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Managing Compassion Fatigue in Caregivers

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Managing Compassion Fatigue in Caregivers

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How to Manage Compassion Fatigue in Caregiving | Patricia Smith | TEDxSanJuanIsland

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The following list of primary references identifies the resources used to develop items on the OCN ® test. ONCC examinations are based on a broad body of knowledge and not on the content of any single resource.

To prepare for the examination, review the Test Content Outline and develop a study plan based on your individual knowledge strengths and weaknesses. It is good practice to use a current, general resource for overall review, and supplement with resources on specific topics to address your individual needs. If you are interested in resources that address specific topics on the Test Content Outline, please contact the ONCC staff for additional guidance.

Note: Use of these resources does not guarantee a passing score on the examination. Test candidates are not required to purchase or review these resources. ONCC does not endorse specific resources, and does not receive compensation from the sale or use of any resources.

Primary Test References

Allen, D.H., Rice, L. (Ed.). (2011). Site-specific cancer series: Central nervous system cancers. Pittsburgh, PA: Oncology Nursing Society.

American Cancer Society. (2017). Cancer facts and figures. Retrieved from: https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts...

Bastable, S.B. (2013). Nurse as educator: Principles of teaching and learning for nursing practice (4th ed.). Burlington, MA: Jones and Bartlett.

Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb's Fundamentals of nursing concepts, process and practice (10th ed.). Pearson.

Bernardo, L.M. & B.J. Becker (Eds.). (2017). Integrating physical activity into cancer care. Pittsburgh, PA: Oncology Nursing Society.

Brant, J.M., & Wickham, R.S. (2013). Statement on the scope and standards of oncology nursing practice: Generalist and advanced practice. Pittsburgh, PA: Oncology Nursing Society.

Brown, C.G. (Ed.). (2015). A guide to oncology symptom management (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Burke, C.C. (Ed.). (2009). Psychosocial dimensions of oncology nursing care (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Camp-Sorrell, D., & Matey, L. (Eds.). (2017). Access device standards of practice for oncology nursing. Pittsburgh, PA: Oncology Nursing Society.

Chernecky, C.C., & Berger, B.J. (Eds.). (2013). Laboratory tests and diagnostic procedures (6th ed.). Philadelphia, PA: Elsevier Saunders.

Daugherty, P., Gamblin, K.A., & Rummel, M. (Eds.). (2017). Oncology nurse navigation case studies. Pittsburgh, PA: Oncology Nursing Society.

Davidson, G.W., Lester, J.L., & Routt, M. (2014). Surgical oncology nursing. Pittsburgh, PA: Oncology Nursing Society.

Eggert, J. (Ed.). (2017). Cancer basics. (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Erickson, J.M., & Payne, K. (2016). Ethics in oncology nursing. Pittsburgh, PA: Oncology Nursing Society.

Ferrell, B.R., Coyle, N. & Paice, J. (Eds.). (2015). Oxford textbook of palliative nursing (4th ed.). New York, NY: Oxford University Press.

Gullatte, M.M. (Ed.). (2011). Nursing management: Principles and practice (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Hinkle, J., & Cheever, K. (2014). Brunner & Suddarth's Textbook of medical-surgical nursing (13th ed.). Philadelphia, PA: Wolters Kluwer Health.

Ignatavicius, S., and Workman M.L. (2016). Medical-surgical nursing: patient-centered collaborative care. St. Louis, MO: Elsevier.

Irwin, M., & Johnson, L.A. (Eds.). (2014). Putting evidence into practice: A pocket guide to cancer symptom management. Pittsburgh, PA: Oncology Nursing Society.

Iwamoto, R. R., Haas, M.L. & Gosselin, T. (Eds.). (2012). Manual for radiation oncology nursing practice and education. (4th ed.). Pittsburgh, PA: Oncology Nursing Society.

Kaplan, M. (Ed.). (2013). Understanding and managing oncologic emergencies: A resource for nurses (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Katz, A. (2015). Meeting the need for psychosocial care in young adults with cancer. Pittsburgh, PA: Oncology Nursing Society.

Kuebler, K. (Ed.). (2017). Integration of Palliative care in clinic conditions. Pittsburgh, PA: Oncology Nursing Society.

Lester, J.L., & Schmitt, P. (Eds.). (2011). Cancer rehabilitation and survivorship: Transdisciplinary approaches to personalized care. Pittsburgh, PA: Oncology Nursing Society.

Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Kwong, J., & Roberts, D. (2017). Medical-surgical nursing. (10th ed.). St. Louis, MO: Elsevier.

Mahon, S.M. (Ed.). (2011). Site-specific cancer series: Breast cancer (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Newton, S., Hickey, M., & Marrs, J. (2016). Mosby's oncology nursing advisor: A comprehensive guide to clinical practice (2nd ed.). St. Louis, MO: Elsevier Mosby.

Potter, P., Perry, A., Stockert, P., & Hall, A. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier.

