• Nursing is a fabulous profession. Distance yourself from any nurse that tells you otherwise. He/she will not contribute to your success.
• I know nursing school is hard. We all do. Don’t quit. Get study help if you need it. Keep positive people in your life. Make sure you know why you’re becoming a nurse; think about it often.
• School seems like it will last forever. It won’t. Eat clinical experiences like candy bananas. Search them out. It will make you a better nurse, no matter your specialty.
• There will come a day when you won’t have someone asking you about medication side effects and whether or not you’ve looked up lab work. Do it now without someone asking, and you’ll do it later in your nursing practice. It’s what responsible nurses do – every day.
• Never say never. Even if you’re 100% sure you know you’re going to be an L&D nurse, be flexible and prepared to work in other areas. Speaking from experience, sometimes your specialty chooses you rather than vice versa.
• If you don’t understand, seek clarification. Your nursing professors are brilliant men and women. Tap into their knowledge whenever you can. Don’t forget – they’ll soon be your colleagues.
• Don’t ever think nursing school is the end of your education. Nurses learn every single day both formally and informally. (Plan to get your BSN, MSN, and PhD. Nursing needs you.)
• Celebrate nursing school. The check-offs, clinicals, labs, three-hour lectures, papers – celebrate them all. Nursing school really is full of fun experiences, and finishing – it’s a fabulous feeling.
• Take care of yourself. Eat right. Exercise. Stop using/don’t use tobacco. Get enough sleep. (Yes, it can be done.)

If you haven’t thought about or chosen your nursing specialty, seriously consider oncology nursing. I was 100% sure I wanted to be an L&D nurse, yet through seemingly random events, I fell in love with oncology nursing and my professional career diverged for the better. I wish you all the best. If you think I can help you, feel free to contact me! I look forward to working alongside you.

Catherine Wickersham, RN, BSN, OCN®

Catherine Wickersham, RN, BSN, OCN^®, is a clinical nurse IV at Memorial Sloan-Kettering Cancer Center in New York, NY.

Telephone nursing triage is a difficult skill to master and is especially difficult for novice nurses. Strong communication and listening skills are very important because nurses do not have the advantage of a face-to-face encounter. Telephone triage nurses must ask specific, open-ended questions to obtain as much information as possible and best understand the severity of symptoms.

Ambulatory nurses at Memorial Sloan-Kettering (MSK) Cancer Center use the Ambulatory Care Telephone Triage and Symptom Management Protocol Manual as a guide to manage calls. It is a resource that includes the assessment of specific symptoms and follow-up for treatment plans or procedures. We also use the MSK telephone triage manual and telephone nursing triage policy, the policy for documenting on the ambulatory telephone/e-mail communication form, and MSK evidence-based guidelines for prevention, assessment, and treatment of oral mucositis, constipation, and pressure ulcers. Medical and radiation oncology nurses also use guidelines that pertain to their areas of chemotherapy or radiation. Patient education is a huge component of our call interactions, and we are able to send or e-mail educational fact cards pertaining to surgeries, medications, tests, or diseases. It is imperative that each encounter is documented since it is part of the patient’s chart.

Our judgment as nurses can lead to earlier patient interventions and prevent unnecessary urgent care center or emergency room visits.

I could only use what I could hear, not what I could see or feel from the participants. I generally operate using all my senses and rely on all of the nonverbal cues that people exhibit. Therefore, I found that constantly having to verbally confirm what I was hearing and measure the response by the tone and volume of the words being used was exhausting. I vowed to never again try to conduct that type of meeting via telephone.

I was reminded of that long-ago planning meeting as I read this month’s feature article on telephone triage. In this issue, we explore the challenges faced by oncology nurses who respond to telephone calls from patients and family members. These nurses must rely on their ability to discern the severity and significance of what is being reported. In addition, they must develop astute skills to ferret out all of the details needed to fully assess the situation and determine next steps. This assessment may be in the context of having never met that particular patient or family member and not having quick and complete access to the medical record.

The size of the practice and the volume of calls may determine whether the calls are handled by all of the staff as time allows, nurses assigned for the telephone triage, or staff in a centralized call center. Regardless of the size or volume, legal and regulatory requirements must be addressed, and the recommendations found in the month’s feature can be applied to all settings.

