Did you recently give a talk at a health fair? Have you spoken to patient or family support groups? Have you taught chemotherapy class? Did you present a poster at the Oncology Nursing Society’s Annual Congress or another meeting? Have you done in-service work or presented at journal club for your peers?

These are all presentations, some formal and some informal, but all have the potential to serve as the basis for a work for publication. Each year, oncology nurses give hundreds of presentations to coworkers, colleagues, patient support groups, community groups, and executives, yet few transform their presentations into published pieces. A poster or podium/lecture presentation done at a local, regional, national, or international meeting may be a good candidate for publication.

Oncology nurses publish for many different reasons: to share information, give others insight, add to the body of nursing knowledge, develop professionally, and help improve practice. Whatever your motivation, do not let too much time pass before converting the presentation into a publication. Momentum is easily lost, and publishing after a long hiatus will require a new search of the literature.

The thought of publishing can be overwhelming and intimidating for even the most experienced authors. The many reasons for not publishing include lack of time, fear of rejection, and not knowing how to start. The good news: Once you have prepared a presentation, at least half the work needed for a written piece is already done! The topic introduction, literature search, main points, visuals, conclusions, and implications for practice are often completed and polished. A straightforward approach to starting a written piece often involves elaborating on what was presented, and much of the time is spent on reworking components to accommodate the publication format.

Many nurses who have a desire to convert a poster or presentation into a publication have no idea of how or where to begin. Follow these step-by-step instructions to get started.

 What’s your advice for converting a presentation into a publishable work?

Share with your colleagues on Twitter using hashtag 

 Publication is no longer limited to journal articles. Oncology nurses can write for newsletters, health reports, social media, blogs, wikis, or websites. It is often easier to write a short, causal piece than a full-length journal article. Consider starting with patient education, which can often be a more natural way for a nurse to approach a topic.

A writing mentor can provide direction on content, style, and publication requirements. Most important, mentors can offer support and encouragement. Consider asking a colleague (not a friend) who is a seasoned writer to serve as a mentor and coauthor. Mentors do not need to be experts on the subject but do need to be experts on writing and publication.

 What was the presentation’s original purpose or message? What was the takeaway for participants who heard the lecture or read the poster? Determine if the same purpose and goal fit the publication you are considering.

Although presentations may be crafted to educate an audience comprised of individuals with diverse interests—eg, clinical, faculty, research, management&mdash;publications may have a narrower focus. Choose a primary audience, then seek a publication source to match.

The best fit for publication depends on the topic, purpose, and audience. Identify 2 or 3 places to publish and then reach out to the editors to assess interest.

Request guidelines from your target publication(s).

 If an editor expresses interest in your work, ask for editorial guidelines to help shape your piece for their publication. From tone to style to length, the closer your finished piece matches the desired format, the more likely it is that it will be accepted for publication.

Once you have gauged interest, determine which content from the presentation needs to be deleted or expanded for the written piece. Perhaps the publication will cover just 1 section of the  presentation, or perhaps the presentation needs to be expanded upon. Start by incorporating any slide notes or scripts into the first draft of the manuscript.

 Create a writing schedule with smaller deadlines to meet larger timelines. Try to write just 15 to 30 minutes a day or chunk content into small pieces. Have a mentor review small pieces instead of waiting until completion.

When oncology nurses publish, everyone benefits. Don’t say “I can’t write,” “I won’t add anything,” “It’s already been done,” or “I’m too busy.” Every oncology nurse has expertise to share with others. If publishing a presentation is not possible for your most recent presentation, be proactive next time. Plan in advance to publish your next presentation.

1. Alpach G. Converting presentations into journal articles: a guide for nurses. 

 2010:30(2):8-15. doi: 10.4037/ccn2010788.

2. Schrager S. Transforming your presentation into a publication. 

Articles

Professionally Speaking

Extend your professional repertoire with a published work based on a lecture or poster you have already created.

Transform Your Presentation Into a Publication

This letter from the Chairman and CEO of 

 gives an overview of the contents of the 

May was Oncology Nurses’ Month, and while nurses showed their support for their profession through celebrations in their workplaces and on social media, nurse pride was never more evident than at the CURE

 Award for Oncology Nursing event on May 17. Held in conjunction with the Oncology Nursing Society’s (ONS) 43rd Annual Congress, the celebration highlighted three nurses who were nominated by their peers for going above and beyond in their chosen profession.