Polovich, M. (2011). Safe handling of hazardous drugs (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Polovich, M., Olsen, M., & LeFebvre, K. (Eds.). (2014). Chemotherapy and biotherapy guidelines and recommendations for practice (4th ed.). Pittsburgh, PA: Oncology Nursing Society.

Scarpa, R., & Hickey, M. (Eds.). (2016). Site-specific cancer series: Head and neck cancer. (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.

Vallerand, A.H., Sanoski, C.A. & Deglin, J.H. (2017). Davis's Drug Guide for Nurses (15th ed.). Philadelphia, PA: F.A. Davis Company.

Yarbro, C.H., Wujcik, D., & Gobel, B.H. (Eds.). (2018). Cancer nursing: Principles and practice (8th ed.). Burlington, MA: Jones and Bartlett.

# data[].attributes.attachment_link.description
The following list of primary references identifies the resources used to develop items on the OCN ® test. ONCC examinations are based on a broad body of knowledge and not on the content of any single resource. To prepare for the examination, review the Test Content Outline and develop a study plan based on your individual knowledge strengths and weaknesses.

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The ultimate guide to Continuing Nursing Education for specific CEU requirements, finding approved programs, and the best professional development opportunities.

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Abstract

Keywords: Nurses, situation, background, assessment, recommendation, shift handover

Introduction

All patients have a right to effective care at all times. Patients admitted to health care setting are treated by a number of health care personnels. Communication between health care personnel accounts for a major part of the information flow in health care, and growing evidence indicates that errors in communication give rise to substantial clinical morbidity and mortality.[ 1] One of the risk factors leading to communication breakdowns during transition of care is a lack of standardized procedures in conducting successful handoffs, for example, use of the situation, background, assessment, recommendation (SBAR).[ 2] Studies indicate that use of structured handoffs will improve the quality of patient handover.[ 3, 4, 5] Hands off is the transfer of responsibility and accountability of a patient, from one nurse to another[ 6] either during shift handover or transfers of the patient from one department to the other.

SBAR was introduced by rapid response teams at Kaiser Permanente in Colorado in 2002, to investigate patient safety. It is an acronym for SBAR; a technique that can be used to facilitate prompt and appropriate communication. This communication model has gained popularity in healthcare settings, especially among professionals such as nursing staff. It is a way for health care professionals to communicate effectively with one another, and also allows for important information to be transferred accurately. The format of SBAR allows for the short, organized and predictable flow of information between professionals.[ 7] The main purpose of SBAR technique is to improve the effectiveness of communication through standardization of communication process.

Nurses often take more of a narrative and descriptive approach to explain a situation, while physicians usually want to hear only main aspects of a situation. The SBAR technique closes the gap between these two approaches allowing communicators to understand each other better. It includes a summary of the patient's current medical status, recent changes in condition, potential changes to watch for, resuscitation status, recent laboratory values, allergies, problem list, and a to-do list for the incoming nurse. It is specially used for communication between a physician and a nurse when there is a change in patient condition or between a nurse and nurse during patients shift to a new department or during shift change. It is a technique used to deliver quality patient care. It is a skill that can be learned.[ 8]

Published evidence shows that SBAR provides effective and efficient communication, thereby promoting better patient outcomes.[ 9] SBAR communication method is an evidence-based strategy for improving not only interprofessional communication, but all communication[ 10] especially when combined with good assessment skills, clinical judgment, and critical-thinking skills. Nursing documentation must describe patient's ongoing status from shift to shift with records of all nursing interventions.[ 9] In India, no such data was available. Therefore, the aim of this study was to introduce and evaluate the compliance to effective use of SBAR form during nurses' handover in a tertiary care cancer center.

Methods

Data for this study were drawn from a larger research study. Ethical approval for the study was granted by the institutional review board. Of the 113 nurses in the larger study, 20 nurses involved in active bedside care were selected by simple random sampling using research randomizer software. A self-instructional module (SIM) on clinical communication skill for nurses (used in the larger study) incorporated the SBAR format in which information and use of SBAR was illustrated. The content validity of the format was established by giving it to clinical and nursing experts. The SBAR form was disseminated for use in clinical setting for hands off during shift handover.

Inter-rater reliability of the audit checklist was established using the kappa statistic to determine consistency among raters (κ = 0.91, P < 0.001). A retrospective audit was undertaken at 1 st week (referred to as A1) and 16 th week (referred to as A2) respectively, post introduction of SIM. Items in the audit checklist were scored as "1" for yes and "0" for no and "9" if not applicable. Though 100% compliance would be considered as excellent, a benchmark of 80% and above was considered as acceptable. The audit checklist had 29 items in four areas. The number of items under each domain was a situation (10), background (7), assessment (7), and recommendation (5). The content of the SBAR format was verified with clinical record of the patient. Nurses opinion about the SBAR form was captured using a three point (i.e., not at all, somewhat and very much) Likert scale having seven items and three multiple choice questions. The data were analyzed using descriptive (frequency and percentage) and inferential statistics (nonparametric test: Wilcoxon signed rank test).

Results

The study included 20 nurses in the first audit and 19 nurses in the second audit. The survey on nurse's opinion was completed by 17 nurses.

