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This month’s issue of Nursing Notes looks at the field of oncology nursing. In this show, we gathered a group of Oncology Nurses to share what they think it means to be an “Oncology Nurse.” Our guests include Carlton Brown, the President of the Oncology Nursing Society, and Jacquelyn Grandt, Program Director, Outpatient Oncology Services at Long Beach Memorial Medical Center in California.
Oncology Nurse Panel Discussion
Jamie: One of the things I’d like to just touch on first off is the treatment of cancer patients seems to have changed so dramatically over the last twenty years. You must have seen a whole lot of change where we’ve moved from inpatient treatments and lots of surgeries to more targeted treatments and outpatient treatment programs. Tell me a little bit about some of the changes that have occurred that really you’ve noticed most over the last twenty years.
Jackie Grandt: Yes. I can answer that. Actually, I’ve been in oncology nursing for about 30 years. My beginning in oncology nursing was inpatient. At that time we had mostly inpatient patients that we managed. There wasn’t really the outpatient arena that exists today. Over the course of my career, I got into outpatient practice and spent a good portion of my time in private practices and, in doing that, really saw the transition of patients from inpatient care to outpatient care and providing them with chemotherapy treatments which was the primary area that I was in and outpatient office. Initially when I started, all treatments we did in the hospital. It was like patients had to be monitored and followed extensively. Now, we’re giving them these treatments and then sending them home and monitoring them from an outpatient status. That was a significant change. Also the types of treatments have changed. We have now targeted therapies. We also now do combination therapies with chemo and radiation together or do neo-adjuvant treatments which when I first started those kinds of things didn’t exist.
Carlton Brown: Yes. I agree. I recently heard somebody say that, “Yes, you are an inpatient. If you are a patient in an inpatient arena now, you are really the sickest of the sick.” The future of the next three or four years of inpatient care will really become mini-ICUs or intensive care units because the inpatient facilities will be mostly held for those patients that are very ill. I agree that we’ve seen a lot of our treatments – even within the last three years of seeing how – even the care now is moving from the outpatient arena really to the home so it’s not uncommon for patients to be treated in their own homes for cancer and certainly a move more towards the oral chemotherapies or oral medications that certainly have their own special side-effects. I agree with Jackie that we’ve really seen quite a change over the last 30 years and even the last 5 years.
Jamie: I saw on one of the pieces you commented on for the Nursing Notes newsletter that’s coming out this month that you talked about some of the challenges and rewards for oncology nurses based on breakthroughs and cancer treatments. Could you talk a little bit about how those breakthroughs are affecting the oncology nurses here in the United States?
Carlton: Well, the breakthroughs – I think I was talking about the move towards more oral chemotherapy or oral agents. There are probably 50 to 100 chemotherapies out there that each come with their own very individual special symptoms. We always think nausea or alopecia but not all of those cause that. These new agents that we’re using certainly come with their own side-effects like skin alteration, rash. Oncology nurses really need to stay very current on all of the side-effects for the medications that patients are taking. Because, for instance, the patients that’s on oral chemotherapy may have some particular skin or rash and they think that that medication isn’t working but in reality that’s an indication that the medication is working. The nurses have to stay very educated on all of these new drugs as well as keeping the patients educated. It really is a challenge. I think that’s a great opportunity where the Oncology Nursing Society can certainly help to provide oncology nurses with that important education about those new medications.
Jackie: Yes. I definitely agree with you on that. That’s something that being a member of the Oncology Nursing Society for 25-plus years that I’ve been member I really rely on the ONS website to help me research things that are new or things that I haven’t heard of or things that happened with patients. I think too a lot of – as well as in the hospital with, like you say, going to care being more focused like on ICU. In the outpatient setting, it’s becoming very much more complicated in that the nurses have to be constantly updating themselves and aware of new treatments because physicians are out there wanting to give their patients the latest treatment and the best treatment that they can. The nurses need to be on top of it so that they can make sure that when that patient is at home or some of the patients that are being treated are coming in to see their treatment centers, that they can educate them about the side-effects and things to call about relative to whatever treatment they’re getting.
Jamie: Cancer is listed as the second largest cause of death here in the United States and I think in much of the developed world just behind heart disease. I think when people think about oncology patient care, whether they’re experienced nurses or new nurses, they think about death and dying. But really that’s changing rapidly. Carl, would you like to address a little bit about how that continues to progress and we have patients surviving more and more frequently from their cancer treatments?