An audience of 1000 cheered Christine Stone, MSN, RN, OCN, of the Life with Cancer program at Inova Schar Cancer Institute in Leesburg, Virginia, as they heard her colleague, Deborah A. Boyle, MSN, RN, AOCNS, FAAN, describe how Stone helps patients transcend the chaos of cancer through her guidance and advocacy. This month’s issue is dedicated to Stone, her fellow finalists, and all those oncology nurses who do such important work.

 previews the forthcoming publication of a complete update of a classic professional book, 

Chemotherapy and Biotherapy Guidelines and Recommendations for Practice

. The revamped and renamed volume, which will be known as the first edition of the 

Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice

, incorporates the rapidly growing field of immunotherapy, as well as chemotherapy, molecularly targeted anticancer agents, and hormonal therapy.

Editor in Chief Lisa Schulmeister addresses the opioid crisis in the United States and its effect on the ability and willingness of the cancer care ecosystem to support the use of opioids for patients with cancer. She describes the need to enlighten legislators that, when used appropriately and responsibly, opioids remain a safe treatment for many types of cancer-related pain, and that current legislative efforts may have a detrimental effect on patients who might benefit.

Also in this issue, a nurse navigator encounters health illiteracy, and shares how she came to understand and overcome her patient’s barrier to care. Another nurse describes her experience with process improvement at Memorial Sloan Kettering Cancer Center, and explains how nurses can create new roles within their institutions if they see an opportunity to improve patient care.

This issue contains coverage of posters and sessions presented at the ONS Congress. One article describes how nurses should approach patient care before and after immunotherapy. The Clinical Insights section reviews sessions and findings about cancer in adolescents and young adults, LGBT sensitivity among nurses, and managing treatments and adverse effects of those treatments in patients with liver cancer, leukemia, and ovarian cancer. On a related note, Elaine DeMeyer offers advice for presenters who would like to turn their presentations into publishable works.

Other articles cover drumming for breast cancer and its therapeutic potential, the burden of financial toxicity, a recent pilot study which examined patients’ perspectives to help nurses tailor strategies to assist patients in coping with procedures related to caring for their ports, and more.

For more practical insights and important news, sign up for our email newsletter at 

From the Chairman

This letter from the Chairman and CEO of Oncology Nursing News gives an overview of the contents of the June 2018 print issue of the magazine. 

Nurse Pride

Patients with relapsed/refractory non-Hodgkin lymphoma (NHL) have limited options for treatment, and effective advanced stage therapies must be developed for many subtypes of the disease. In the search for solutions, investigators are turning to combination therapies. The phase IIb UNITY-NHL clinical trial (NCT02793583) aims to determine whether these needs can be addressed using the novel drug umbralisib (TGR-1202) as monotherapy or as part of a doublet or triplet. The doublet includes ublituximab (TG-1101), and the triplet includes ublituximab and bendamustine (Treanda).

Umbralisib’s unique mechanism of action makes it a good candidate for combinations and monotherapy. The orally available PI3Kδ inhibitor has demonstrated strong activity in numerous preclinical models and in primary cells from patients with hematologic malignancies, according to the drug’s developer, TG Therapeutics in New York, New York. PI3Kδ is strongly expressed in hematopoietic cells and believed to be important in the proliferation and survival of B-cell lymphocytes.

Umbralisib stands out among PI3K inhibitors for its superior safety and tolerability.

Ublituximab, also developed by TG Therapeutics, is a monoclonal antibody that targets an epitope on the B-lymphocyte CD20 antigen. Anti-CD20 antibodies target and aid in the depletion of B-lymphocytes.

The chemotherapy bendamustine is a bifunctional mechlorethamine derivative that has shown alkylator and antimetabolite activity. The exact mechanism of action is unknown, but the bifunctional covalent linkage can lead to cell death via several pathways, and the drug is active against both quiescent and dividing cells.

The trial has 3 experimental arms: umbralisib oral daily dose used alone, combined with intravenous (IV) ublituximab, and combined with IV ublituximab and bendamustine. Overall response rate will be the primary outcome measure, with a time frame of 8 to 12 weeks for up to 2 years. The secondary outcome measure will be progression-free survival, assessed from the date of randomization until the first documented progression, through 2 years.

 Future cohorts will evaluate umbralisib and ublituximab for indolent lymphoma.

The UNITY-NHL study is enrolling patients with 4 different subtypes: diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), small lymphocytic lymphoma (SLL), and marginal zone lymphoma (MZL). Umbralisib is being tested as monotherapy in FL, SLL, and MZL, whereas the DLBCL subtype is being treated with doublet or triplet therapy. Each subtype has its own eligibility criteria. All participants must have relapsed/refractory NHL that has not responded to standard treatment.

Umbralisib (TGR-1202). Pipeline. TG Therapeutics website. 

