the power of nursing interventions in holistic oncology...

The Power of Nursing Interventions in Holistic Oncology Treatment

1Oncology Nursing Society 41st Annual CongressApril 28–May 1, 2016

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Going Beyond Patient-Centered Care to What Matters Most

Feasibility Study with a GI Cancer Population an Ambulatory Infusion

Suite

Janet Bagley, MS, RN, AOCNS, NEA-BC

Director of Nursing, Dana Farber Cancer Institute

Patient & Family Centered Care

• How do we deliver on this promise?• Primary Nursing (Relationship-based Care)• The patient experience is new, foreign, and

often overwhelming. • We know patients are anxious and

vulnerable.• We are expert clinicians.• Are we connecting with the patient priorities?

Setting

• Yawkey 7 Infusion: MM & GI Cancers 22 RNs, 5-35yrs experience, average 20yrs 33 Chairs/Beds Open 7a-8p, M-F 90-100 treatment patients per day Multi-drug regimens, clinical trials

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Diagnostic Data

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1Q10 2Q10 3Q10 4Q10 1Q11 2Q11 3Q11 4Q11 1Q12 2Q12 3Q12 4Q12 1Q13 2Q13 3Q13 4Q13

Percen

tile

Press Ganey ScoresNurse concern for questions & worries

GI ALL Longwood

Diagnostic Data

4.6 4.8 4.8 4.8

1.0

2.0

3.0

4.0

5.0

Addressing what is Most Important Creating the Space to Voice YourConcerns

Treating You as a Unique Person Concerns were addressed

Low to

High

Question

GI Patient Survey

Diagnostic Data

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1

0 2 4 6 8 10 12 14

Did the RN sit? Y/N

Was the RN Multitaking? Y/N

Was the RN Interrupted? Y/N

Number

RN/Patient Interaction Observation(First 10 min)

N=15 observations

2 Oncology Nursing Society 41st Annual CongressApril 28–May 1, 2016

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Problem Statement

• Only 20% of the time we are addressing what is most important to the patient on a given infusion visit. The magnitude of a cancer diagnosis and

dependency a patient and family has on the health care team can create a dynamic where the patient feels overwhelmingly vulnerable. The team, focused on delivering the safest

expert care, can miss the issues and concerns that are most important to the patient.

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Process Map

Cause & Effect Diagram

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Assume we know!


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Baseline Data

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Nursing Assessment of What is Most Important to PatientsYawkey 7 Nurses- GI Infusion

(p-chart 3-sigma)

p-bar p-hat LCL UCL

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AIM Statement

• The Yawkey 7 nursing staff will address the most important need of the patient at each infusion appointment 60% of the time by June 18th, 2014.

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PDSA PlanDate of PDSA cycle

Description of intervention Results Action steps

5/2,3,4

Staff meeting with Nurse Director, 1 on 1 training with Staff co-leader.

RN will sit with their GI patient in the middle of the infusion and ask “What is most important to you today?” (In their own words)Prizes offered, Sponsor email, additional staff meeting, staff leader solicitation

Chart documentation went from 20% to 40%

Individual feedback via email, ad hoc conversations with both leaders to explore barriers.

5/26Poster , Magnet Survey, Cleveland clinic video sent with email encouragement.

Chart documentation compliance increased to 56%


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Materials Developed

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Change Data

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Nursing Assessment of What is Most Important to PatientsYawkey 7 Nurses- GI Infusion

(p-chart 3-sigma)

Mean Compliance Rate Lower Control Limit (LCL) Upper Control Limit (UCL)

1st PDSA

2ndPDSA

Change Data

15

0

1

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Monday Tuesday Wednesday Thursday Friday

Number of Nurses doing the intervention (asking

and documenting conversation in the charts >

1/3 of the patients)

How is the team doing? Who is trying?Yawkey 7 Nurses (Average N=13/ day)

GI patients

Baseline Week Week 1‐ Intervention 5/12‐16 Week 2‐ Intervention 5/19‐23


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Conclusions

• Yawkey 7 infusion nurses were successful in specifically assessing, addressing, and documenting what was most important to 56% of their patients with GI cancer on a single visit.

