 2014 ONS Congress reported that many oncologists who are treating patients with head and neck cancer are proactively starting these patients on enteral nutrition (EN) support to avert malnutrition in a population which is especially vulnerable to this complication of this diagnosis and treatment.

Early Nutrition Support in Head and Neck Cancer

Despite decades of research, experts agree that, for many patients with advanced cancer, clinicians may still fail to accurately assess—or sufficiently manage&mdash;the symptoms associated with a cancer diagnosis and its treatment.

For this situation to improve, oncology nurses should take the lead, urged Susan C. McMillan, PhD, ARNP, FAAN, during her presentation at the 2014 ONS Annual Congress where she received the organization’s Distinguished Researcher Award.

McMillan began her career in oncology nursing in the 1970s, at a time that when people thought about cancer, they thought about death. She became deeply interested in helping patients with cancer to manage their pain and embarked on a four decade—long career investigating questions surrounding symptom management.

As the World Health Organization and others have noted, most of the resources spent in caring for cancer patients are directed to curative care; yet, there is growing awareness that a focus on palliative care should really begin at diagnosis, said McMillan.

In addition to both the occurrence and intensity of symptoms associated with cancer and its treatment, the level of distress patients have about their symptoms—what the symptoms mean to them&mdash;is also important, especially because many patients worry that if they complain about their symptoms to their providers, it may disrupt their cancer treatment.

“What I’ve been doing in my career is trying to make symptoms and quality of life better for cancer patients,” said McMillan, the Lyall and Beatrice Thompson Professor of Oncology Quality of Life Nursing at the University of South Florida (USF) in Tampa. McMillan said that the philosophy at the graduate oncology program she directs at USF recognizes that, “What oncology nurses do is palliative care. What oncology nurses focus on is quality of life.”

	“Paying Attention” Improves Outcomes

One of the first questions that McMillan and colleagues at the Moffitt Cancer Center explored early on was whether accurate assessment of pain might impact patient outcomes, and they found that in a relatively small sample of patients with cancer with whom the Center’s comprehensive pain assessment tool had been used at the time, these patients experienced significantly less pain intensity over a 24-hour period.

“This made sense to me, because I knew that nurses know how to manage pain,” although sometimes they may not understand it, she said, because they don’t ask the right questions.

McMillan went on to conduct further research exploring this connection between accurate assessment and pain management in patients with cancer—not just for those receiving treatment in a cancer hospital or hospice, but in other settings as well. Among this research was a study of nurse pain management in cancer patients in an ICU and a surgical unit. In this study, patients’ pain intensity was measured three times over 24 hours, and patient charts were reviewed to determine how much analgesia was provided.

The researchers found that patients in both units continued to have pain even with pain management interventions. Intensive care nurses administered an average of 30% of the maximum pain relief dose ordered, and in the surgical unit, nurses administered 36.8% of the maximum ordered dose. Eighteen percent of patients who reported moderate pain received no analgesia over the 24-hour evaluation period, McMillan noted. In addition, 70% of the patients in this study reported opioid-related constipation.

“We found that many patients had unrelieved daily pain,” said McMillan. “I often hear nurses complain: ‘physicians won’t give us what we need.’ Well, that means that there is a good nurse advocating for the patient, but these nurses obviously were not advocating for their patients.The doctor had ordered it, it was there, but the nurses were only giving about a third of it.” “Is that what we want? I don’t think so.” Our goal, as nurses, stressed McMillan, is that the patient’s pain is completely relieved. “If the patient says, ‘No, I don’t like the side effects or gives some other reason,’ the nurse should back off, but complete pain relief should be our goal.”

Pain is not the only symptom associated with cancer and its treatment, nor does it always rank highest on scales that measure frequency, severity, and distress, noted McMillan. She noted that in fact fatigue often ranks highest on these dimensions. In a study of 275 hospice patients with cancer, fatigue, pain, dry mouth, drowsiness, loss of appetite, and shortness of breath were reported most frequently.

 McMillan added that dry mouth routinely appears in the top five or six symptoms every time she looks at data from cancer patients, and these are not all head and neck cancer patients.

Fatigue, pain, shortness of breath, constipation, and loss of appetite (especially with well-meaning family members “pushing food at them all the time,” said McMillan) also caused distress among patients in this study.

Given that these symptom outcomes are not ideal, why is this happening?

McMillan and colleagues decided to look at the impact of what nurses know and believe about pain may have on how they help patients to manage it. This research involved a self-selected sample of 85 nurses, who, though not all specializing in oncology, were all working in inpatient units where cancer patients were receiving care at two VA hospitals in southwest Florida. Data were collected on the nurses’ knowledge of pain management principles and attitudes toward managing patients experiencing pain.