Demographic variables

There were 6 (30%) males and 14 (70%) female nurses. Majority (80%) of nurses were in age group 21-30 years. There was an equal representation of qualifications, i.e., nurses who had a diploma or a degree in nursing. Nearly, two-third (60%) of them had <5 years of experience. SBAR score was correlated with demographic variables. A statistically significant association ( P = 0.019) was seen between overall audit scores and education/qualification. Nurses who were certified with a graduate degree showed a better score as compared to nurses who held a diploma in nursing [].

Audit findings

Compliance to SBAR documentation was audited at 2 times points A1 (first audit in 1 st week) and A2 (second audit in 16 th week). There was an absolute difference of 4% between A1 and A2, valid percent score was A1 (mean: 82, range: 61-96) and A2 (mean: 86, range: 70-96). There was a significant improvement ( P = 0.043) in overall scores between A1 (mean: 23.20, standard deviation [SD]: 2.96) and A2 (mean: 24.26, SD: 2.20). This difference may be due to the routine use of the form. When analyzed further into different domains of SBAR, a significant improvement was seen in "Situation" domain ( P = 0.045) as compared to other domains. The difference can be attributed to simplicity and objectivity of the content in situation domain.

Analysis on compliance to the four domains of situation, background, assessment, recommendation

There was an overall improvement in all sections of SBAR [] from first observation to second observation.

Situation

During A1, only 45% ( n = 20) of the nurses in the study group had documented the age of patient while it was 79% ( n = 19) in A2. Item, wise comparison of A1 and A2, was carried out using McNemar test. Out of seven items in this domain, there was a significant difference in one item only, i.e., documentation of age ( P = 0.039). There was only a marginal improvement (A1-40%, A2-47%) in documentation related to patient's allergies and relevant past history while identifying comorbidities decreased from 45% in A1 to 5% in A2 [].

Background

Though 95% compliance was seen in most of the items under "Situation" in both audits, important information like the current treatment of patient (e.g., antiepileptic, or withhold tablet amlodipine, injection 5 fluorouracil is on continuous infusion and patient is on injection clexane) was not documented. Injection clexane is a high alert drug and requires nursing assessment and observation for bleeding, petechiae, hematuria, and black tarry stools. Transmission of this information is essential for patient care and safety [].

Assessment

There was almost 100% compliance in most of the items under the "Assessment" category in both audits. An area that needed to be focused on in A1 was pain score, Glasgow coma scale (GCS) score and fall risk as the compliance was 85%. Pain is considered to be a fifth vital sign and as a routine 4 hourly assessments is carried out. The area where nurses do not pay much attention is on GCS and fall risk assessment. Both these areas are important especially in an oncology unit, where patients may have neurological problems, are in older age group and are on medications for comorbidities, and thereby prone to electrolyte imbalance or have gastrointestinal disturbances. In A2, the compliance was 100% [].

Recommendation

Compliance was around 90% in most of the area of recommendation. Though there was around 85-95% compliance related to investigation and reports, in some of the patient files that were sampled, the information related to pending reports such as those pertaining to serum electrolytes, calcium, or urine was not documented. Referrals for physiotherapy, psychiatry, and dietician reference were also not captured in approximately 90% of forms. One area which needed improvement was in plan of care. Only about 70% of the nurses had documented the plan of care. Information related to 4 hourly mouth care, watch for the motor deficit, neurological monitoring, incentive spirometry, observation for bleeding, discharge plan, care of tracheostomy tube, pressure points, and use of thromboembolic deterrent stocking was not incorporated in plan of care. This may be due to lack of clarity about information to be documented [].

Nurses opinion about situation, background, assessment, recommendation

Most (79%) of the nurses expressed that they found the SBAR form for shift handover very useful. This was consistent with a study by Velji et al. nurses reported use of SBAR helped them to "organize their thinking" and streamline data.[ 4]

They also opined that all information relevant to patient care was only somewhat (68%) captured, and 63% of nurses felt that it will improve patient safety. The contents were not at all difficult for 74% of nurses. Only 53% of nurses felt that patient involvement in documenting information in SBAR was very much necessary [].

It was interesting to note that though majority (68%) of the nurses expressed that they completed the documentation in 5-10 min, 21% nurses felt filling SBAR form was very much time consuming, while 42-37% expressed somewhat and not at all, respectively. They also opined that Assessment was easy (47%) to document while recommendation was the difficult (47%) part [].

Discussion

This study aimed to examine the introduction of SBAR into nursing practice using a self-instructional method. Currently, use of SBAR is not prevalent in hospitals across India. With the advent to accreditation concept in India, where the focus is on patient safety, it has become essential for nurses to excel in the work they undertake. Handover of the patient being an important area where information of the patient is transferred from one shift to another. The SBAR has been tested in Western countries and have been a part of standard care. It was unclear whether or not the SBAR tool would be commensurate with the needs of Indian nurses.