Ublituximab (TG-1101). Pipeline. TG Therapeutics website. 

tgtherapeutics.com/pipeline/TGTX-1101.cfm

Treanda [prescribing information]. Frazer, PA: Cephalon, Inc; 2010. 

accessdata.fda.gov/drugsatfda_docs/label/2010/022249s005lbl.pdf

Study to Assess the Efficacy and Safety of Ublituximab + TGR-1202 With or Without Bendamustine and TGR-1202 Alone in Patients With Previously Treated Non-Hodgkins Lymphoma (UNITY-NHL). NIH website. clinicaltrials.gov/ct2/show/NCT02793583. Accessed May 9, 2018.

Clinical Trials in Progress

The phase IIb UNITY-NHL clinical trial (NCT02793583) aims to determine whether the novel drug umbralisib (TGR-1202) could be used as monotherapy or in combination with other drugs to treat patients with relapsed/refractory non-Hodgkin lymphoma (NHL). 

Promising Umbralisib Combinations Tested in Non-Hodgkin Lymphoma Subtypes

Nurses are experts at assessing and helping manage the adverse effects (AEs) and toxicities of cancer treatment. We know how to assess pain and nausea and offer multiple treatment options. But what about financial toxicity? What is it, how does it affect our patients, and what can nurses do to help?

DISTRESS FROM WORRY OVER FINANCES CAN AFFECT WELL-BEING

New cancer treatments offer hope but often come with a hefty price tag. Cancer treatment costs are rising, insurance co-pays are increasing, and patients are managing higher out-of-pocket (OOP) expenses. One in three American families have healthcare bills they cannot afford and about half of elderly Americans with cancer pay at least 10% of their income on OOP treatment- related expenses.

 These factors contribute to financial toxicity. Financial toxicity is the distress caused by financial concerns and affects patients’ well-being and quality of care.

In addition to the OOP cost for cancer treatment, cancer patients may face additional costs related to travel, childcare, and lost wages. Travel costs, including gas, parking, lodging, and food, can accumulate if a patient and family members need to travel distances to their treatment center and stay for extended periods. Furthermore, the effect of cancer treatment on employment for both patients and caregivers should be considered when evaluating the cost associated with cancer treatment.

The strain of financial distress adds to the suffering associated with the cancer experience and may interfere with the patient’s ability to cope effectively with cancer’s physical symptoms and the complexities of treatment.

 When income streams are limited, patients may downscale their standard of living and accumulate debt. Individuals may feel it necessary to spend retirement savings, borrow money, or carry a high credit card balance to pay for treatments.

The impact of the high OOP costs of cancer care is illustrated in a study that found 42% of participants reported a significant or catastrophic financial burden, 68% cut back on leisure activities, 46% reduced spending on food and clothing, and 46% used savings to defray expenses. Individuals with a high financial burden compared with those with a low burden were more likely to skip a recommended test, procedure, or an appointment.

To save money, 20% took less than the prescribed amount of medication, 19% partially filled prescriptions, and 24% avoided filling prescriptions altogether. The impact of financial toxicity has far reaching consequences.

WE NEED TO EDUCATE OURSELVES AND OUR PATIENTS ABOUT THE COST OF CARE

If we identify financial distress as a toxicity of cancer care, we need to consider a patient’s financial health as a routine part of clinical assessment. We must identify patients at greatest risk for high financial burden and offer support. Unfortunately, built-in support systems to assist with financial strain are not standard in oncology settings. Although some settings employ financial counselors or financial navigators, more work is needed to find the best way to meet our patients’ needs.

All healthcare team members need to collaborate to meet the needs of their patients, including assessing and addressing financial distress experienced by the patient.1 We can start by educating ourselves and then educating our patients about the cost of care.

identify resources for financial assistance

advocate for improved patient-physician communication about the cost of cancer care

We must recognize how difficult it is for patients with cancer to raise the topic.

 Some worry about the perception the oncologist has of them if they bring up money; others fear that a discussion of cost will result in inferior treatments. Yet most do want to have this conversation.

Nurses and other providers can allow patients a voice by simply asking “Do you have concerns about the cost of your treatment?” Some questions patients may ask include:

I’m worried about how much cancer treatment is going to cost me. Can we talk about it?

Will my health insurance pay for this treatment? How much will I have to pay myself?

Does my health insurance company need to preapprove or precertify any part of the treatment before I start?

If I can’t afford this treatment are there others that might cost less but work as well?

Is there a way I can get help to pay for this treatment?

Resources are being developed to assist nurses in having the discussion about the value of cancer care. One helpful resource is 

, which focuses on promoting conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.

The burden of financial toxicity is great and our patients need our help. In addition, the larger topic of the cost of healthcare is also important to address. All stakeholders including the pharmaceutical industry, payers, providers, and patients must continue the discussion of cancer treatment cost to ensure the delivery of high value care. Fortunately for now, nurses are in a great place to help with the latest AE of cancer treatment—financial toxicity. 