Lessons Learned• Consistently asking patients “What Matters

Most?” was feasible in a busy infusion clinic.• The intervention was acceptable to staff as 100%

of nurses engaged on more than 3 occasions.• The intervention does not take more time in most

cases.• Behavior change takes time and support.

This new communication approach was awkward and uncomfortable at times.

• The intervention elicited patient concerns that otherwise would not have been voiced!

• Anecdotal evidence that RN satisfaction may improve with confirmation of patient care impact.(Will repeat Survey)

Next Steps/Plan for SustainabilityThings to consider

Hard Coding & Expansion Elicit more stories of the patient vulnerability to engage nurses’ hearts.

Team training with additional staff & patients to discuss vulnerability as a human experience.

Compile resource guide with social services to support interventions as pt topics arise.

Develop cognitive behavioral training to help staff over come barriers to challenging conversations.

System based changes Continue to display run chart & quotes. Present findings at Nursing Quality, Nursing Council. Engage nurse leaders and staff from other units.

Measurement & reporting Create weekly chart audit with continual feedback to nurses.

People Engage Y7 staff, patients, and nursing leadership.


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Thank You Team Members

Project Leaders: Katie Murphy, BSN, RN, OCN; Belen Fraile MD, MHA

Y7 Team Members:Shannon Boyle, BSN, RN, OCNMaura Ferguson, BSN, RN, OCNMary Maloney, RNElena Tansy, BSN, RN, OCNMellanee Taylor, MAPN, PatientEntire Y7 Nursing StaffCoach: Carole Dalby, RN, MBA, OCN, CCRPProject Sponsor: Anne Gross, PhD, RN, NEA-BC, FAAN


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Hands in Harmony: Implementation of a Nurse Delivered Hand Massage Program in an Outpatient

Chemotherapy Infusion Suite

Caitlin Braithwaite BAN, RN, OCN

Deborah Ringdahl DNP, RN, CNM

Geri Quinn MSN, RN, OCN

Purpose

• The purpose of this project was to incorporate positive and therapeutic touch in the form of a nurse delivered hand massage at an academic NCI designated chemotherapy suite in order to strengthen the nurse patient relationship and improve patient comfort, relaxation, experience, satisfaction, and reduce stress and anxiety.

Setting

• NCI designated outpatient chemotherapy infusion suite

• 32 chairs and 8 beds for infusions• Average of 92 infusions daily• At the time of implementation no

integrative therapies were considered standard of care

• Paclitaxel and docetaxel require nurses to sit at the chairside for the first 15 minutes of the 1st and 2nd

infusion


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Background• Research to support intentional touch in the form of a hand massage

(HM) as a nursing intervention– Utilized in a variety of settings

• Ambulatory surgery: 5 minutes of HM resulted in a decrease in anxiety, blood pressure, heart rate, epinephrine, and norepinephrine, and cortisol (Brand, Monroe, & Gavin, 2013; Kim, Cho, Woo, & Kim, 2000)

• Inpatient: Patient improvement in perception of pain. Nurses experienced an increase in pride and perceived level of care (Thompson, Wilson, James, Symbal, and Izumi, 2013)

• Hospice: Individuals on hospice that received a hand massage twice weekly for three weeks had increased comfort compared to those that didn’t (Kolcaba, Dowd, Steiner, & Mitzel, 2004)

• Overall HM has been shown to improve patient anxiety, stress, comfort, pain, and experience

• Found to be safe, effective, and efficient with positive patient and nurse outcomes

• Contraindications include deep vein thrombosis, intravenous access, open wounds, rashes, lymphedema, or any pain or sensitivity in the arm or hand.