The findings suggest that introduction of a standardized handover tool like SBAR helped nurses to capture all relevant information pertaining to the patient. It is noted that in many instances important clinical findings were not documented. Laws and Amato, in his review, found reports of inconsistency between information provided and the actual status of the patient.[ 11] Miller et al., in his study also suggested that nurses need to recognize and identify important clinical cues and act promptly to ensure patient safety.[ 12] Around 21% nurses felt SBAR form documentation as time-consuming. This was also brought forth by Renz et al. where 28% of nurses responded that SBAR tool was time-consuming.[ 13] It can be seen that only 53% of nurses felt patient involvement in documenting information and plan of care was necessary.

Patient's involvement is crucial as it provides them with an opportunity to ask questions, clarify, and share information which makes them less anxious, more compliant with the plan of care and more satisfied because they know what things are being monitored throughout the shift.[ 11] One area which needs improvement is in the documenting plan of care.

Limitations

The SBAR format was a self-report tool and some nurses might have had difficulty in understanding the contents required for documentation, and therefore, the accuracy of entry of SBAR data were questionable:

1. Content analysis of all the SBAR forms was not done.

2. The sample size was small and hence cannot be generalized.

3. Patient care outcomes in terms of average length of stay were not evaluated but are important considerations for future research.

Conclusion

Nurses have a vital role in ensuring successful team performance by transferring relevant and critical information. SBAR technique helps in focused and easy communication between nurses especially during transition of patient care from one nurse to another. SBAR communication has become a standard, across disciplines as a mode of hands off communication.[ 9] Use of standardized hands off communication during bedside shift handover is essential for patient safety, as the benefits for patients outweigh the risks and cost of implementation.[ 14] The patient, who is the focus of all interaction, should be involved in decision-making and updated with information relevant to them, which in turn will help in reducing errors and create a sense of well-being and satisfaction.

The results suggest that individual and team training in various aspects of SBAR need to be initiated to bring about an impact by use of SBAR form. Importance and relevance of capturing information related allergies, comorbidities, assessment of pain, neurological monitoring, and aspects to be documented under the plan of care need to be incorporated as a regular part of continuing education program. An audit to look for reduced number of incidents related to communication failures is essential for long-term evaluation of patient outcomes[ 3] and thus, provide safe and quality care to patients.

Implications

SBAR form modified to organizational requirement can play an important role in transferring of information from one nurse to next during bedside shift handoff. SBAR can play an important role in communication between nurse and physician, especially when the doctor is not available in the premises and vital information regarding patient status need to be communicated. Though SBAR is regularly used in Western world and has been found to be effective, it is time that Indian nurses understand the importance of a standardized approach to bedside shift handoff and implement in their clinical practice to bring about a positive outcome for patients and thus play an important role in ensuring patient safety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

This article was written on the basis of a presentation given at the AONS 2015 Conference held in Seoul Korea by the Asian Oncology Nursing Society.

References

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Introduction of Situation, Background, Assessment, Recommendation into Nursing Practice: A Prospective Study

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Keywords: Nurses, situation, background, assessment, recommendation, shift handover All patients have a right to effective care at all times. Patients admitted to health care setting are treated by a number of health care personnels.

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June 2014 Vol. 9 No. 6

Author: Brian T. Conner, PhD, RN, CNE

Research, evidence-based practice (EBP), and quality improvement support the three main goals of the Magnet Recognition Program ® and the Magnet Model component of new knowledge, innovation, and improvements. The three main goals of the Magnet Recognition Program are to: 1) Promote quality in a setting that supports professional practice 2) Identify excellence in the delivery of nursing services to patients or residents 2) Disseminate best practices in nursing services.

The Magnet Model includes five components:

transformational leadership

structural empowerment

exemplary professional practice

new knowledge, innovation, and improvements

empirical quality outcomes.

To achieve the goals of the Magnet Recognition Program and the "new knowledge innovation and improvements" component of the Magnet Model, nurses at all levels of healthcare organizations must be involved. Many nurses may be unaware of the importance of their contributions to developing new knowledge, innovations, and improvements and may not be able to differentiate among those processes. This article explains the basic differences among research, EBP, and quality improvement (QI.) (See PDF link: Comparing research, evidence-based practice, and quality improvement.)

Understanding research

The purpose of conducting research is to generate new knowledge or to validate existing knowledge based on a theory. Research studies involve systematic, scientific inquiry to answer specific research questions or test hypotheses using disciplined, rigorous methods. While research is about investigation, exploration, and discovery, it also requires an understanding of the philosophy of science. For research results to be considered reliable and valid, researchers must use the scientific method in orderly, sequential steps.

The process begins with burning (compelling) questions about a particular phenomenon, such as: What do we know about the phenomenon? What evidence has been developed and reported? What gaps exist in the knowledge base?

The first part of investigation involves a systematic, comprehensive review of the literature to answer those questions. Identified knowledge gaps typically provide the impetus for developing a specific research question (or questions), a hypothesis or hypotheses, or both. Next, a decision can be made on the underlying theory that will guide the study and aid selection of type of method to be used to explore the phenomenon.