Carlton: We do – it’s pretty amazing that the numbers are somewhere between 12 or 13 million cancer survivors currently in the United States. That means that they survived their treatment. Depending on what definition they use are now living past their cancer diagnosis and are considered survivors. There really need to be a much better focus in the area of providing care and follow up for these survivors because it’s not just enough to receive your treatment and then go away and be a survivor because they really need to be managed. I really think that’s a great area where an advanced practice nurse, a nurse practitioner, or a clinical nurse specialist could be [granted] some of their own survivorship clinics where a patient could come in and periodically—every year, every couple of years—really be followed with being a cancer survivor. It’s an area that we’ve not really done enough work in. As I tell nurse practitioners and clinical nurse specialists all the time, the opportunities there for them to have their own practices is a great opportunity and a lot of work still needs to be done in that area.
Jackie: Yes. I definitely agree with you on that. As an advanced practice nurse practitioner, as part of my program directing at Long Beach Memorial and hopefully over the next few years focusing on developing a survivorship clinic that will be run by nurse practitioners. Also in the same regard with these survivors is looking at—giving them survivorship plans. If [you do] not have survivorship clinics within [your] cancer program, being able to communicate with their community physicians and make sure that those community physicians—who may not have a focused oncology practice and probably don’t see a lot of other things as well—[be given] some help. The advanced practice nurse is a way to be able to connect with those primary care physicians and make sure that our survivors are being taken care of.
Jamie: With the recent Institute of Medicine report on nursing and the continued push for increased scope of practice and I’ve seen recent articles about insurance companies recognizing nurse practitioners as primary care practitioners in their insurance programs, certainly there is a lot of opportunities for those advanced practice nurses and nurse practitioners to set up their practices and find these unique niches to provide that unique nursing care that provides all of the additional support. Not just treatment for disease but the treatment for the patient as a whole, that psychosocial support, and looking at their overall healthcare aspects.
Carlton: I think there’s really a great call for more prevention, early detection, screening because if we were to put—we have got all these great drugs that are under development right now for all kinds of different medications but they really do cost a lot in the development. It’s interesting that if we even took 50% of those dollars away from drug development for cancers in late stage and put that into the other side of the spectrum—doing dietary changes, smoking cessation—putting those upfront then if somebody got those kinds of dietary control or exercise or smoking cessation today, 20 years from now or 30 years from now they would have no need, or potentially have no need, for some of these medications that are under development. There should be much more of a big focus in prevention. I think that the current health care reform calls for much more of that focus. As far as advanced practice nurses are concerned, the nurse practitioner or the clinical nurse specialist, few people realized that their practice—each of their practices is guided by each of the 50 states—or 51 states including DC. You may have somebody that has very wide practice like, say, in the District of Columbia where they can basically do just about everything short of surgery or those kinds of things. Where others they have very restrictive advanced practice nurse rule. It’s not always comparable and I think what the IOM report was trying to get at is that every trained nurse practitioner should be able to practice within their scope and we’re really [are] working to try to push those states that are lagging into allowing these nurse practitioners and clinical nurse specialists really to practice within their scope. I think that’s going to be really important moving forward. We know there is already a shortage of oncologists. They are certainly not going to be able to provide all of the cancer care that’s coming down the road. We think that not just nurse practitioners and clinical nurse specialists but properly trained physician assistants. There’s room for all of that in the healthcare team towards the care of the patient and family with cancer.
Jackie: Yes. That’s very true. Like you said, it’s going to be key to being able to identify ways that nationally we can all kind of come maybe just some kind of standard to be able to increase the scope of practice of those mid-level practitioners as much as possible because there’s definitely going to be a need for them as you said with fewer medical oncologists coming down the road. The advanced practice nurse or PA definitely can, with years and years of experience in the area, be able to function to care for those people.
Carlton: I think it’s a really exciting time for nursing. Oncology nursing has recently been talking about – we know that we have 37,000 members and we think that we do a pretty good job of educating those but we also know that there are somewhere between 2 and 3 million nurses in the United States and we know that many of them come into contact with a patient with cancer every day whether it would be in a mammogram center or hospice nurse. We’re really trying to focus now on how we really get a good amount education out to those nurses who don’t consider themselves oncology nurses but come into contact with cancer patients all the time. It’s really quite a challenge when you think about educating 2 million nurses.