Kate Yeager, PhD, RN is an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Georgia. 

Carrera PM, Kantarjian HM, Blinder VS. The financial burden and distress of patients with cancer: Understanding and stepping-up action on the financial toxicity of

2018;68(2):153-165. doi: 10.3322/caac.21443.

Zafar SY, Newcomer LN, McCarthy J, Fuld Nasso S, Saltz LB. How should we intervene on the financial toxicity of cancer care? One shot, four perspectives.

2017;37:35-39. doi: 10.14694/EDBK_174893.

Zafar SY, Peppercorn JM, Schrag D, et al. The financial toxicity of cancer treatment: A pilot study assessing out-of-pocket expenses and the insured

2013;18(4):381-390. doi: 10.1634/theoncologist.2012-0279.

Partner Perspectives

How does financial toxicity affect patients, and what can nurses do to help?

Financial Toxicity and Patient Care

Selinexor (KPT-330), a promising drug that retards cell malignancy by blocking the transport of tumor-suppressor proteins out of the cell nucleus, is under investigation as combination therapy in heavily pretreated patients with relapsed/refractory multiple myeloma (MM). The phase III BOSTON trial is enrolling patients in over 100 clinical sites across 14 countries globally and expects to complete enrollment in 2018, with top-line data anticipated in 2019.

Further boosting confidence in the drug’s development, the FDA and the European Medicines Agency agreed that the BOSTON trial design was acceptable to support an application for approval, should the results prove positive.

Under investigation in both solid and hematological malignancies, selinexor previously received orphan drug designation from the FDA in both MM and diffuse large B-cell lymphoma. The designation promotes the development of treatments for rare disorders.

Selinexor inhibits chromosomal maintenance protein exportin-1 (XPO1), levels of which cancer cells increase in order to transfer tumor-suppressor proteins out of the nucleus, and thus, inactivate cancer-fighting proteins.

 High levels of XPO1 also promote production of oncoproteins that fuel the growth of the tumor. Blocking XPO1, limiting oncprotein production, and preventing the transfer of tumor-suppressor proteins out of the nucleus have emerged as promising new therapy.

Additionally, selinexor inhibits XPO1 from exporting the glucocorticoid receptors to which corticosteroids bind. Keeping those receptors in the nucleus strengthens the effects of steroids in the cell. In MM, corticosteroids can induce their own clinical antitumor response, and selinexor improves other agents’ efficacy.

The selinexor-containing triplet regimen has demonstrated positive responses in heavily pretreated patients with MM in the ongoing phase Ib/II STOMP trial, according to findings presented at the 2017 American Society of Hematology Annual Meeting.

The multicenter interventional trial will randomize 364 adult participants to receive the triplet or bortezomib (Velcade) and dexamethasone. The primary endpoints are progression- free survival and overall response rate. Notably, patients who have progressive disease while on bortezomib and dexamethasone will have the option to cross over to the experimental arm to be treated with selinexor.

Eligible patients will have documented evidence of relapsed/refractory MM after at least 1 but no more than 3 prior treatment regimens, which may include bortezomib or another proteasome inhibitor. Participants also must have no central nervous system involvement.

Overview. Karyopharm Therapeutics website. karyopharm. com/about/. Accessed April 24, 2018.

Oral selinexor (KPT-330). Karyopharm Therapeutics website. karyopharm.com/pipeline/oral-selinexorkpt- 330. Accessed April 26, 2018.

Selinexor (KPT-330), a promising drug that retards cell malignancy by blocking the transport of tumor-suppressor proteins out of the cell nucleus, is under investigation as combination therapy in heavily pretreated patients with relapsed/refractory multiple myeloma.

Trial Combines Selinexor With Standard Therapy in Multiple Myeloma

Opioid addiction is being called an epidemic and public health crisis in the United States. In response, the CDC issued guidelines for prescribing opioids that have been widely adopted. In addition, the federal government and many state legislatures have introduced or enacted laws on opioid abuse prevention and treatment. Generally, legislation includes prescription drug monitoring and restrictions on dosages and amount dispensed. In many states, opioid prescriptions are limited to 3- to 7-day supplies. These efforts are intended to decrease the unnecessary use of opioids and reduce opioid diversion; however, their impact on cancer pain management is worrisome.

Years ago, the undertreatment of pain was a reality for many individuals with cancer. Fortunately, over the years, the complexity of pain was acknowledged and addressed. It’s now known that cancer pain can involve inflammatory, neuropathic, ischemic, and compression mechanisms at multiple sites. Pain also can be triggered by adverse effects of cancer treatment, such as mucositis, arthralgia, and neuropathies. The introduction of new analgesics in improved formulations such as extended release, as well as advanced delivery systems such as transdermal patches, improved pain management for many patients. We learned that many patients, especially those with advanced disease, required relatively high doses of opioids to control their pain. There was concern about addiction; however, addiction rarely occurred among patients using opioids as prescribed for cancer-related pain.