The researchers found that participating nurses knew least about the physiology of pain, the pharmacology of analgesics, non-pharmacologic methods of pain relief, and treatment goals. The mean score on the knowledge scale was 64%, and nurses knew most about the need to ask patients about their pain. With respect to attitudes, 84% of nurses disagreed that around-the-clock dosing is better, and 82% agreed that around-the-clock analgesics increase the risk for sedation and respiratory depression.

McMillan noted that around-the-clock dosing actually decreases the risk, because patients are receiving less opiate medication and reminded her audience that, “our goal is 100% relief. We want them to be completely relieved of their pain.”

Notably, 51% agreed that the doctor or nurse pain assessment is more valid than that of the patient. McMillan said that the clinician assessment can be especially unreliable for chronic pain, because the patient will typically not have the symptoms of acute pain (eg, rise in blood pressure, turning pale, and/or sweating). Forty-one percent of nurse respondents indicated that concerns over addiction, dependence, and respiratory depression would allow them to reduce the dose of pain medication, and 46% would not increase pain medication in a patient grimacing in pain if vital signs were stable. Moreover, McMillan said, some nurses would lower doses in older patients (>72 years) because of their age.

“They [nurses] didn’t know enough, they had negative attitudes, and the pain management was poor.” This study took place almost 15 years ago, McMillan acknowledged, so one of her graduate students replicated it for her master’s thesis, which has been accepted for publication this year in the

 Journal of the Advanced Practitioner in Oncology

. The range of scores on the knowledge scale was 39% to 81% (mean = 62%), which was two points below what it was 10 years earlier, McMillan observed. “Only 17% of nurses had scores higher than 70%.”

Attitudes from the more recent study were actually worse, said McMillan, noting that 95% of nurses in this survey disagreed that around-the-clock dosing was better. “It’s very disheartening that we’re still seeing this kind of data.”

McMillan presented research at ONS on a new tool she designed to assess the intensity, frequency, distress, and interference with quality of life of 35 common cancer symptoms (Box).

 The tool employs a 0-10 scale to make interpretation of findings more straightforward, McMillan explained, and the questionnaire is computer-based so that patients can easily rate multiple symptoms across the four dimensions.

The value of this tool is that a nurse can look at the printout and decide which are the priority symptoms for each individual patient and then use the findings to begin the discussion—and, importantly, let the patient decide which symptom is most distressing to them. With the information captured with the CSS, the practitioner can begin by saying, “I see you have this list of symptoms, and we’re going to deal with them one at a time. What would you like to start with?”

		Using a Cancer Symptom Scale Across the Disease Trajectory

	This study evaluated a Cancer Symptom Scale (CSS) in 234 adult outpatients who were being treated for cancer or cancer symptoms. Participants were asked to rate 35 symptoms on a 0-10 scale. The researchers concluded that the tool performed well on both validity and reliability in assessing multiple dimensions of symptoms.

 Data were collected from patients (average age = 60 years) an average of 28 months after diagnosis.

	Diagnoses included leukemia (15%), breast cancer (12%), lymphoma (11%), and colorectal cancer (9.4%). CSS findings included the following:	

 was the most intense symptom (mean = 7.3) and also the most distressing (mean = 6.9)

 (mean = 6.9) were the most frequent symptoms reported

 caused the most interference with quality of life (mean = 6.0)

In this study, approximately 25% of patients reported problems with sex, sweats, and diarrhea, McMillan pointed out. “These are highly sensitive symptoms when they happen.”

Among the symptoms causing most distress was “feeling irritable.” McMillan was not surprised by this finding, she said, because patients don’t want to be perceived as being difficult by their family and friends. For the study participants, diarrhea interfered most with quality of life, in part, explained McMillan, because the fear of having it might prevent patients from going out, or if they do go out, they feel the stress of needing to know that a restroom is nearby. “I really encourage nurses to use a multisymptom type of assessment, so that we don’t only ask patients about pain.”

Who should be the primary source for symptom assessment? Of all those who interface with the patient—eg, the oncologist, the nurse&mdash;it’s the caregivers, usually family members and most often spouses, who are with patients 24 hours a day, listening to the patient, and giving the medication, said McMillan. Another research question, then, is whether caregivers may be best positioned to provide information about a patient’s quality of life.

Research has shown, however, that caregiver assessments are not reliable. In a study of hospice patients with advanced cancer and their caregivers designed to evaluate consistency in symptom reporting, researchers found that caregivers significantly overrated symptom intensity for pain, dyspnea, and constipation, suggesting a role for healthcare practitioners in training family caregivers to conduct more systematic assessments, rather than assuming that they know the patient’s symptoms.

For the most accurate information about symptoms, McMillan stressed, “The patient remains the gold standard.”