Just as I have honed my skills in project management, nurses providing telephone care to patients with cancer can increase their skills and expertise by focusing on the desired outcome and practicing to get there. For patients at the other end of the telephone, a confident oncology nurse who is asking the right questions and giving the best advice can literally save a life. Or at the very least, provide quality oncology care over the telephone.

Determine patients’ preferred learning styles and use these during discussions. Some patients may want to know all of the details about their situation whereas others may only want to know where they will go from here.

Telling a patient bad news is never easy. Whether sharing information about an initial cancer diagnosis, disease recurrence, evidence of metastatic disease, or a move to hospice care, the healthcare team needs to be sure patients are prepared for the news and understand what it means for them. In the August 2010 Supportive Care department in the Clinical Journal of Oncology Nursing, Kaplan describes two step-by-step methods that will help oncology nurses deliver bad news to patients and respond to patients’ emotions upon hearing that news.

SPIKES

SPIKES (see Figure 1) is an acronym for a six-step protocol that outlines important considerations when breaking bad news (Buckman, 2005). Its use can help ease distress for both the patients receiving the news and the healthcare providers who are sharing the news.

Setting: Choose a quiet, private setting in which to share bad news. Turn off all phones and pagers (or put them on vibrate) and give patients your undivided attention. Include family members if patients wish. Try to deliver the news while seated, without a barrier (e.g., a desk) between you and patients. Although you may feel anxious sharing the information, try not to let it show in your body language. Show respect for patients by listening to their concerns in a calm and attentive manner.

Perception: Determine patients’ understanding of their medical situation before you deliver any news. Patients may not have a handle on the seriousness of the situation or may be in denial. If so, this may need to be addressed gently over several discussions before breaking the bad news.

Invitation or Information: Ask patients or family members directly what information would be helpful to them. Determine their preferred learning styles and use these during discussions. Some patients may want to know all of the details about their situation whereas others may only want to know where they will go from here.

Knowledge: Give patients a few seconds’ warning that bad news is coming by prefacing the news with statements such as “Unfortunately, I have some bad news to share” or “I’m sorry, I have some serious news to tell you.” Use clear, lay language rather than technical terms or jargon that may be difficult to understand in times of distress. Make sure patients and family members have time to absorb the information and respond with questions.

Empathy: Acknowledge patients’ emotions and reactions and respond to them in an appropriate manner. Use statements such as “I wish the news were better” or “This is obviously distressing news” to show empathy. More information on conveying empathy through the NURSE method will be presented in the next section.

Summarize or Strategize: Ensure that patients understand the information you just presented by summarizing what you told them and giving them the opportunity to ask questions. Present a strategic plan for the next steps the healthcare team or the patient will take. Assess patients’ understanding by asking questions such as “Does this make sense to you?” “Are you clear about the next steps?” or “Do you have enough information to make a decision?”

NURSE

Patients may respond to bad news with a variety of emotions, and often they are looking for an “accepting response” from the healthcare provider rather than an immediate reassurance, rebuttal, or agreement. NURSE (see Figure 2) is a five-step method that may help you provide an empathetic response to patients’ emotions (Back, Arnold, Baile, Tuksky, & Fryer-Edwards, 2005).

Naming: Naming an emotion shows empathy for a patient’s distress; however, it is better to suggest a name for the emotion rather than declaring it. Saying, “I wonder if you’re feeling angry?” is preferred to “You must be angry.”

Understanding: Ensure that you have a clear understanding of a patient’s fears and concerns before offering a response. Repeat your thoughts to the patient: “My understanding of what you’re saying is . . .” Although it seems contradictory, even statements such as “I cannot imagine what it is like” show that you understand.

Respect: Empathy and respect go hand in hand. Give patients permission to express their feelings, acknowledge those feelings, and show respect for their expression of emotion. This can be done nonverbally through body language and touch or verbally by matching the intensity of your statements to the intensity of patients’ emotion.

Supporting: Share resources with patients and support their ability to cope. Recommendations for support groups can help prevent patients from feeling abandoned and reinforce their coping skills.

