A second challenge is that there's always so much to learn. This is exciting, but it can also feel overwhelming—new drugs, new treatments, new ways to treat symptoms of chemotherapy, and new protocols for giving chemotherapy.
I guess the biggest challenge is that there are just some really sad times because people are often long-term patients. You get to know them well, and then it's hard when things end badly.
How can we as nurses help each other meet these challenges?
First, supporting the idea of ourselves as trained professionals and underscoring that we need to always keep learning. Oncology nurses could really lead the way on that really support new nurses in that learning process.
When we’re dealing with the sad parts, such as the promise and the frustration when treatment doesn't work, what's most helpful is having an emotionally open environment. That's what really helped me. If I was feeling sad about a death on the floor, I knew I could go talk to one of the nurses I worked with. My colleagues would just get it, and they would acknowledge that. There were times when it seemed like death would sometimes come in waves, and it was really hard on all of us, but everybody acknowledged that. I think acknowledging this part of our work is so important for not burning out and holding onto your humanity and what got you into the field in the first place.
In your book you talk a lot about the nurse/doctor relationship. What is your take on the relationship? For example, if we feel a patient needs more pain medication but the doctor doesn't agree, how do nurses navigate this and get the patients the support that we feel they need?
That is a great question, and the answer of course varies depending on what kind of doctor you're dealing with. If it's a new intern or a resident, they may just not know or they may have been cautioned against overmedicating patients. Or they've never been in oncology and they don't know how painful cancer is and how freely we give people narcotics because they need them. That can be a process of educating them and saying: “This is a standard dose. This is what we do,” and then trying to work with them. If they say, "I need to talk to my resident," if there's time to let that play out, let that play out.
If it's a fellow or an attending being kind of stubborn for reasons that aren't clear, that's when I tend to be more assertive and say, "We really need to treat this pain. This patient is really uncomfortable. Here's what we've been giving. Here's how they've been responding to it. It just seems like it's really not working," and then have a proposal, for example, "What if we put them on patient-controlled analgesia, or what if we scheduled regular Dilaudid instead of having them ask for it?"
I've found even with some attending physicians, who can be brusque, if I spell out a problem like that, it usually gets their attention and they'll do something. Physicians are so busy themselves that sometimes they really have to be pressed to make that extra diagnostic and prescribing effort. That's my experience with most of them. It's not that they don't care or they're indifferent, they're just in too much of a hurry.
If you could make one change, what do you think could make the biggest difference in improving life among patients on the oncology ward right now?
The first thing that comes to mind is staffing. Have more nurses. Just have more nurses so that every patient could have the level of attention they really need. Then our documentation could also get done the way that it's supposed to get done. I visited MD Anderson Cancer Center a few years ago, and their ratios are 2 to 1 on the bone marrow transplant floor—amazing. The nurses were still busy, they just weren't frantic. I think we could then really perform to the full scope of our practice because we wouldn't have to be always thinking, "How can I get this all done?"
That's something that really comes through in your book—that you're mentally revising your “to-do list” all the time. Has technology made the job easier?
I find that charting takes us away from patients. I've been wondering if one aspect of it is just computers and med carts. I wonder if we could chart on iPads, because then you could really sit in a room and look at the patient and talk to them. It would be just like writing, which really doesn't feel that intrusive. If in the old days I'm talking to my primary care provider and he's writing things down, I never felt like that was alienating in the way I do now when he's on the laptop.