There are many different causes of cancer-related pain and cancer treatment-associated pain, so whenever possible, the underlying issue should first be addressed and treated. For some patients, that treatment, such as radiation therapy for bone metastasis, may also relieve or reduce their pain. Other patients may continue to experience pain despite treating the underlying cause. Some respond well to nonopioid analgesics and nonpharmacologic modalities, such as acupuncture, massage, and physical therapy. However, for many patients battling pain, opioids may be the only effective treatment.

Patients now have a new battle, as they encounter difficulties with insurance carrier authorizations, delays in filling prescriptions for pain medications, and, in some cases, new procedures, such as a pharmacy requiring an opioid prescription to be picked up by the person it is prescribed for. Prescriptions that are limited to 3 to 7 days require frequent trips to the pharmacy, which is especially burdensome for patients living in rural areas. Although treatment of chronic cancer pain was intended to be exempted from the CDC prescribing guidelines, many patients are finding that this is not occurring. When patients with cancer experience delays in obtaining their pain medications or receive reduced amounts, they may begin to ration their supply, resulting in inadequate pain control.

As clinicians, we too are engaged in battle with the new legislative restrictions. Prescribing paperwork, controlled substance agreement contracts, and advocating for exemptions for patients now consume vast amounts of time in daily practice. Pharmacists likewise are frustrated by additional responsibilities in prescription drug monitoring and dispensing opioids.

So, what can we do? A guiding principle of pain management has always been to use opioids just when needed and at appropriate doses and administration frequencies. We need to engage our patients in this endeavor and help them understand principles of pain management. We also must explore nonopioid medications for pain relief and encourage patients to consider nonpharmacologic pain control methods.

A challenge arises for clinicians and patients alike when opioids are used to cope with the anxiety, stress, depression, and sleeplessness that often accompany a cancer diagnosis or its treatment. Patients’ emotional distress and coping behaviors need to be assessed, along with all their medications, during every outpatient visit or day of hospitalization. Early referral to support groups, exercise programs, stress management classes, and behavioral therapists may be needed. Most facilities now have pain management teams that provide holistic care, and referral may be indicated for some patients. Patients also may benefit from palliative or hospice care when appropriate.

Logs or diaries can be used to track patients’ pain and response to management measures. They help identify breakthrough pain and the need for dose adjustments, rescue medications, or extended-release or long-acting analgesic formations. The American Cancer Society has extensive cancer pain resources for patients on its website, Cancer. org, including tools for rating pain and a diary for recording a pain score, characteristics, alleviating and aggravating factors, medications taken, nondrug techniques used, duration of pain, and effectiveness of interventions.

We’re now in an era when we need to curb misuse and abuse of opioids yet continue to help our patients manage their pain. We must collect data on the impact of new prescribing legislation and regulations on our patients and our workloads as clinicians. Our legislators need to be informed of how current legislative efforts are putting our patients at risk of poor control of their pain. They need to know that when used appropriately and responsibly, opioids remain a safe treatment for many types of cancer-related pain.

1. Pinkerton R, Hardy JR. Opioid addiction and misuse in adult and adolescent patients with cancer. 

2017;47(6):632-636. doi: 10.1111/imj.13449.

Nurse's Notes

Government efforts to decrease unnecessary opioids use and reduce opioid diversion are creating a worrisome impact on cancer pain management.

Managing Cancer Pain in an Era of Opioid Abuse

A theoretical model developed to instill trust in nurses proposes that generating and promoting nurse trust requires identification of interventions which promote nursing care quality, individuality and patients’ health status.

 The concept of trust is defined as “the confidence that care would be appropriate, reliable, and as successful as possible.”

 Patients who trust their nurses believe that nurses will protect them from harm, provide reliable assistance when needed, and be honest during interactions.

According to 2007 estimates, Americans lived with inserted central vascular access devices for 168,113,488 days.

 One type of these is the totally implantable vascular access device (TIVAD) or port. The first TIVAD was inserted in 1982 and, since then, has been considered a safe alternative to peripheral intravenous lines for administering chemotherapy infusions to oncology patients.

 Subsequently, the use of TIVADs has increased in the oncology population.

 Research has shown that pain and anxiety are related to port access.

 However, a need exists to capture patients’ feelings and emotions related to living with a port, as well as effective nursing interventions aimed to address those patient experiences.