Exploring: Asking patients direct questions or clarifying on patients’ prior comments can reinforce the healthcare provider’s empathy. It also gives patients permission and opportunity to share additional emotions and feelings that they may have hesitated to reveal earlier.

For more information on delivering bad news and responding to patients’ emotions, refer to the complete article by Kaplan (2010).

• Back, A.L., Arnold, R.M., Baile, W.F., Tuksky, J.A., & Fryer-Edwards, K. (2005). Approaching difficult communication tasks in oncology. CA: A Cancer Journal for Clinicians, 55, 164–177. doi: 10.3322/canjclin.55.3.164
• Buckman, R.A. (2005). Breaking bad news: The S-P-I-K-E-S strategy. Community Oncology, 2, 138–142.
• Kaplan, M. (2010). SPIKES: A framework for breaking bad news to patients with cancer. Clinical Journal of Oncology Nursing, 14, 514–516. doi: 10.1188/10.CJON.514-516

Five-Minute In-Service is a monthly feature that offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes “SPIKES: A Framework for Breaking Bad News to Patients With Cancer” by Marcelle Kaplan, RN, MS, AOCN^®, CBCN^®, which was featured in the August 2010 issue of CJON. Questions regarding the information presented in this Five-Minute In-Service should be directed to the CJON editor at CJONEditor@ons.org.

Patients who received ipilimumab lived nearly four months longer than those who received an alternative experimental vaccine that previously showed activity against melanoma. The median survival was 10.1 months for ipilimumab versus 6.4 months for the vaccine.

The 676-patient trial compared outcomes in three arms: ipilmumab alone, ipilimumab plus the experimental vaccine, and the vaccine alone. The researchers found that adding the vaccine to ipilimumab did not help patients live longer. Instead, the median overall survival in the ipilmumab group was slightly better than in the combination group.

• O’Day, S., Hodi, F.S., McDermott, D.F., Weber, R.W., Sosman, J.A., Haanen, J.B., . . . Urba, W.J. (2010). Phase III, randomized, double-blind, multicenter study comparing monotherapy with ipilimumab or gp100 peptide vaccine and the combination in patients with previously treated, unresectable stage III or IV melanoma [Abstract 4]. Journal of Clinical Oncology, 28(18, Suppl.).

The trial enrolled 200 patients with various stages of prostate cancer and used an automated imaging device, called a microfluidic CTC chip, to evaluate the prognostic and predictive value of monitoring CTCs before and after treatment. In the pilot analysis, the researchers detected CTCs in 8 of 19 (42%) patients with localized prostate cancer. For six of the eight patients with preoperative CTCs, a postoperative decline in CTC levels occurred within 24 hours of surgery. In patients with metastatic cancer, CTCs were detected in 23 of 36 (64%) cases and declined after the initiation of effective therapy.

• Stott, S.L., Lee, R.J., Nagrath, S., Yu, M., Miyamoto, D.T., Ulkus, L., . . . Maheswaan, S. (2010). Isolation and characterization of circulating tumor cells from patients with localized and metastatic prostate cancer. Science Translational Medicine, 2(25), 25ra23.

The four-year trial showed similar rates of disease recurrence as current treatment. The current treatment involves weeks of radiotherapy to the whole breast to kill any remaining cancer cells after surgically removing cancerous breast tissue. With the new technique, surgeons use a mobile radiotherapy machine that can be inserted into the breast during tumor removal surgery to target the exact site of the cancer.

Six patients who had the single-dose technique experienced recurrence, compared to five undergoing a prolonged course of radiotherapy—not a statistically significant difference. However, the single dose of radiotherapy during surgery prevents potential damage to organs such as the heart, lung, and esophagus which can occur during radiation to the whole breast. Complications were similar for both groups.

One drawback of the study was that it only followed the women for four years and it is not unusual for cancers to reoccur after eight or more years. It is possible that further study will show significant differences in recurrence rates between the two radiation treatment options.

• Vaidya , J.S., Joseph, D.J., Tobias, J.S., Bulsara, M., Wenz, F., Saunders, C., . . . Baum, M. (2010). Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): An international, prospective, randomised, non-inferiority phase 3 trial. Lancet, 376, 91–102.