McMillan is leading a multidisciplinary team of researchers and experts in the study of a self-care approach to managing cancer symptoms through a $2.1 million grant award from the Patient-Centered Outcomes Research Institute. The research will evaluate the American Cancer Society’s COPE intervention (Creativity, Optimism, Planning, Expert information), as a tool to educate cancer patients about how they can manage their high-priority symptoms. She has previously studied the intervention in four patient populations, as well as in family caregivers of hospice patients where the intervention significantly decreased symptom distress among patients whose caregivers were trained to better manage patients’ symptoms.

She expanded briefly on the COPE intervention’s four dimensions from the perspective of the oncology nurse. Creativity, she explained, means seeing problems differently and developing new strategies for problem-solving targeted to the specific situation. To encourage optimism, nurses need to help patients to understand that symptoms do not have to be “crosses that they must bear,” but rather, “We want them to be optimistic and believe that it can be fixed.” Some examples of planning, she said, are being prepared for an episode of breakthrough pain before it happens or helping the patient to be able to attend an important family occasion.

			Palliative care should begin at diagnosis

			Multidimensional symptom assessment includes frequency, intensity, and distress

			Patients—not clinicians or caregivers&mdash;remain the most reliable source for symptom assessment

			Employ systematic, multi-symptom assessment tools

Finally, the COPE resource offers specific information from experts that can be shared with patients and caregivers. They should also be reminded that their staff nurses are experts, too, said McMillan.

McMillan concluded by raising the question in the title of her talk, “Symptom Management: Are We There Yet?” Audience members concurred that the answer remains “No,” but there is also consensus on who can make a big difference in improving the situation. As McMillan noted: oncology nurses are uniquely positioned to take the lead in their units and help other nurses in making sure that patients’ pain and other symptoms are addressed.

			Tittle M, McMillan SC. Pain and pain-related side effects in an ICU and on a surgical unit: nurses’ management. Am J Crit Care. 1994;3(1):25-30.

			McMillan SC, Rivera HR. The relationship between depressive symptoms and symptom distress in patients with cancer newly admitted to hospice home care. J Hosp Palliat Nurs. 2009;11(1):41-51.

			McMillan SC, Tittle M, Hagan S, et al. Knowledge and attitudes of nurses in veterans hospitals about pain management in patients with cancer. Oncol Nurs Forum. 2000;27(9):1415-1423.

Cover Story

Despite decades of research, experts agree that, for many patients with advanced cancer, clinicians may still fail to accurately assess-or sufficiently manage-the symptoms associated with a cancer diagnosis and its treatment.

Symptom Management in Oncology Nursing-"We're Not There Yet"

Each year in connection with the ONS Annual Congress, CURE magazine announces the winner of its Extraordinary Healer Award for Oncology Nursing, and the 2014 recipient Cindi Cantril, RN, OCN, was honored not only for the outstanding care she provides to individual patients with breast cancer, but also for going above and beyond to forge a number of programs to support other patients living with cancer.

Cantril, who works at Sutter Pacific Medical Foundation in Santa Rosa, California, was nominated by Ann Taliman, a breast cancer survivor and colleague who detailed the many ways that Cantril cared for her during her diagnosis, surgery, and treatment. Beyond this, however, Cantril has developed a peer-to-peer support program called WINGS—Women Inspiring, Nurturing, Giving, Supporting&mdash;in which volunteer survivors are paired with newly-diagnosed women. The program has been so successful that it has been expanded to help women with other types of cancer, not just breast cancer. A men’s group&mdash;called WINGMEN&mdash;has also grown from Cantril’s efforts. Cantril is currently developing an equine therapy program for patients to work with the healing power of horses.

In addition to Cantril, two other pairs of nurse finalists and essayists were honored at the reception. Noelle Paul, RN, OCN, CAPA, from Memorial Sloan Kettering Cancer Center in New York City, was nominated by caregiver Mary Kay Morelli of Sparta, New Jersey, and Anne Todd, RN, OCN, from Indiana University Health Southern Indiana Physicians, was nominated by caregiver Chuck Wilson of Bloomington. All three nurse finalists were chosen based on an essay contest, which asked cancer patients, survivors, and caregivers from across the country to nominate oncology nurses who demonstrate exceptional compassion, expertise, and commitment in their patients’ fight against cancer.

“This year’s finalists represent a very diverse group of writers and nurses, but the common link between them is the fact that each story details very different ways that all three nurses went above and beyond to make a tremendous impact on the lives of their patients,” said Kathy LaTour, cancer survivor and editor-at-large of CURE.

The event featured actor, producer, director, and author Rob Lowe, who spoke to the crowd of more than 750 individuals about his family’s experiences with cancer. The award, now in its eighth year, is made possible through financial support from Amgen Oncology's Breakaway from Cancer and Millennium: The Takeda Oncology Company.