Project Design

• Two patient group design– Group A: Usual/baseline care

• Data collected July 2015-September 2015

– Group B: Evidence based practice post implementation group: Received hand massage

• Data collected September-December 2015

• Staff nurses taught hand massage– 1 hour class for CEU credit during work time– One on one classes

• Utilized Iowa Model (Iowa Model‐Revised, in review)

Data Collection

Created for the purpose of this project and validated by two nurse scientists


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Ethical Considerations

• HSRD approval • Nursing Research & EBP Committee

approval• No patient identifiers used • Massage is within a nurse’s scope of

practice (Iowa Board of Nursing, 1998)

• No adverse events occurred during implementation

Patient Results• 69 patients in group A 43 patients in group B• Statistically significant improvement in patient comfort from group A

to group B• All patients either strongly agreed or agreed the hand massage was

beneficial to them and it has a positive impact on their experience

Results of Patient SurveysPre Post p‐valueMean Std Dev Mean Std Dev

Q1 I feel relaxed 3.4 0.7 3.6 0.6 0.099Q2 I feel comfortable 3.4 0.7 3.7 0.6 0.025

Q3

I have had a positive experience at the cancer center today 3.6 0.6 3.7 0.6 0.289

Q4 I feel stressed 2.0 0.9 1.7 0.7 0.185

Q5

The hand massage had a positive impact on my experience 3.8 0.4

Q6

I feel the hand massage was beneficial to me 3.8 0.6

VAS 2.2 2.3 2.3 2.0 0.861

Patient Results • Patient Themes

– Ease with talking to the nurse– Helped them relax and feel more at ease– Took their mind off of their chemotherapy

• Patient Quotes:– “I was apprehensive about the entire experience and [the

hand massage] helped” - Male patient in early 70’s– “[The hand massage] took my mind off chemo” -Male

patient late 40’s – “Promotes comfort and wellbeing. Massage is true to the

essence of nursing. The hand massage made me feel like someone cared about me” -Female patient late 50’s


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Nurse Results• 21 nurses filled out the pre intervention survey and 18

filled out the post program implementation survey• 15 nurses administered a hand massage

Results of Nurse SurveysPre Post p‐value

Mean Std Dev Mean Std Dev21 18

Q1 A hand massage program would be beneficial to patients 2.9 0.9 3.7 0.5 0.002

Q2The hand massage program would have a positive impact on patient anxiety 2.9 0.9 3.6 0.5 0.002

Q3I feel well prepared to administer an effective hand massage 2.2 0.7 3.5 0.7 0.001

Q4 I feel well prepared to administer a safe hand massage 2.2 0.7 3.6 0.7 0.001

Q6 A hand massage program would be improve my nursing practice 2.6 0.9 3.2 0.8 0.031

Nurse Quotes– “Providing a hand massage was the most

relaxing part of my day”– “Giving a hand massage allowed me to connect

with my patient in a deeper way– “Such an easy way for me to help my patients

relax without medication!”– “It was so much easier than I thought it would

be!”

Summary• Hand massage should be integrated into patient care

as part of a nurse’s essential job functions. • It is efficient, safe, and effective for patient’s across all

healthcare settings• Providing a hand massage is part of the core value of

patient centered nursing care. • It is an effective non-verbal way for the nurse to

communicate compassion, empathy, and concern while reconnecting to mindfulness and presence

• Nurses that provide hand massage experience greater job satisfaction, connection to their patients, and feel an increased pride in their nursing work


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Thank You!

Contact Information: Caitlin BraithwaiteEmail: [email protected]

ReferencesBrand, L., Munroe, D., & Gavin, J. (2013). The effect of hand massage on preoperative anxiety in ambulatory surgery patients.