All of the patients enrolled in the phase III trial had epidermal growth factor receptor (EGFR) mutations that were sensitive to the tyrosine kinase inhibitor (TKI) gefitinib. The enrolled patients did not have the resistant EGFR mutation T790M, and they had not been treated with chemotherapy previously. The researchers believe that the study establishes EGFR tyrosine kinase inhibitor as first-line therapy in patients with NSCLC and sensitive EGFR mutations.

The trial was stopped early after an interim analysis of the first 200 patients revealed a 70% reduction in disease progression or death in patients receiving gefitinib. Ultimately, 230 patients were enrolled; at year 1, 42.1% of patients receiving gefitinib had not progressed compared with 3.2% receiving chemotherapy. After two years, all of the chemotherapy recipients had progressed but 8.4% of those receiving gefitinib still had not. Women had a significantly longer progression-free survival than men.

• Maemonda, M., Inoue, A., Kobayashi, K., Sugawara, S., Oizumi, S., Ksove, H., . . . Nukiwa, T. (2010). Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR. New England Journal of Medicine, 362, 2380–2388.

Many women with breast cancer will have surgery that destabilizes the shoulder, so the guidelines encourage the use of exercise to strengthen the surrounding shoulder muscles.

A panel of 13 experts convened by the American College of Sports Medicine (ACSM) has published updated guidelines on exercise and physical activity in patients who are undergoing active treatment for cancer or who have completed treatment. The panel concluded that exercise training is safe during and after cancer treatment and results in improved physical functioning, quality of life, and cancer-related fatigue for many cancer survivor groups, but implications for disease outcomes and survival are still unknown.

Historically, clinicians have advised patients with cancer to rest and avoid activity. However, research on the benefits was sufficient for the panel to challenge this recommendation. The panel recommended that cancer survivors follow the 2008 Physical Activity Guidelines for Americans (U.S. Department of Health and Human Services, 2009), with specific adaptations based on disease- and treatment-related adverse effects (Schmitz et al., 2010). For example, in men who have undergone androgen deprivation therapy for prostate cancer, trainers need to be aware of fracture risk. And many women with breast cancer will have surgery that destabilizes the shoulder, so the guidelines encourage the use of exercise to strengthen the surrounding shoulder muscles. The panel noted that although the benefits of exercise are clear, patients may feel too sick to tolerate exercise. In these cases, the panel recommends temporarily decreasing activity. Specific guidelines, including objectives, goals, and contraindications, are available for patients with breast, prostate, colon, gynecologic, and hematologic cancers (Schmitz et al., 2010).

Two of the primary goals of exercise noted in the guidelines are improved body image and body composition. In the case of body image, many patients undergo extensive surgery or treatments that alter their physical appearance and their feelings about sexual attractiveness. According to the panel, there is good evidence that physical activity can improve body image and thereby quality of life. Body composition changes are also very common in patients. Some cancers such as gastrointestinal cancers are associated with muscle wasting; in this group, exercises can help build lean muscle. In other cancers, such as breast cancer, systemic treatments can lead to weight gain; in these patients, exercise can be used to control body weight and maintaining a healthy body mass index.

The guidelines noted the numerous issues that need to be addressed before physical activity becomes fully integrated into cancer treatments, including insurance coverage for exercise training and expanding the ranks of fitness professionals who understand the issues and needs faced by patients with cancer and survivors.

Several initiatives are under way to expand the supply of fitness professionals with cancer-specific training. ACSM and the American Cancer Society have a certification program for trainers who want to work with patients and survivors. In addition, the Lance Armstrong Foundation has partnered with the YMCA to help train fitness staff at YMCAs across the country to meet the needs of cancer survivors.

• Schmitz, L.H., Courneya, K.S., Matthews, C., Demark-Wahnefried, W., Galvao, D.A., Pinto, B.M, . . . Schwartz, A.L. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise, 42, 1409–1426.
• U.S. Department of Health and Human Services. (2009). 2008 physical activity guidelines for Americans. Retrieved from http://www.health.gov/paguidelines