The two main study methods are quantitative (numeric) and qualitative (verbal), although mixed methods using both are growing. Quantitative studies tend to explore relationships among a set of variables related to the phenomenon, whereas qualitative studies seek to understand the deeper meaning of the involved variables.

Quantitative studies typically involve scientific methodology to determine appropriate sample size, various designs to control for potential errors during data collection, and rigorous statistical analysis of the data.

Qualitative studies tend to explore life experiences to give them meaning.

In all research, discovery occurs as data are collected and analyzed and results and outcomes are interpreted.

A final important step in the research process is publication of study results with a description of how they contribute to the body of knowledge. Examples of potential nursing research include conducting a systematic review of studies on preventing catheter-associated urinary tract infections (CAUTI), a randomized controlled trial exploring new wound care methods, and a qualitative study to investigate the lived experiences of patients with a specific chronic disease.

Understanding EBP

Unlike research, EBP isn't about developing new knowledge or validating existing knowledge. It's about translating the evidence and applying it to clinical decision-making. The purpose of EBP is to use the best evidence available to make patient-care decisions. Most of the best evidence stems from research. But EBP goes beyond research use and includes clinical expertise as well as patient preferences and values. The use of EBP takes into consideration that sometimes the best evidence is that of opinion leaders and experts, even though no definitive knowledge from research results exists. Whereas research is about developing new knowledge, EBP involves innovation in terms of finding and translating the best evidence into clinical practice.

Steps in the EBP process

The EBP process has seven critical steps:

1. Cultivate a spirit of inquiry.

2. Ask a burning clinical question.

3. Collect the most relevant and best evidence.

4. Critically appraise the evidence.

5. Integrate evidence with clinical expertise, patient preferences, and values in making a practice decision or change.

6. Evaluate the practice decision or change.

7. Disseminate EBP results.

Cultivating a spirit of inquiry means that individually or collectively, nurses should always be asking questions about how to improve healthcare delivery. The burning clinical question commonly is triggered through either a problem focus or a knowledge focus. Problem-focused triggers may arise from identifying a clinical problem or from such areas as risk management, finance, or quality improvement. Knowledge-focused triggers may come from new research results or other literature findings, new philosophies of care, or new regulations.

Regardless of the origin, the next step in the EBP process is to review and appraise the literature. Whereas a literature review for research involves identifying gaps in knowledge, a literature review in EBP is done to find the best current evidence.

Hierarchy of evidence

In searching for the best available evidence, nurses must understand that a hierarchy exists with regard to the level and strength of evidence. All of the various hierarchies of evidence are similar to some degree.

The highest (strongest) level of evidence typically comes from a systematic review, a meta-analysis, or an established evidence-based clinical practice guideline based on a systematic review.

Other levels of evidence come from randomized controlled trials (RCTs), other types of quantitative studies, qualitative studies, and expert opinion and analyses.

Critical appraisal

Once the evidence is gathered, the researcher must critically appraise each study to ensure its credibility and clinical significance. Critical appraisal often is thought to be tedious and time-consuming. But it's crucial to determine not only what was done and how, but how well it was done. An easy method for conducting critical appraisal is to answer these three key questions:

What were the results of the study? (In other words, what is the evidence?)

How valid are the results? (Can they be trusted?)

Will the results be helpful in caring for other patients? (Are they transferable?)

Final steps of EBP

The final steps of the EBP process include integrating the evidence with one's clinical expertise, taking into account patient preferences, and evaluating the effectiveness of applying the evidence. Disseminating or reporting the results of EBP projects may help others learn about and apply the best evidence. Examples of potential EBP projects include implementing an evidence-based clinical practice guideline to reduce or prevent CAUTIs, evaluating an evidence-based intervention to improve wound healing, and applying an EBP to improve compliance with a specific treatment for a chronic disease.

Understanding QI

The purpose of QI is to use a systematic, data-guided approach to improve processes or outcomes. Principles and strategies involved in QI have evolved from organizational philosophies of total quality management and continuous quality improvement.

While the concept of quality can be subjective, QI in healthcare typically focuses on improving patient outcomes. So the key is to clearly define the outcome that needs to be improved, identify how the outcome will be measured, and develop a plan for implementing an intervention and collecting data before and after the intervention.

QI methods

Various QI methods are available. A common format uses the acronym FOCUS-PDSA:

F ind a process to improve.

O rganize an effort to work on improvement.

C larify current knowledge of the process.

U nderstand process variation and performance capability.

S elect changes aimed at performance improvement.

P lan the change; analyze current data and predict the results.

D o it; execute the plan.

S tudy (analyze) the new data and check the results.

A ct; take action to sustain the gains.

Unlike research and EBP, QI typically doesn't require extensive literature reviews and rigorous critical appraisal. Therefore, nurses may be much more involved in QI projects than EBP or research. Also, QI projects normally are site specific and results aren't intended to provide generalizable knowledge or best evidence. Examples of QI projects include implementing a process to remove urinary catheters within a certain time frame, developing a process to improve wound-care documentation, and improving the process for patient education for a specific chronic disease.

