The satisfaction of extreme challenges
Like many fields, oncology nursing is so broad that it is hard to know where to start. Cancer takes many forms. It may strike any part of the body and manifest as fairly benign or rapidly fatal. Treatment ranges from a simple excision to drastic surgery, with months of chemotherapy and radiation. One constant? In almost every case, some of the care will fall to a nurse, often one who specializes in oncology.
What draws people to this specialty? Page Bertolotti, RN, BSN, OCN, tells a story. Her patient was a young man with myeloma. He was popular with the staff and had more visitors than she thought possible. She was a brand new nurse, unsure of herself, but anxious to get everything right. The patient, whom she remembers vividly, “took me under his wing and led me through the procedures. Instead of my teaching him, he taught me.”
She was hooked. Now, years later, as a practice nurse at the Cedars-Sinai Outpatient Cancer Center, what does she love most? Without hesitation, she says it's the patients and their families, their courage and the enormous difficulties they overcome.
Kristen Merkh, RN, BSN, OCN, reports that even when she started as a new graduate from Biola University, she always connected to patients who faced a serious diagnosis, who perhaps stayed in the hospital a little longer, often those with cancer. That interest never left her; now, 10 years on, she still welcomes the challenges.
Navigating the System
Because of the wide range of cancers and the unending supply of fresh treatments, the science of the field continues to fascinate her. Fortunately, her employer, St. Joseph Hospital in Orange, provides ample time to learn. For new nurses it offers a formal plan that allows a gradual introduction into the complex care of “in hospital” oncology nursing.
Even for an experienced nurse, keeping up with new developments is a constant requirement. Ms. Merkh points out that consulting with experts is part of the job, including getting guidance from nurse practitioners on the palliative care team. She and her colleagues also utilize the Oncology Nursing Society website for up-to-date resources. In a slightly different role, an oncology nurse practitioner works to coordinate inpatient and outpatient care for the underserved and uninsured.
Nurse navigators, a rather new title for nurses who help patients “navigate” the oncology system, also work at St. Joseph. They assist patients in coming to terms with the cancer diagnosis by providing emotional support and helping them get optimal care. So much oncology care has moved to the outpatient realm that coordination is a critical nursing intervention.
Dealing with Death
Many patients still have extended hospital stays, and Ms. Merkh welcomes the opportunity to come to know them and their families. “We have a lot of leukemia patients…they get their chemo, it kind of bottoms out their blood count, and so we keep them here to support them through the risk of infections. They get a lot of blood transfusions, those sorts of things, and they usually stay with us about a month.”
How does she deal with the deaths of patients whom she has come to know well? It gets easier with time, she says. “You have to find the balance between getting close to your patients and not getting devastated when you lose them.” Her first years were all about learning and organizing. Not until her third year did she become comfortable with the nitty-gritty of nursing practice and begin to reflect on what these devastating diagnoses meant to her.
Now, she says, she is more able to know when to pull back and still maintain the professional care she needs to give. She cautions nurses who are thinking about this fast-paced field: Usually, it involves aggressive medical treatment supported by intensive nursing, all with the hope of recovery. While there are end-of-life issues at times, it is not the same as hospice nursing.
For Page Bertolotti, patient involvement extends beyond the job at Cedars. She is an active participant in the American Cancer Society’s Relay for Life and sits on the nurse leadership board of the International Myeloma Foundation.
As a practice nurse, she does not round on inpatients, but she is closely involved in their continuing care. After initial treatment, many patients come back for years of follow-up. The physician group that she works with concentrates on patients with multiple myeloma, and her role on any given day depends on what individual patients need. This may involve triage, medication coordination, scheduling or insurance matters. During the day, she might deal with issues for 10-15 patients, some requiring brief interventions, some needing extended time.
According the Stephanie Chang, RN, the director of the Outpatient Cancer Center where Ms. Bertolotti works, another role for oncology nurses is staffing the hospital’s Infusion Center. It is open 24/7 and provides support, complex chemotherapy, antibiotics, blood and sometimes hydration. What counts most in either role is a thorough understanding of oncology nursing practice and the ability to set priorities.
Then and Now
For Linda Sarna, RN, DNSc, FAAN, the introduction to oncology nursing came 40 years ago when the field was just breaking out with new developments. She had an opportunity to work in the float pool at the National Cancer Institute in Bethesda, Md., caring for adults and children suffering from all kinds of cancer. “This was really the beginning of the oncology specialty,” she says. “It was the first time they had chemotherapy treatment to cure cancer in adults, namely Hodgkin’s disease. It was the time of very drastic surgical procedures to cure cancer and also the time of the laminar air flow rooms, which were used for isolation…and also it was in the very early days of bone marrow transplantation.”
As she furthered her education she became a nurse researcher; an educator; and co-author, along with colleagues at UCLA’s Schools of Nursing, of Concepts of Oncology Nursing (1981), one of the first texts on that specialty.
“In the very early days there was a tremendous amount of emphasis on symptom management, death and dying, and the best ways nurses could take care of terminally ill patients,” Ms. Sarna says. “Now, a little bit later, I have the luxury and the opportunity to work with the issues of cancer survivors. The over 10 million cancer survivors in the U.S. also need attention.” She finds that, “some patients struggle with depression, or struggle with some of the emotional consequences of having a devastating diagnosis…For other patients, it is sort of an epiphany, that life is short and limited. They may have a renewed joie de vive.”
Most recently, her research has come full circle and focuses on the use of evidence-based guidelines for nurses to help patients quit smoking. “Nurses,” Ms. Sarna says, “are really primed to provide the social support and are also skilled in knowing about the side effects of nicotine withdrawal and side effects of medications. [They] are perfect to deliver tobacco dependence treatment,” (see sidebar).
Even after 40 years, Ms. Sarna sees the particular challenge of oncology nursing as symptom management. Some symptoms linger on, even years after an experience of cancer treatment. “The oncology nurse of today needs to be up to date on the new kinds of treatment and many nursing interventions, including medication and other things that can help ease the suffering. They also need to attend to the quality of life and psycho-social issues that affect all people who experience cancer and their families.”
Another challenge affecting oncology nurses of the 21st century is the economies of scale. What are the most cost-effective and evidence-based interventions? Not all patients will require the same intensity of care. According to Ms. Sarna, current emphasis in oncology nursing research and in the clinical practice realm is to identify those people who are most at risk for poor outcomes. Their lung cancer, for instance, might co-exist with COPD or heart disease. They may have pre-existing conditions like mental illness, substance abuse or just “aloneness” that make more support essential. A paradox reigns: There are not enough resources available to help all patients, and yet many resources go under-utilized.
Like Kristen Merkh, Ms. Sarna points out that while oncology nursing is not for the faint of heart, it is not all about dying patients either. Much of it is health promotion, like her work in tobacco control. She also points to a terrible shortage looming in oncology research and education due to the aging of the current workforce. Moreover, clinical nurse specialists and nurse practitioners are in short supply. These roles require preparation at the graduate level, something that is very accessible in California.
Consider that, as Linda Sarna, Kristen Merkh and Page Bertolotti point out, a career in oncology nursing can be both extremely challenging and satisfying.
Beyond the Bedside
Relay for Life
– Celebrates the lives of those who have battled cancer
– Remembers the lives of those who have died
– Earns money for research
For More Information:
Tobacco Free Nurses Initiative
– Helps nurses to quit smoking
– Provides resources to nurses wanting to help patients quit
– Promotes tobacco control as an objective of nursing organizations
For More Information:
Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.
This article is from workingnurse.com.