Association of periOperative Registered Nurses Journal, 97(6), 708-717. doi:10.1016/j.aorn.2013.04.003

Cassileth, B. R., & Vickers, A. J. (2004). Massage therapy for symptom control: Outcome study at a major cancer center. Journal of

Pain and Symptom Management, 28(3), 244-249. doi:10.1016/j.jpainsymman.2003.12.016

Cino, K. (2014). Aromatherapy hand massage for older adults with chronic pain living in long-term care. Journal of Holistic Nursing,

32(4), 314-315. doi:10.1177/0898010114557800

Connor, A., & Howett, M. (2009). A conceptual model of intentional comfort touch. Journal of Holistic Nursing, 27(2), 127-135.

doi:10.1177/0898010109333337

Greenlee, H., Balneaves, L., Carlson, L., Cohen, M., Deng, G., Hershman, D., . . . Tripathy, D. (2014). Clinical practice guidelines

on the use of integrative therapies as supportive care in patients treated for breast cancer. Journal of the National Cancer

Institute Monographs, 50, 346-358. doi:10.1093/jncimonographs/lgu041Grunfeld, E., Zitzelsberger, L., Coristine, M.,

Whelan, T. J., Aspelund, F., & Evans, W. K. (2004). Job stress and job satisfaction of cancer care workers. Psycho-

Oncology, 14(1), 61-69. doi:10.1002/pon.820

Iowa Board of Nursing. (1998). Iowa Board of Nursing. Retrieved from

http://www.state.ia.us/government/nursing/nursing_practice/massage_therapy.html

Karagozoglu, S., & Kavhe, E. (2013). Effects of back massage on chemotherapy-related fatigue and anxiety: Supportive care and

therapeutic touch in cancer nursing. Applied Nursing Research, 26(4), 210-217. doi:doi:10.1016/j.apnr.2013.07.002

Kim, M., Cho, K., Woo, K., & Kim, J. (2001). Effects of hand massage on anxiety in cataract surgery using local anesthesia. Journal

of Cataract & Refractive Surgery, 27(6), 884–890. doi:10.1016/S0886-3350(00)00730-6

Kolcaba, K., Schirm, V., & Steiner, R. (2006). Effects of hand massage on comfort of nursing home residents. Geriatric Nursing,

27(2), 85-91. doi:10.1016/j.gerinurse.2006.02.006

Kolcaba, K., Dowd, T., Steiner, R., & Mitzel, A. (2004). Efficacy of hand massage for enhancing the comfort of hospice patients.

Journal of Hospice & Palliative Nursing, 6(2), 91-102. doi:10.1097/00129191-200404000-00012

Leonard, K., & Kalman, M. (2015). The meaning of touch to patients undergoing chemotherapy. Oncology Nursing Forum, 42(5),

517-526. doi:10.1188/15.ONF.517-526

Nazari, R., Ahmadzadeh, R., Mohammadi, S., & Kiasari, J. (2012). Effects of hand massage on anxiety in patients undergoing

ophthalmology surgery using local anesthesia. Journal of Caring Sciences, 1(3), 129-134. doi:10.5681/jcs.2012.019

Ruffin, P. (2010). A history of massage in nurse training school curricula (1860-1945). Journal of Holistic Nursing, 29(1), 61-67.

doi:10.1177/0898010110377355

Sheldon, L., Swanson, S., Dolce, A., Marsh, K., & Summers, J. (2008). Evidence-based interventions for anxiety. Clinical Journal of

Oncology Nursing, 12(5), 789-797. doi:10.1188/08.CJON.789-797

Thompson, A., Wilson, M., James, T., Symbal, J., & Izumi, S. (2013). Feasibility study to implement nurse-delivered massage for

pain management. Journal of Hospice & Palliative Nursing, 15(7), 403-409. doi:10.1097/njh.0b013e31829e0ed2

Westman, K., & Blaisdell, C. (2016). Many benefits, little risk: The use of massage in

nursing practice. American Journal of Nursing, 116(1), 1-7.


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Erasing Patient Anxiety and Increasing Nurse-Patient

Communication through Whiteboard Utilization in an Ambulatory Infusion

RoomAuthors:

Sheila Hunt, RN, CENAndrea Vranich, BSN, RN

Julie Pederson, BSW, RN, OCNJoni Watson, MBA, MSN, RN, OCN

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National Patient Safety Goals

Improve the effectiveness of communication

amongst caregivers

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Patient Comments

• “I like knowing where we are on the timeline.”• “The nurse and her whiteboard helped me

understand my medications!”• “A checklist seems to make the time go by

faster!”• “I like knowing the plan.”