Jackie: Yes. That it is.
Jamie: It certainly is. When you consider all of those various nurse specialties that treat cancer patients: your infusion nurses, hematological specialists and school nurses and there’s just a ton of resources. I know that the ONS.org website has a ton of information and resources on it.
Carlton: It does. We have a cancer journey now which is an education for patients. In the middle part of 2011, we will be creating what’s called a portal. That will be where you don’t have to be a member of ONS to actually have access to important information about caring for a patient with cancer. For example, there are certain nurses, like rheumatoid nurses, who work with patients with rheumatoid arthritis that administer chemotherapy for that disease. They still need the same safe handling information around those chemotherapy drugs as a nurse giving chemotherapy day-in and day-out. Our portal that we’ve created hopefully will help to get out to those 2 million nurses providing them numerous types of education so that they too can still qualify or to ask questions or are looking for particular information they can go to our portal.
Jackie: I think that’s really awesome. I hadn’t heard about that. I have many colleagues who are in other areas in oncology and who call me for information. I will go on the ONS website for them but it will be awesome to be able to tell them, “Hey, you can go on there and get the information you need.” That’s really great that ONS is doing that.
Jamie: It’s interesting. You talked about a journey for those cancer patients. Jackie, we talked previously about a nurse navigator that really is a new concept by helping that patient navigate with this nurse to go along with them on a journey. Can you tell us a little bit? I know you’re working on developing a nurse navigator program at Long Beach Memorial Medical Center. Just what your thoughts are and what it means to be a nurse navigator and what you’re thinking about for newer patients.
Jackie: Yes. Nurse navigation has been around for a while but is really starting to pick up and becoming a requirement of many cancer accreditation programs. With our nurse navigator program, we’re looking at focusing on using advanced practice nurses. We’re looking at following the patient from the time that they’re diagnosed. Through the diagnostic workup, through the treatment—be it surgery, chemo, radiation—and then on into survivorship which ultimately hopefully having then our advanced practice nurses providing survivorship clinics. This is a concept. I know that many nurses feel and kind of thinking about our discussion relative to other nurses out there: our home health nurses, our hospice nurses. This is something I know that a lot of them feel that they’re definitely a part of and they definitely are. By having a central point of contact like we’re developing through our cancer program for our patients, we’ll hopefully connect all the pieces for the patient be it medical, nursing, diagnostic, so that they don’t get lost in the care that they’re getting. They get expedited care. They get complete care. They get informed care that they’re well aware of all their options and can make a definite informed decision about which way they want to go with their treatment. Our nurse navigators will be looking at interacting the patient’s extended family as well and we have a large psychosocial team that’s part of our cancer program that will be involved in the care of our patients also.
Jamie: Carl, what about at the national level? As more nurse navigator programs are growing out there, are you really seeing this being picked up across-the-board in many systems in implementing the nurse navigator concept?
Carlton: I certainly think it is a hot topic. Nurse navigation was really created probably 30 years ago by Harold Freeman. His focus really was on the underserved population. He thought it would be great to create this particular nurse who would help those underserved. So somebody who didn’t have complete access to the full realm of care or who may find the care system very confusing. We certainly have seen it grow into more and more of a larger program. Certainly, I think, a new role for nurses. At the Oncology Nursing Society, we’re trying to decide what is it that a nurse navigator really does and how is that different than a clinical nurse specialist and a nurse practitioner? Later this year we’re going to be doing a role delineation where a study where we will we will talk to these nurses who consider themselves nurse navigators and then try to figure out what it is exactly that a nurse navigator does on a day-to-day basis. Then once we’ve decided how different that role is, if it is different, then we can really decide on how much involved we want to get within the nurse navigator new role. There are certainly two new nursing national organizations that are already focusing in nurse navigation. I think it’s a very interesting role. I’ll also point out that you also have social work navigators. Oncology Nursing Society works with the social worker group to write a position statement on nurse navigation both for the registered nurse and the social worker. You also have this group of lay navigators who may help patients make appointments, may walk them around maybe to different parts of the hospital. It really is a very interesting new role. We certainly welcome it because anything that we can do to help the patient and the family with cancer during this very difficult time, it’s certainly wanted and welcomed.
Jamie: As we wrap up here and we could certainly. I think all of us talk about this topic for much longer. But as we have a limited amount of time, for those people that are listening to this: the existing nurse, or perhaps a new nurse or the nursing student that is considering perhaps oncology nursing as a career option and direction for their nursing career. Carl, what would be some of the advice you would offer to them as far as resources they could find to get more information or how they would best find if oncology nursing is indeed for them?