A recent pilot study examined patients’ perspectives to help nurses tailor strategies to assist patients in coping with procedures related to caring for the TIVAD. Qualitative interpretive phenomenology was chosen to conduct and explore the meaning of oncology patients’ perspectives of living with a TIVAD.

 Some examples of the semistructured interview questions used in this study: “Can you tell me what the port means to you?” “What actions by the nurse make it easier to live with the port?” “How would you improve care of your port?” Institutional Review Board approval was obtained from Duquesne University in Pittsburgh, Pennsylvania, and Penn Medicine’s Chester County Hospital in West Chester, Pennsylvania, to interview oncology patients undergoing active chemotherapy treatment using a TIVAD.

Three participants were interviewed for this pilot study, and data were transcribed and analyzed using qualitative software. The data were read, coded, and categorized into common themes. Interview analysis revealed 16 topics that were combined into 9 themes supported by verbatim patient statements: (1) advantages of the port, (2) complications, (3) disadvantages of port, (4) discomfort, (5) emotion, (6) human contact, (7) nurse knowledge of port care, (8) strategies used by patient to make life easier, and (9) trust of care provider. Due to the pilot nature of this study, data saturation was not achieved. The theme, trust of care provider, emerged prominently from all 3 participants. Participant 1 best illustrated the need to have trust in the care provider: “If you have good professional advice, you will be fine; you need good professional advice. These nurses have been unbelievable, and I trust them [implicitly].”

However, trust placed in the nurse may not be unquestionably acquired by the patient based solely on the need for nursing care, as explained by participants 2 and 3:

“I would much rather a nurse tell me honestly that they are not comfortable accessing my port than attempt to access the port and cause an infection or pain.”

“I don’t want them [home care nurses] accessing my port unless they know how to do sterile technique. I know immediately when they put on their gloves if they know sterile technique in accessing my port.”

Participant 3 talked about the uniqueness and fragility of trust in the nurse by the patient: “I will call [the home infusion company] and say, ‘So-and-so [nurse] doesn’t have good sterile technique. I don’t want them back here [in my home] unless they learn how to use sterile technique.”

Without the presence of trust in a nurse, negative outcomes can occur, such as not feeling safe in the healthcare environment and agreeing to accept essential treatments and procedures.

 Participant 2 described feeling uncomfortable with the lack of expertise exhibited by a particular radiology nurse: “I try to make appointments for [CAT scans] when she is not there working. If she is working, I will reschedule my appointment for another day and time. I know she is not an oncology nurse, but if she works in this department, she should be able to access my port.” The TIVAD was more than a means to provide access to deliver chemotherapy to a patient. The TIVAD was also viewed as an object of vulnerability for the patient. “If you are going to access the port, access it properly because I am the one who pays the consequences if they [nurses] don’t,” said participant 3.

In a concept analysis of nurse—patient trust, Bell and Duffy (2009) proposed that patients assume certain attributes demonstrated by the nurse that convey this trust. These attributes include nurse clinical competency, goodwill, and understanding patient vulnerability related to the risks involved with caring for a patient.

 The comments related to nurse trust that were expressed by patients in this pilot study reflected attributes of honesty, clinical competency, and acknowledgement by the nurse regarding the vulnerability of the patient.

In summary, this pilot study suggests that a deeper meaning exists between the nurse and the patient when the patient’s TIVAD is accessed. Further exploration into the trust that patients have in nurses who care for their TIVADs can inform nurses about implementing quality patient-centered nursing interventions that promote positive health outcomes. Such outcomes aim to ensure that oncology patients accept their treatment, feel safe in the healthcare environment, effectively manage their disease processes, and achieve optimal wellness.

Lois Rajcan, MSN, RN, CRNI is working toward a PhD in nursing at Duquesne University in Pittsburgh, Pennsylvania.

Charalambous A, Radwin LE, Berg A, et al. An international study of hospitalized cancer patients’ health status, nursing care quality, perceived individuality in care and trust in nurses: a path analysis

. 2016;61:176-186. doi: 10.1016/j.ijnurstu.2016.06.013.

Radwin L, Alster K. Outcomes of perceived quality nursing care reported by oncology patients. 

Centers for Disease Control and Prevention (CDC). Vital signs: central line-associated blood stream infections—United States, 2001, 2008, and 2009. 

Niederhuber JE, Ensminger W, Gyves JW, Liepman M, Doan K, Cozzi E. Totally implanted venous and arterial access system to replace external catheters in cancer treatment.

Singh KR, Agarwal G, Nanda G, et al. Morbidity of chemotherapy administration and satisfaction in breast cancer patients: a comparative study of totally implantable venous access device (TIVAD) versus peripheral venous access usage. 

. 2014;38(5):1084-1092. doi: 10.1007/s00268-013-2378-x.