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Here’s the Plan for the Day

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Win/Win!Patient Benefits

• Decrease anxiety• Explains what to expect• Improves perception of

length of stay• Reinforce chemo education• Medication side effects

review• Facilitates Speaking Up

Nurse Benefits

• Mechanism to engage patient• Prompt to explain actions• Orderly to do list• Helpful for handoff report• Way to show empathy• Decrease patient frustration• Increase patient satisfaction

The strongest predictor of overall HCAHPS/CGCAHPS scores is how patients rate

provider communication skills.

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Whiteboard Tips• Place it in clear view of the patient• Keep the pen near the board• Record name of nurse, date, and chair number• Keep the information concise• Med: name/order/estimated time/purpose • Encourage patients to write down their

questions

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Common Patient Response

“Nurse, where is that whiteboard that explains what we are doing today?

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I’ve got this!

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Sources:The Joint Commission News Release, August 4, 2010

Communication: The Key to Unlocking Patient Care Improvement,Michael Peters, MBA, CSSBB, CMC R.T(R)(T)[email protected]

HCAHPS and Communication: The Strongest PredictorSource: Bevis & Fulton, Press Ganey Whitepaper

Busy Nurse Spinning Plates, Felix Bennett www.felixbennett.com

[email protected]

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Spirituality Workshop for Those Touched by Cancer

Kathy Seymour, BSN, RN, OCN

Suzanne Barone, MA, RMTCarla Guess, BSN, RN, CBPN-IC, CBCNJessica Peckham, MSN, RN NP-C, OCN

Background

• Support group members asked the Oncology Nurse Navigators for classes on spirituality.

• Dearth of information in the Cancer Community

• Creation of a new project focused on the unique needs of cancer patients.

Purpose

• Studies show that 40% of oncology patients report a significant level of spiritual distress.

• Cancer patients with poor spiritual wellbeing are more likely to report hopelessness and desire hastened death.

(Puchalski, 2012)


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Process Improvement

• Nurse Navigators thought this would be a good project to address standard 3.1 for Commission on Cancer (CoC) accreditation.

Goal

• Cancer is a traumatic life event that causes significant distress leading to a potential disruption in spiritual wellbeing.

• We wanted to help patients cope with the usual upsets in life so they may heal and focus on the challenges of oncology treatment.

Creating the Program

• Nurses addressing the spiritual needs of patients in a nonreligious environment.

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FACIT SP-12

• FACIT SP-12 SurveyValidated tool used for assessing spirituality in those with a chronic illness such as cancer.

Results

• Overall spiritual wellbeing• FACIT SP-12 scores increased form 77%

to 85%• p value of 0.02

Intervention

• Presentation of first workshop and data.• Approval by the New Knowledge and

Innovation Committee as a Process Improvement Project.

• Approval by the Cancer Committee.


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The Workshop

• 4 week 90 minute workshop• Average 15 participants per week• Topics

– Spirituality and Love– Forgiveness: Self and Others– Meditation and Prayer– Self Awareness and Self Care

Comments by Participants

• “This was the best thing I could have done for myself.”

• “It was helpful to go through the workshop with others in a similar situation.”

• “Presenters were great and I loved the examples they shared.”

Comments by Participants (cont.)

• “I liked the interactive nature of the workshop. It allowed us to get to know each other.”

• “The class provided tools for me to further my spirituality.”

• “My needs are many and this opened up my mind to see how they can be met.”

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Discussion

• Success was not replicated• Marketing• Offer classes to nursing staff

References

• Puchalski, C.M. (June 2012). Spirituality in the cancer trajectory. Annals of Oncology,23(Suppl.3), 49-55.


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the power of nursing interventions in holistic oncology...

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