Take-away points

Research, EBP, and QI support the three main goals of the Magnet Recognition Program and the Magnet Model components of new knowledge, innovation, and improvements.

Research applies a methodology (quantitative or qualitative) to develop new knowledge.

EBP seeks and applies the best clinical evidence, often from research, toward making patient-care decisions.

QI uses systematic processes to improve patient outcomes.

All nurses should know and understand the differences among these three concepts.

Brian T. Conner is an assistant professor and undergraduate program director in the College of Nursing at the Medical University of South Carolina in Charleston.

Selected references

American Nurses Credentialing Center. Magnet Program Overview. www.nursecredentialing.org/Magnet/ProgramOverview. Accessed April 21, 2014.

Brown SJ Evidence-Based Nursing: The Research-Practice Connection. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2013.

Burns N, Grove SK, Gray JR. The Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. 7th ed. St. Louis, MO: Elsevier Saunders; 2012.

Harris JL, Roussel L, Walters SE, et al. Project Planning and Management: A Guide for CNLs, DNPs, and Nurse Executives. Sudbury, MA: Jones & Bartlett Learning; 2011.

Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. London: Churchill Livingstone; 2000.

Tappen RM. Advanced Nursing research: From Theory to Practice. Sudbury, MA: Jones & Bartlett Learning; 2011.

Titler MG, Kleiber D, Steelman VJ, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497-509.

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Differentiating research, evidence-based practice, and quality improvement - American Nurse Today

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June 2014 Vol. 9 No. 6 Author: Brian T. Conner, PhD, RN, CNE Research, evidence-based practice (EBP), and quality improvement support the three main goals of the Magnet Recognition Program ® and the Magnet Model component of new knowledge, innovation, and improvements.

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PLEASE NOTE: You DO NOT have to sign up for this educational activity. Instead, click the article link below to begin.

This educational activity is based upon a peer-reviewed article published in the February 2017 Clinical Journal of Oncology Nursing. To receive CNE credit for this activity you must

Read the entire article START HERE

Register and submit a completed evaluation.

As an exclusive benefit to ONS members, this is a free CNE activity. To access the article visit https://cjon.ons.org/cjon/21/1/chemotherapy-safe-handling-limiting-nursing-exposure-hazardous-drug-control-program. For nonmembers, please note that CNE activity registration and article access include specific fees.

ILNA Breakdown
OCN®, CBCN®, 0.5 ILNA points may be applied toward: CPHON®, BMTCN®, AOCNP®, and AOCNS®

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ONS Journal Activity 2017: Chemotherapy Safe Handling: Limiting Nursing Exposure With a Hazardous Drug Control Program

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PLEASE NOTE: You DO NOT have to sign up for this educational activity. Instead, click the article link below to begin. This educational activity is based upon a peer-reviewed article published in the February 2017 Clinical Journal of Oncology Nursing. To receive CNE credit for this activity you must

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Oncology nurses know the intricacies of cancer treatment. They know how to interact with patients in distress. And they know how to handle long-distance relationships. It is a skill nurses have developed in the past 10 years, as cancer treatment has largely moved into the outpatient arena. To help manage the side effects of chemotherapy, radiation, and targeted therapies, nurses often must contact patients at home, assess their conditions, and offer solutions-sight unseen.

Checking in with patients can bring positive results, since oncology nurses are able to offer interventions for most symptoms of cancer treatment. But the process is not simple. It requires a great deal of insight from nurses, who must discern when patients are withholding information about their symptoms, when they are unlikely or unable to comply with their treatment plans, and when they need immediate medical attention. And determining how best to accomplish that from afar-without exceeding a practice's resources- involves decisions about what to ask patients, when to contact them, and how.

In general, clinics combine two strategies to track the well-being of cancer outpatients: educating them about what to expect, and then questioning them after treatment, either by phone or online, about how they are feeling and what kind of interventions they might need.

Table. Common Symptoms of Cancer Treatments and Suggested Interventions

"The call is really just about reinforcing the teaching, finding out how they did, and being able to fine-tune it," said Mary Elizabeth Davis, RN, MSN, AOCNS®, a clinical nurse specialist at Memorial Sloan-Kettering Medical Center in New York City. "For instance, one of our patients who has prostate cancer has been taking a hormone for it that causes terrible pain in his joints an hour and a half later. I suggested that he take pain medication half an hour before he takes the hormone, to see if it can prevent that from happening."

For patients who are taking cancer medications at home, both education and symptom assessment can provide vital protection, Davis added.

"It's a big safety concern that patients are taking it the right way," she said, "because it can be so tragic if they don't. An example is an oral chemotherapy drug for brain tumors, Temodar. If a patient took too much, his white blood count would plummet and he would be at risk for bleeding or infection."

Education Matters
Oncology nurses know which side effects will arise from a specific chemotherapy or targeted treatment, and that is one reason education is so useful.