Goossens GA, Vrebos M, Stas M, De Wever I, Frederickx L. Central vascular access devices in oncology and hematology considered from a different point of view: how do patients experience their vascular access ports? 

Reiners GM. Understanding the differences between Husserl’s (descriptive) and Heidegger’s (interpretive) phenomenological research. 

. 2012;1:119. doi: 10.4172/2167-1168.1000119.

Rajcan L, Zoucha R, Goodfellow L. The lived experience of a person with a subcutaneous vascular access port: a mini-study. Poster presented at: Infusion Nurses Society National Convention; May 6-9, 2017; Minneapolis, MN.

Mollon D. Feeling safe during an inpatient hospitalization: a concept analysis.

 2014;70(8):1727-1737. doi: 10.1111/jan.12348.

Bell L, Duffy A. A concept analysis of nurse-patient trust. 

Research has shown that pain and anxiety are related to port access, so a need exists to capture patients’ feelings and emotions related to living with a port, as well as effective nursing interventions aimed at addressing those patient experiences.

Nurse Trust Among Patients With Ports

You have been working with Mrs Smith for the past month. With each passing day, you notice that she appears more depressed, angry, and anxious. She doesn't chat like she did when she started her treatments for breast cancer. She rarely maintains eye contact. She is quiet and sullen.

Your mind starts wandering over ways to help her that go beyond the bag of chemo you give each week. At the next few appointments, you notice that she is never without her earbuds and music. As she sits in the chair, eyes closed, she quietly drums her fingers to a beat you can't hear. Could this be the way to help Mrs Smith? You have read a few stories about drumming as a means of helping patients with breast cancer deal with emotional side effects. But does it work?

Life is set to a rhythm. The first sound heard by every child is the beat of their mother's heart. It is no surprise, then, that the beat of a drum can bring peace, calm, and even transcendence to a hurting soul.

According to the American Music Therapy Association, music therapy combines the clinical and evidence-based use of music interventions to help patients reach specific goals.

 It addresses physical, emotional, cognitive, and social needs. Patients work with a music therapist to create, sing, move to, and/or listen to music.

Drumming can be used as a type of music therapy. In a 2017 interview with Medscape, Theodore Zanto, PhD, a top music therapy researcher, states that the rhythmic sounds of music and drumming can be healing.

Similar to meditation, drumming produces positive mental health effects in patients. The brain is also rhythmic, so during drumming, the brain is interpreting every sound wave created. Drumming creates both a sound and a physical effect on the body. This creates a good environment for meditation and relaxation to take place.

There is limited research on the effects of drumming on patients with breast cancer. What we do know is that music can be healing. One encouraging study looked at the effects of group drumming on anxiety, depression, social resilience, and inflammatory immune response among mental health patients.

 It found that levels of anxiety and depression decreased in patients who participated in group drumming for 10 weeks compared with those in a control group.3 Drumming produces plenty of other health benefits, as well. This form of music therapy:

Drumming releases endorphins and oxytocin, hormones that elevate mood and decrease stress.

 Breast cancer treatment is stressful, and drumming offers patients an outlet.

 Researchers at the Mind-Body Wellness Center, an outpatient medical facility in Meadville, Pennsylvania, investigated whether group drumming music therapy alters stress-related hormones and enhances specific immunologic measures associated with natural killer cell activity and cell-mediated immunity. Killer cells, a type of white blood cell, destroy infected or cancerous cells. This study is the first known research using group drumming music therapy to create biological changes in patients.

 This important experimental research indicated that group drumming does boost the immune system's ability to fight cancer and other viruses by increasing the release of killer cells. Done regularly, group drumming may produce lasting, sustained immunological effects on patients facing long-term conditions for which an increase in killer cells is beneficial.

 Drumming classes are often done in a group setting, which helps create a connection between the instructor and students. Each person is challenged to connect with their own spirit and the spirits of others in the group during class. Community and connection is important during breast cancer treatment and beyond—having someone else understand firsthand what you are feeling and experiencing can be healing and validating.

This form of self-expression can help release anger, frustration, and fear. Literally drumming out and releasing negative feelings can improve the overall health and well-being of patients with breast cancer.

Indigenous communities across the globe have practiced ceremonial and medicinal drumming for millennia.

Drumming can connect the body and mind to time, space, self, environment, community, cosmology, and spirit.

 Patients who take part in drumming on a physical, emotional, and cognitive level will likely experience many positive effects, similar to those of exercise, laughter, and meditation.