Carlton: Well, I am biased because I think it’s the best career in the world. I had a couple of other careers before I finally made my way to nursing, particularly oncology nursing. As I said, I’m biased. But if I were a nursing student or even a nurse who was potentially interested, I would ask for opportunities to rotate through in-patient oncology ward or ask—if I were a nursing student, to ask my nursing professor if I could particularly have a rotation during nursing school on an oncology ward. I hear all the time, people become nurses to work in the emergency room or maybe newborn nursery or those kinds of things that are exciting like what we see on television today. But it’s after they’ve had an opportunity— sometimes it was an opportunity that they didn’t want to go and work in an oncology floor unit that they really fell in love with the work and with the patients and the works that we’re doing. That would probably be some advises to – go and sample, keep your mind open to the different aspects of nursing. The beauty of nursing is that you can really do anything and you can change just about any time you want. There’s a tremendous amount of opportunities really for all nurses.
Jackie: Yes. I agree with that. Actually, how I got into oncology nursing was during the final rotation in nursing school on an oncology unit. It was during that experience that I really identified an oncology nursing that there’s many challenges and there’s many rewards. That was what I was looking for in my nursing career. I wanted to be challenged and I wanted to feel that – every day I was learning something new and definitely with what I’ve seen over 30 years on oncology nursing that that’s been very true. For our new person, I agree with you having opportunity to spend some time and rotate in that area while you’re in training is absolutely an excellent way. Also identifying people who are already working in the field then asking to spend some time with them and learning from them how they got into it and what they do on a day-to-day basis and even developing maybe some opportunities for mentorship if you decide to go into that area and get the support because oncology nursing and oncology treatment can sometimes be really overwhelming. But having someone who has done this for a while be there and available for you I think is really important. I think the Oncology Nursing Society offers you the opportunity to connect and have mentors as you go through your career. I know they were very important to me through my involvement in local chapters and stuff to identify people who could be resources to me and meet with them and discuss patients and that.
Carlton: That’s a great idea to keep that in mind. For those people who are out there that don’t really know how to find ONS, it’s very easy to find on the web at www.ons.org.
Jamie: I urge people to, whether it’s their oncology nursing or whatever your nursing specialty is, to really connect with your professional nursing societies and associations because they really offer you opportunities to solve problems that you might be having with patient care and treatment for certain patients and you have the opportunity to find someone else who’s maybe already found a solution. By mentoring and working together and communicating through your associations and societies, you can really find a lot of information. I know, Carl, you’d agree with that wholeheartedly. It’s one of the benefits of strong associations. I think nurses really bring a lot to the table because of them.
Carlton: Yes. Absolutely. You can’t say enough for all of the organizations. Oncology Nursing Society is not the only one on the block. There’s an oncology organization for pediatric nurses. ANA has been very helpful and continues to be very helpful. Many of the organizations out there, nursing organizations, could certainly be very helpful to anybody that’s really interested in nursing as a career or once they have become a nurse.
Jamie: Well, I want to thank both of you for joining me on the call today and sharing brief insights into what it is to be an oncology nurse.
Carlton: Thank you for the opportunity.
Jackie: Yes. Thank you very much.
Don’t forget to check out the entire January, 2011 issue of Nursing Notes, featuring a look at treatment and care of patients by oncology nurses, including information on nurses’ impact on medication compliance, and a link to “A Day in the Life” video following Oncology Nurse Tanisha through her day caring for patients living with cancer. You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month where I interviewed this month’s “Get to Know” nurse, Jackie Grandt, Program Director of Outpatient Oncology Services at Long Beach Memorial Medical Center in California. You’ll find this and our other podcast episodes at www.NursingNotesLive.com and in the podcast area in iTunes.
Nursing Notes Live is an audio extension of the national award-winning monthly e-newsletter, Nursing Notes – which offers the latest industry news, trends and updates in nursing. You can subscribe to the e-newsletter at www.discovernursing.com. Each month’s Nursing Notes issue will be accompanied by a couple of episodes of Nursing Notes Live, which will expand on the content and provide you greater insights into the topics presented in the e-newsletter. Check out NursingNotesLive.com or visit iTunes to subscribe to all episodes of this podcast!