Oncology Nurses Take Initiative With Three Innovative Programs

August 1, 2001

At Memorial Sloan-Kettering Cancer Center, nurses are recruiting newly diagnosed cancer patients into a smoking cessation program. At Marshfield Clinic Cancer Care, Marshfield, Wisconsin, nurses are teaching phlebotomists how to do venous access device (VAD) blood draws. And at St. Joseph Medical Center, Towson, Maryland, nurses have made depression assessment part of standard oncology care.

SAN DIEGO, California—At Memorial Sloan-Kettering Cancer Center, nurses are recruiting newly diagnosed cancer patients into a smoking cessation program. At Marshfield Clinic Cancer Care, Marshfield, Wisconsin, nurses are teaching phlebotomists how to do venous access device (VAD) blood draws. And at St. Joseph Medical Center, Towson, Maryland, nurses have made depression assessment part of standard oncology care.

"The nurses at each institution saw a need and addressed that need," said Gabriela Kaplan, RN, MSN AOCN," who moderated a session on innovations to improve patient outcomes at the Oncology Nursing Society’s 26th Annual Congress. "In some cases, the innovation did not even require money. It just required the good intentions of the participants," Ms. Kaplan, an advanced practice oncology nurse at Bayonne Hospital, Bayonne, New Jersey, told ONI.

Smoking Cessation

Smoking cessation programs have been offered at Memorial Sloan-Kettering Cancer Center for many years, and the medical and nursing staff have always made referrals as needed, Christine Gillens-White, RN, BSN, a Clinical Nurse III, said at the meeting. "But as clinicians, we saw an opportunity to grab more patients."

With the new referral program, "we capture patients right after they are diagnosed—in the preoperative setting," Ms. Gillens-White told ONI. "Being newly diagnosed, they’re more open to smoking cessation than they might be after they’ve gone through their surgeries and treatment. So we have initiated this referral and made it a standard part of our assessment. Our success rate is very good."

The oncology nurses in the Pre-Surgical Center, who specialize in assessment, plans of care, and education, incorporated a smoking assessment form to identify smokers and a form for patient referrals.

Patients are asked about their current smoking status and interest in quitting. Those interested in quitting are counseled on the risks of smoking and the benefits of quitting during their pre- and postoperative period, and nurses make the referrals during this preadmission testing period.

The current data at Memorial Sloan-Kettering, Ms. Gillens-White noted, show that 85% of the referrals initiated to the hospital’s smoking cessation program have been made by registered nurses. The implication for nursing, she said, is that nurses need to initiate a smoking cessation intervention "at every office visit and hospitalization."

Training Phlebotomists

At Marshfield Clinic, about 5 years ago, a decision was made to alter the traditional practice of requiring nurse clinicians to perform all of the venous access device (VAD) blood draws and care. Instead, phlebotomists would perform the uncomplicated VAD blood draws and site care. To implement the decision, the nurses developed a VAD training program for phlebotomists.

"We had a system of nursing care where we were performing all the venous access device draws and all the care and all the teaching—and administering all the chemo and telephone triage and symptom management. What we had was a conflict," said Darlene M. Pawlik Plank, RN, MSN, AOCN, oncology services manager at the Marshfield Clinic.

If nurses were performing VAD blood draws and dealing with minor complications, they we were not available to give chemotherapy, she said. So it made sense to have the phlebotomists perform the uncomplicated VAD blood draws and site care.

"Our goal was to use the best skill mix of each profession to create a partnership in the care of patients with VADs, and previously, the phlebotomists’ training had not included VADs," Ms. Plank said. The phlebotomists, she pointed out, "are skilled at accurately obtaining samples, labeling them, and sending them to the lab." The nurses, with their clinical expertise, focus on patient care, she said.

To implement the training program, the nurses developed simulation VAD models using actual ports and catheters, and a skills checklist that reflected policies and procedures. The model provided an overview of the types of VADs, catheter care, and the signs and symptoms of catheter problems.

During a clinical practicum phase, a nurse accompanies the phlebotomist during the blood draw. The review made the process visible to all, Ms. Plank said. "We had increased understanding of the role of each profession, and we identified each other’s professional blind spots," she said.

Teamwork has been fundamental to the program. "Successful partnership requires strong coaching," she said. Paraphrasing the words of the legendary Wisconsin Green Bay Packers coach Vince Lombardi, Ms. Plank explained, "You don’t just tell them what to do, you show them the reasons."

Assessing Depression

Back in 1999, nurses at St. Joseph Medical Center who attended an oncology congress heard a talk about how nurses underestimate the depression of their clients, and they decided to do something about it.

"It became a performance improvement project," said Mary C. Thompson RN, BSN, patient care coordinator at St. Joseph, a 460-bed community hospital. "Identifying these symptoms is a very common first step for most nurses," she said. "However, it can be very difficult to separate the symptoms of depression from disease symptoms or even treatment side effects."

For instance, she said, sleep problems can stem from dexamethasone therapy, or impaired concentration can result from pain control medication.

The nurses’ response to this need was to look at ways to assess the depression quickly and accurately. "Our first goal was not to set ourselves up for something so complicated to follow through on that neither the staff nor the patients would continue to do it," Ms. Thompson said.

They chose to use the Zung Self-Rating Depression Scale, a 20-item questionnaire. The nurses report the results to medical oncology and provide referrals. Patients scoring greater than 50 are referred to a psychiatric liaison nurse or supportive care nurse—known in some hospitals as a palliative care nurse.

Even with a normal Zung score, Ms. Thompson said, nurses may still make referrals based on their observations or on patient or family requests.

Patients are screened for depression at least once a month. "Having the patient complete a self-assessment of depression on a regular basis has given them the message that being depressed can be part of the total picture of dealing with a cancer diagnosis and is nothing to be ashamed of," Ms. Thompson commented.

She added that nurses like to be proactive and sometimes are uncomfortable talking about issues where no solution is available to them. "This process has given us direction, accountability, and a mechanism of action for dealing with patients with depression," she concluded.