Extraordinary Healer Goes "Above and Beyond"

	Polly Mazanec is an assistant professor at the Frances Payne Bolton School of Nursing at Case Western University in Cleveland, Ohio.

To meet the complex healthcare demands of today’s patients, healthcare professionals need to learn how to practice as members of an interprofessional collaborative team. Here at the Frances Payne Bolton (FPB) School of Nursing, we have placed a priority on advancing interprofessional collaborative practice in oncology through several interprofessional education (IPE) initiatives.

Although oncology nurses traditionally have recognized the importance of our colleagues in social work, psychology, and chaplaincy, as well as medicine, we often work with these colleagues as consultants/referrals rather than as members of the patient’s and family’s oncology team. Each professional contributes to the care of the patient and family, but often in the silos of his or her respective discipline. This model of practice has been part of clinical training, which historically has been discipline-specific, with little opportunity to engage in interprofessional experiences.

Recently, however, many professional training programs have initiated interprofessional collaborative practice educational experiences at both the undergraduate and graduate level to help trainees from many healthcare disciplines learn to work in teams.

Interprofessional education has been defined as “an intervention where the members of more than one health or social care profession, or both, learn interactively together, for the explicit purpose of improving interprofessional collaboration (IPC) or the health/wellbeing of patients/clients, or both.”

 In 2011, the Interprofessional Education Collaborative issued core competencies for interprofessional collaborative practice.

 The expert panel included representatives from the American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association, Association of American Medical Colleges, and Association of Schools of Public Health. The expert panel established the four essential competency domains for interprofessional practice:

		Values/ethics for interprofessional practice

Many medical schools and nursing programs are beginning to integrate IPE into their curricula. Programs offer didactic sessions together, and many now are introducing interprofessional clinical experiences where the application of IPC principles is encouraged. Healthcare professionals trained in IPC are more likely to demonstrate respect for other professionals’ roles and responsibilities and to become collaborative members of the team.

 Ultimately, this collaboration has been shown to improve patient outcomes of quality and safety for a variety of acute and chronic illnesses.

 Such training is especially important for quality cancer care.

For the past two years, the Adult-Gerontology Primary Care Oncology & Palliative Care MSN program at FPB has offered its two semesters of symptom management courses as interprofessional classes. We have partnered with the University Hospitals Seidman Cancer Center Oncology Fellowship program and the MetroHealth & Hospice of the Western Reserve Palliative Medicine Fellowship to present symptom management sessions on interprofessional topics, such as cancer pain management, the ethics of medical decision-making, and common symptoms of advanced cancer, in an interprofessional format.

The two-hour sessions combine one hour of didactic instruction with one hour of team-based case studies. A faculty member from the three areas (nursing, oncology, and palliative medicine) facilitates a group of students and guides the discussion within the core domains of IPE: valuing and respecting disciplines, roles and responsibilities, communicating as a team, and teamwork.

FPB has been involved also in integrating IPE into clinical practice. The school has participated for more than two years in a project on Interprofessional Specialty Care-Cancer at the Louis B. Stokes Cleveland VA Medical Center. Nurse practitioner students have the opportunity to work as trainees in an interprofessional oncology clinical practice with other trainees from medicine, oncology, social work, psychology, and nursing.

The NP students are able to apply their classroom education to the clinical setting in the care of patients with breast cancer, melanoma, lymphoma, or sarcoma. They participate in the clinic weekly for eight weeks at a time. A 90-minute team huddle begins the clinic day, with all disciplines contributing to the patient plan of care prior to the visit.

Students stay in the patient clinic, visit while each discipline assesses the patient and family needs, and learn the roles and responsibilities of all members of the team. The day ends with a 30-minute patient review where the trainees discuss plans of care. This project, funded by the VA Offices of Academic Affairs and Specialty Care, has successfully integrated the core domains of IPE into the training experience.

Quality cancer care in the 21st century demands a team approach to attend to patient and family physical, psychological, social, and spiritual needs.

However, working in an interprofessional collaborative practice requires training to become a successful team. Opportunities to learn the principles of interprofessional practice are emerging in educational programs, but these need to be made available to oncology professionals already in practice if we are to improve patient outcomes and deliver quality cancer care.

			Bridges DR, Davidson RA, Odegard P, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. 

			Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes (update). 

			Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. May 2011. http://www.aacn.nche.edu/education-resources/ipecreport.pdf. Accessed May 20, 2014.

			Barker K, Oaandasan I. Interprofessional care review with medical residents: lessons learned, tensions aired—a pilot study. 

			Gagliardi A, Dobrow M, Wright FC. How can we improve cancer care? a review of interprofessional collaboration models and their use in clinical management. 

To meet the complex healthcare demands of today's patients, healthcare professionals need to learn how to practice as members of an interprofessional collaborative team. 

June 2014