Cancer Care - A Need for New Guidelines to safeguard Oncology Nurses


 
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Oncology Nurses

The majority of oncology nurses in the United States are located in university-affiliated hospitals serving cancer patients in the medical oncology setting. Most of them work from protocols and perform procedures traditionally performed by physicians with some having a prescriptive authority (Kinney et.al, 1997). Changing trends in Health Care has thrown many challenges to Oncology Nursing like providing greater number and variety of treatments on an outpatient basis in a situation where there is a shift from indemnity insurance to a managed care environment to help control the costs. Thus, Oncology Nursing has to deliver care efficiency in spite of enhanced patient caseloads and shortage of Oncology Nurses (O'Leary and Williamson, 2003).

Oncology Nurse Challenge

Changing patient perceptions, technological innovations, the threat of medical litigations and the emotional nature of cancer care, where, most of the patients are in the end of life stages makes Oncology Nursing specialty stressful. One of the worst situations in Oncology Nurse Practice is that, despite the best efforts, some patients will die. Thus, Oncology Nurses, apart from dealing with problems pertaining to interventions like infusion chemotherapy and adverse drug reactions have to deal with both physiological and psychological problems pertaining to End- of-Life Care.

Challenges from Therapeutic Interventions

Challenges due to Therapeutic Interventions range from chemotherapy-induced alopecia (Dougherty, 2007) to risky complications. Complications of implantable venous access devices such as Port-a-Cath during intermittent continuous infusion of chemotherapy investigated recently has shown major complications such as infection, occlusion, thrombosis, extravasation and migration (Poorter et.al, 1996). Extravasation is a complication in chemotherapy caused by the leaking of fluids used in chemotherapy from the blood vessels into surrounding tissue (Langer et.al, 2007). Although relatively uncommon, it is estimated to occur in 0.1% to 1.0% of all anthracycline treatments (Buter, 2007) and is seriously debilitating and disabling demanding immediate attention. Although monoclonal antibodies (mAb) used in oncology care are well tolerated, a major complication with mAbs is the development of mild to life threatening infusion reactions (Carney and Ollom, 2008).

A study to evaluate the incidence and causes of complications associated with balloon-occluded arterial infusion chemotherapy (BOAI) for pelvic malignancies has shown that infusion from the anterior division induces neurological complications more frequently and cystitis-like symptoms are common during balloon-occluded arterial infusion (Sugimoto et.al, 1999). Complications of Subcutaneous Infusion Port (SIPs) have also been investigated recently. These SIPs display delayed complications, frequently related to clinical conditions of the neoplastic patients and immediate complications, often due to the placement techniques. Infection and thrombosis are the two major complications of SIP in general oncology patients. Although neurological complications following stem cell infusion are rare, cerebral infarction and transient global amnesia episodes have been documented (Hoyt et.al, 2000). Chemotherapy-Induced Neutropenia (CIN) is a common and serious toxicity of cancer chemotherapy that can lead to Febrile Neutropenia (FN). Prophylactic use of Colony-Stimulating Factors (CSFs) has been shown to reduce the incidence, duration, and severity of Febrile Neutropenia.

Challenges in End-of-Life Care

Enhanced threat of medical litigations has forced Oncology Nurses to provide Advanced Care Planning and provide documentation based practice interventions. Advanced Care Planning is a modern day service in which people start thinking about their death, what is important to them and how they like to die. Advanced Care Planning includes preparation of Advance Directives and Proxy Directives. Documentation includes the Health Record and Informed Consent. Finding time to perform thorough documentation in a busy oncology setting is an increasingly difficult task. A new documentation system has been designed for an oncology outpatient unit that consists of a set of documentation tools that are specific for the type of patient visit, an initial assessment form, and guidelines for using the forms (Pfeifer, 1992).

Recent Guidelines in Oncology Nursing

It is important to note that Oncology Nurses do not receive any specific training to manage such complications. Hence, the implementation of new guidelines on the management of Therapeutic Complications is essential to safeguard Oncology Nurses from such adverse events. New guidelines for the use of Colony-Stimulating Factors in cancer treatment have been published in 2006 and there is evidence that, regardless of practice type or size, implementing guidelines for CSF use within a multidisciplinary team improves patient outcomes (Kearney and Friese, 2008). New guidelines for Extravasation have also been very recently implemented to help Oncology Nurses (http://www.medicalnewstoday.com/). Recently, a role development and staffing pattern guidelines for Radiation Oncology Nurses that help to elicit support from the hospital administration have been developed to manage complications in Cancer Care (Bruner, 1993). The development of a consistent productivity system has also been recommended to manage resource allocations and determine appropriate staffing and space allocation for Cancer Care (Medvec, 1994). A quasi-experimental study to test a model Pain Management Program (PMP) to implement the American Pain Society (APS) quality assurance standards for the management of acute and chronic Cancer pain using a Continuous Quality Improvement (CQI) approach to improve professionals' knowledge and skills, patient satisfaction and to identify areas needing improvement has documented significant improvements in patients' satisfaction, nurses' knowledge and attitude scores, and reductions in nurses' perceptions of treatment barriers (Bookbinder et.al, 1996).

An educational manual has been devised to assist Oncology Nurses to understand the emotional impact of parental advanced Cancer providing clinically relevant information and evidence-based recommendations to guide supportive care. The manual, designed primarily for nurses, addresses the very personal impact for professionals working with parents with advanced disease, encouraging reflection and engages the reader in clinical exercises which encourage active learning and application of knowledge into authentic clinical contexts (Turner et.al, 2008). The recent evolution of Nurse led Cancer Clinics makes the need for such  new guidelines more appropriate (Loftus and Weston, 2001). The Assessment, Information, and Management (AIM) Higher Initiative is a quality improvement program that has been very recently initiated to improve, assess and manage chemotherapy-related toxicities in patients with Cancer. AIM Higher addresses five chemotherapy-related toxicities, namely, Neutropenia, Anemia, Depression and Anxiety, Diarrhoea and Constipation, and Nausea and Vomiting (Moore et.al, 2008). Clinical Practice Guidelines developed by the National Consensus Project for Quality Palliative Care and Preferred Practices defined by the National Quality Forum also serves as a framework to guide Oncology Nurses to integrate palliative care into disease-focused care (Ferrell and Virani, 2008).

Conclusion

Changing trends in Health Care has thrown many challenges to Oncology Nursing with changing patient perceptions, technological innovations and the threat of medical litigations. The implementation of new guidelines on the management of Therapeutic, Psychosocial and Legal Complications of Cancer Care is essential to safeguard the interests of Oncology Nurses in the United States.

Reference

 

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  • Turner J, Clavarino A, Yates P, Hargraves M, Connors V and Hausmann S (2008). Enhancing the Supportive Care of Parents with Advanced Cancer: Development of a Self-Directed Educational Manual. Eur J Cancer. Mar 27 [Epub ahead of print].

Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved


 
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Articles in this issue:

Masthead

  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Contributors:
    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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