Nurses can warn patients if their treatment will cause a rash, hair loss, pain, fatigue, or nausea, and offer advice about how to handle those problems and when to ask for help, said Susie Newton, RN, MS, AOCN®, AOCNS®, who conducts symptom management for the outpatient Dayton Cancer Center in Ohio. More importantly, she said, nurses can explain that fever after chemotherapy can indicate sepsis, an emergent condition that patients might otherwise dismiss as a harmless cold.

"Studies show that patients who are more thoroughly educated about drugs and their side effects have better outcomes," Newton said. "That's the difference between doing a 10-minute shpiel right before the patient gets the drug and doing an hour-long class that includes the families four days before the patient gets the drug. Even though everybody is busy and the practice is not getting reimbursed for it and there are obstacles, it's just critically important that these patients are well educated, because they'll recognize when something is not right. If they don't, and they just let it go, they'll end up getting admitted to the hospital."

Not surprisingly, a lack of education can lead to noncompliance with medical advice, said Carlton G. Brown, PhD, RN, AOCN®, former president of the Oncology Nursing Society (ONS), and an assistant professor in the School of Nursing at the University of Delaware in Newark. To help keep patients informed, he has written a handbook titled A Patient's Guide to Cancer Symptom Management.

"There's a lot of research now into compliance, particularly with oral medications," Brown said. "Some patients have a rash with oral medications, and we've been acculturated to believe that a rash means we should stop. In this case, it's the opposite-it means the agent is really working. In other cases, a patient sometimes comes back after three weeks and says, 'I had nausea so bad that I don't want chemo, or I want to delay it or lower my dose.' That's not good if we're trying to deliver a cure or control."

Newton added that, if patients haven't been properly educated, they might react to the cost of medications-particularly oral agents-by altering their own dosing schedules.

"They're expensive," she said, "and sometimes patients will try to stretch out the time period and take half the amount."

Teaching patients is so important to leaders at ONS that they have drafted legislation that would require Medicare to fund an hour of pre-treatment chemotherapy education for each of its patients newly diagnosed with cancer. Medicare should be involved because more than half of all people diagnosed with cancer are over the age of 65, the bill states. A similar education program is already required by law for Medicare patients who have diabetes, Brown said.

Making the Call
Even educated patients can get overwhelmed, though, and forget to take a medicine or carry out a recommended intervention. To help them succeed, many nurses rely on telephone triage-a set of techniques for contacting patients and assessing how they are feeling and functioning.

Lori Williams, PhD, RN, MSN, BSN, BA

"Our standard is that patients are called 24 to 48 hours after their first chemotherapy treatment and after any change in chemo," Davis said. "If you're starting a regimen, the next day you're usually feeling quite well, because medications for nausea and other symptoms last. So we call two or three days later, and that's when the patients need the help."

When calling patients, Davis said, Sloan- Kettering's oncology nurses work from a computerized menu of questions.

"We have a phone triage book and an electronic manual for our phone calls," she said. "If somebody calls with nausea and vomiting, it guides the nurse in what questions to ask to make sure you're getting the right assessment of it. We have guidelines about what is considered emergent, when a patient may need to go to the emergency room or come see us."

At the University of Texas MD Anderson Cancer Center in Houston, Lori Williams, PhD, RN, MSN, BSN, BA, is conducting research using another form of triage for cancer outpatients: automated telephone surveys that ask 25 questions about symptoms. A similar system is in place at the University of Utah, Brown said.

A computer-generated voice asks the questions, patients type their answers into their telephone key pads, and the system sends results to oncology nurses, who save time by calling only those who are experiencing troublesome symptoms. Meanwhile, other leading cancer centers, including Duke University, use assessment systems that patients access online. In either case, the regularity of the assessments has the added benefit of allowing nurses to determine whether their interventions are succeeding, said Williams, an assistant professor in MD Anderson's Department of Symptom Research and a member of the ONS Board of Directors.

MD Anderson's automated system is particularly useful when patients aren't assertive enough to call about their symptoms, or when they become too depressed to reach out for help, Williams said. Patients seem to be more honest when responding to the automated survey than when speaking with a "real person," Williams added. And often, she said, the surveys bring to light symptoms that patients didn't realize were connected with their treatments, like dry mouth and trouble sleeping.

Sometimes, the results surprise physicians, too. "We did one survey with our surgery patients who'd had thoracotomies," Williams said. "They did well in the hospital, and surgeons said they'd be fine at home. They came back three weeks later and they were perfectly fine. We did our study and found out that when they got home and had less monitoring, they had high pain levels and many were not calling their doctors because they thought they should expect it. It changed the practices of our surgeons."

An Idea Grounded in Science
A pilot study ¹ conducted by Cancer Care Associates in Michigan also found that there is value in using an automated voice response system plus nursing intervention to monitor adherence to oral chemotherapy agents. According to a study abstract, "an association between symptom management and adherence was found."

Nurse Perspective

Susie Newton, RN, MS, AOCN®, AOCNS®
Dayton Cancer Center
Dayton, Ohio

With the movement of most cancer treatments into an outpatient setting, oncology nurses must routinely work from afar to help patients manage their side effects. It is an art that Susie Newton, RN, MS, AOCN®, AOCNS®, practices regularly. Oncology Nursing News asked Newton to share some of the insights she has developed through her work, which includes symptom management duties at the Dayton Cancer Center, a hospital-owned outpatient oncology clinic in Ohio.