Drumming is still a relatively new complementary therapy in the United States, but it has been used for centuries in other countries. If you have a patient with breast cancer who might benefit from drumming or another kind of music therapy, talk with your supervisor about opportunities in your facility or community. You can also search for classes and music therapists online at the 

American Music Therapy Association's website

Melissa Mills, BSN, RN, CCM, MHA is a freelance healthcare writer and the owner of MakingSpace.company. She has been a registered nurse for 20 years and is passionate about case management, nursing leadership, and finding the right care for patients in every setting.

What is music therapy. American Music Therapy Association website. musictherapy.org/about/musictherapy. Accessed May 4, 2018.

Stetka, BS. The therapeutic potential of drumming and rhythm. Medscape

website. medscape.com/viewarticle/886726. Published October 12, 2017. Accessed May 4, 2018.

Fancourt D, Perkins R, Ascenso S, Carvalho L, Steptoe A, Williamon A. Effects of group drumming interventions on anxiety, depression, social resilience and inflammatory immune response among mental health service users. 

. 2016;11(3):e0151136. doi: 10.1371/journal.pone.0151136.

Vinesett, A, Price, M, Wilson, K. Therapeutic Potential of a Drum and Dance Ceremony Based on the African Ngoma Tradition. Journal of Alternative and Complementary Medicine. 2015(8): 460-465.

Bittman BB, Berk LS, Felten DL, et al. Composite effects of group drumming music therapy on modulation of neuroendocrine-immune parameters in normal subjects. 

Nunez, S. Medicinal drumming: An ancient and modern day healing approach. 

. 2016;14(2). neuroquantology.com/index.php/journal/article/view/939. Accessed May 9, 2018.

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The rhythmic sounds and sensations of drumming can be healing for patients with breast cancer.

Finding a New Beat: Drumming as Therapy for Breast Cancer

Last summer, I received a frantic call from a patient’s son. His father had been diagnosed with stage IV non—small cell lung cancer in the spring and had never told anyone. The son found out about the diagnosis because his father was currently in our emergency department (ED) for a cardiac complication, and the ED doctor inquired about his lung cancer treatment.

As their nurse navigator, I sat down with the father and son to discuss what the next steps should be after discharge from the hospital. Unfortunately, the patient, whom I will call Sam, had insurance that was nonparticipating with my institution. I called his insurance company and found out where Sam could receive his oncology care and still be covered. I made his first appointment and requested records to be sent to the new provider. I answered all his son’s questions and offered emotional support. I did not expect to hear from Sam or his son again.

At the end of that summer, Sam’s name came across my desk again. He had requested an appointment with our institution’s pulmonology group. When I called and spoke with Sam, he was adamant about receiving care at my institution. Since his insurance was state Medicaid, I knew he would be able to switch to a different company that our institution accepted. I connected him to one of our financial advocates, who helped him change insurance companies. When I next spoke with Sam, I told him that although he did not need a pulmonologist, he needed a medical oncologist, and I scheduled an appointment for him with one that specializes in lung cancer. Unfortunately, he was very ill at this appointment, and our oncologist directly admitted him to our hospital.

After that hospital stay, Sam did not keep his next appointment with the medical oncologist or return any of my calls. I reached out to his son and received no response. I did not hear from Sam until 3 months later, when he called and scheduled another appointment with the medical oncologist. I found out that he had not received any treatment for his cancer that he was diagnosed with 7 months earlier, and I was naturally extremely concerned for him.

I met with Sam, and we had a very frank discussion. I realized that he had huge knowledge gaps about his disease and prognosis. I think Sam didn’t realize how sick he was because he felt alright. Many patients with lung cancer don’t have symptoms until the late stages of the disease. Sam also had transportation barriers, and he was reluctant to treat his cancer. To ensure Sam’s attendance and comprehension of the situation, I accompanied him to his appointment with the medical oncologist. We made sure he understood what the treatment regimen would be. We also discussed his prognosis with and without treatment. At the meeting, he told me he hadn’t realized how serious his diagnosis was. He said he did not want to give up hope and chose to get the prescribed treatment.

During this meeting, I found out about a social worker in his community who could assist him with keeping his medical treatments. Together, we were able to coordinate his treatments, arrange his rides, and remind him the night before about his appointments. We offered him the support he needed to get through treatment.

Sam’s delay in care was directly attributable to his lack of health literacy. According to the US Department of Health and Human Services, “health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

 Health literacy is a barrier that is hard to measure because patients are good at pretending they understand everything they are told. In my experience, patients who are labeled “noncompliant” tend to have a health literacy deficit.

Nurse navigators must assess how much patients understand and make sure that they have all the information and support needed to make an informed decision about their care. Now, I make a point of asking my patients questions about what the doctor told them so I can assess what educational needs they have in relation to their health and treatment regimens.

Sam didn’t understand the scope or severity of his illness until his nurse navigator intervened.

June 2018

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