Symptom Management: An Expanded Role for Nurses in Educating and Supporting Patients
The value of nursing in symptom management is so important and becoming increasingly so, as the treatment becomes more complex.
Barbara Given, PhD, RN, FAAN
Director of PhD Program
Michigan State University College of Nursing
Ruth McCorkle, PhD, FAAN
Florence Schorske Wald Professor of Nursing
Yale School of Nursing
Helen C. Foley, MSN, RN, AOCNS
Clinical Faculty, Frances Payne Bolton School of Nursing at Case Western Reserve University
Clinical Nurse Specialist University Hospitals Seidman Cancer Center
Rebecca Kronk, PhD, CRNP, MSN
Duquesne University School of Nursing
Janine Overcash, PhD, GNP-BC
Director of Nursing Research at The James Cancer Hospital & Solove Research Institute Clinical Associate Professor The Ohio State University College of Nursing
EDITOR’S NOTE This is the first part of a three-part series spotlighting key issues and challenges for oncology nurses practicing today. Oncology Nursing News was honored to host a roundtable with faculty leaders from some of the top schools and colleges of nursing with oncology programs— many of which are members of our Strategic Alliance Partnership initiative—who were in Washington, DC, for the 2013 Annual Congress of the Oncology Nursing Society. Here, we feature panelists’ perspectives on the critical role played by oncology nursing professionals in helping patients with cancer to manage their symptoms and any treatment-related adverse events. For video highlights from our Oncology Nursing News roundtable, click here.
Barbara Given (segment moderator): The value of nursing in symptom management is so important and becoming increasingly so, as the treatment becomes more complex. While our healthcare system struggles with how care is going be coordinated, nursing remains key, not only to the success of patients, but also to the success of family caregivers in helping these patients. Nurses work across the care continuum and across healthcare settings in a role that is continually evolving. There are approximately 200 pipeline drugs in oncology,and many are oral agents with new side effects. As more responsibility falls upon the patient to manage these oral therapies at home, nurses must gain new knowledge to assist them and also engage family care.
What does the future now hold for nurses in this complex care environment? What are the information needs, and how does this information get communicated to nurses and patients?
Ruth McCorkle: We have 12 disease-specific clinics at our institution, for breast, lung, etc. where nurses can amass a body of knowledge that is evidence-based, but nurses in community practices often see patients across many tumor types. They have to know everything. How do you wrap your mind around that? How can we give them enough information, whether it is through our nursing education programs or after graduation? How do we keep them current on these issues that patients experience? Symptom management and monitoring by nurses is critical. They are really the patient’s lifeline, so we need to set up a system for communicating with patients. The best way to do that is to be able to see the same patient. Some practices understand the benefits of the nurse seeing the same patient and building that relationship of trust, because you want patients to call back if they are having a problem. If you are dealing with someone who is receiving radiation and chemotherapy, it’s a double whammy. As nurse educators, we have the responsibility to set up systems and provide tools that will help nurses meet these challenges and make their jobs easier.
Rebecca Kronk: There is a thirst for continuing education. Once you graduate—and especially when working in an oncology facility or specialty— you are going to have to stay up to date and seek out continuing education or certifications. It also is really important to teach nurses how to work with interdisciplinary teams. We can’t do it all. We may be the coordinator, or we may be the person who the family trusts. But we also have to work with physical therapists, speech and language therapists, and other disciplines involved in the patient’s care—communicating, coordinating, and continuing to improve care.
Helen Foley: Nurses need to gain a lot of technical expertise, whether it is cardiac monitoring on the oncology unit or managing complex patients who used to be monitored in the ICU. Much of the nurse’s role revolves around the whole area of symptom management and care coordination. This is where nurses often can have the biggest impact for the patient and the family, and it is really a very rewarding part of many staff nurses’ practice—to work with patients and families very closely, identify problems, and make the appropriate referrals to other team members.
Janine Overcash: Nurses are very good at symptom management. We have done so much research in pain management since the 1980s, and also in managing nausea and fatigue. Now, as many of the therapies are going to be oral agents to be administered at home by family members, education becomes increasingly important. When these issues come to nursing, we are there, ready to address them. This is an arena where we shine.
McCorkle: Yes, there has been a huge body of research done by nurses, and that can make a difference. How do you disseminate those research results?
Overcash: Dissemination has always been an issue. I’m proud of how far we’ve come, but that is the work we have to do, to improve on our dissemination mechanisms, to think about how we collect data and get it to the folks who need it.
We’ve looked at this from the nurse’s perspective. What are the symptom management challenges for patients? What should they be looking to oncology nurses for?
McCorkle: Our goal—especially with patients who are early-stage and have a good prognosis—is for them to become their own self-managers. There are periods of time when patients are vulnerable and unable to care for themselves, so nurses can teach the caregiver during those times. Empowering is critical: empowering the patient and the caregiver to know what to expect, to be able to take their medicines on time, to be able to recognize when something might happen and get early intervention to prevent a complication. The Caregiver Toolkit is now used in many places across the country, and for patients to have this resource at home is really useful. They can see that they are experiencing symptoms that many other patients have and understand that this is part of what they should expect to be experiencing.
Kronk: In pediatric cases, one of the things I like to do is have the patient guide the visit, asking them, “What are your questions? What do we need to address today?” It is important to educate patients that this is their visit. Also unique to pediatrics is that children are constantly developing, so we must add that component in as well. There are a lot more variables that we have to take into account.
Overcash: So much of this comes to families now. Patients are discharged earlier and may be a little more compromised than in the past. And, as other family members themselves face the comorbidities that often come with aging, this can affect the effectiveness of caregiving, for example, remembering all of the medications. This is a growing problem. Families do a great job, but they need our support with these often very complicated treatment regimens. Nurses are trained to do this, and we do it well. I also would hope to see more resources directed to home care.
What should nurses be looking to in the future? How will changes in the healthcare system affect practice, and what would you like to see nurses more involved in from a symptom management perspective?
McCorkle: With Obamacare, nurses have an opportunity to step up. There are people who champion the role of the nurse practitioner, and clearly, there are not going to be enough physicians in some areas of the country. If nurses can do it—which they can—and take advantage of this opportunity, it will be amazing.
Foley: I would love to see nurses establish palliative care clinics, with advanced practice nurses having their own clinics, with their own schedules, and managing patients. I think cancer centers who really understand the needs of patients will begin to think about doing that.
Given: We also need to think about how we are going to integrate technology into support for patients and families in symptom management. There are many apps out now for recording all kinds of information, and the professional organizations are also producing these apps. How these are integrated, so that families can use them, is really important. And we have to consider those patients who aren’t appsavvy as far as symptom management goes. This is an important area of research for the future.