Oncology Nursing News: How are you involved in helping patients manage their side effects from cancer treatments?
Newton: I work for a typical practice. It has an infusion room with infusion nurses, and we treat every kind of cancer and hematologic disorder. We also refer people out if clinical trials are more appropriate.

In the clinic, I do primarily telephone triage with patients, managing their symptoms over the phone. Outside the clinic, I do some nurse education activities.

I've also co-edited two books published through the Oncology Nursing Society. One of them, Telephone Triage for Oncology Nurses, goes through different methods. There's not one that's right or wrong; it's what works best for the practice setting they're in. The book takes every symptom that patients would call in for and gives a quick and easy guide for what to ask. The protocols are written by nurses all over the country. The book also has a whole chapter on legal issues, because there are a lot of legal implications for giving medical advice over the phone.

Beyond asking about symptoms and suggesting interventions, are there any tactics nurses should incorporate into phone conversations with patients?
Don't conclude that you know what's concerning the patient. Let the patient completely describe the problem, ask him questions, and listen. It's normal for nurses to think they know what's going on, but you could be wrong a lot of times

Before hanging up, ask, "Can you repeat back to me what we've just agreed upon?" That way, you know they understand. A second question before hanging up should be, "Is there anything that's going to keep you from doing what we've just decided?" Sometimes they'll say, "I can't afford to get the medicine," and I'll say, "Come get samples."

What is the biggest obstacle to providing remote symptom assessment and management to patients being treated for cancer?
The biggest obstacle is that telephone triage is not reimbursed, even though most offices require one dedicated full-time person, or a full-time equivalent. If a nurse is giving chemo, payers reimburse for the drug and the time that the patient is in the chair. But there's no reimbursement for education or time on the phone with patients.

Have you ever run into unexpected situations while consulting with patients over the phone?
Absolutely. Patients with cancer have all kinds of problems besides their cancer. One lady called me and said, "I just got my chemo. I'm sick and having people come help take care of me and my family, and my electricity is being cut off. Is there anything you can do to help?" I called Dayton Power & Light and explained the situation, and they said they had a program that could help. I filled out a form, faxed it back, and they kept her power on. That's one reason I love doing the phones: You can make such a big difference for people.

I've also asked patients to come in when their symptoms sounded suspicious. Once, someone with an implantable infusion port called about swelling in her neck. Normally, we'd think she might have a superior vena cava syndrome, but I said, "Just come on in and let's look." It turned out she had this big blood clot right where her port was. You have to ask the right questions, and sometimes you just have to bring them in.

In addition, a 2002 study ² conducted by experts at the University of Utah, which considered the feasibility of using a telephone-based computerized system to monitor symptoms after chemotherapy, found that "The telephone-linked care system has the potential to improve dramatically symptom monitoring and symptom care of patients with cancer at home."

Such systems work most effectively, Williams added, when they rely on scientifically validated assessment tools, such as the MD Anderson Symptom Inventory. There are other such tools available for quick assessment of oncology symptoms, including the Memorial Symptom Assessment Scale (which is used at Sloan-Kettering), the Functional Assessment of Chronic Illness Therapy (FACIT), and the newer Patient Reported Outcomes Measurement Information System (PROMIS), which is being tested in clinical settings.

Yet Williams believes that few oncology practices rely on standardized questions, let alone validated instruments-and she views that as a mistake.

Because they've been subject to research, Williams said, validated assessment tools ask questions that are free from clinician bias about what is important. And, she said, they're easy for patients to understand and for healthcare providers to score.

A Worthwhile Endeavor
In the big picture, the remote management of cancer treatment side effects makes sense for a couple of reasons, Williams said.

"Controlling the symptoms of patients with cancer has always been important to oncology nurses, but over the last 10 years, physicians have started to look at it more," she said. "Cancer is becoming more of a chronic illness. We're better now, if not at curing it, then at least at controlling it for long periods, so it's much more important if patients are living with symptoms that are fairly debilitating."

The practice may also soon be helpful from a financial point of view.

"The FDA is more interested, in general, in patients reporting outcomes from treatments," Williams said. "If we get into pay-for-performance systems, controlling symptoms may come out as something that would be considered a quality indicator that you might be paid on, and these systems let you collect data for that, too."

References

1. Decker V, Spoelstra S, Miezo E, et al. A pilot study of an automated voice response system and nursing intervention to monitor adherence to oral chemotherapy agents. Pubmed.gov. http://www.ncbi.nlm.nih.gov/pubmed/19816160. Published 2009. Accessed March 28, 2012.
2. Mooney KH, Beck SL, Friedman RH, Farzanfar R. Telephone-linked care for cancer symptom monitoring: a pilot study. PubMed.gov. http://www.ncbi.nlm.nih.gov/pubmed/11972569. Published 2002. Accessed March 28, 2012.

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