RE:Connect

What Next?

I can not believe I am finally finished with school. It is a really weird feeling to have worked on a goal for so long and then to have actually completed that goal. I was talking with my mother yesterday and I had the thought that I have been in school for two decades, pretty much my whole life!

So, what does a person do after they have actually fulfilled their dreams and goals? I guess you are to strive for the next big thing in life. For me, the next big thing is passing the NCLEX. That is pretty scary in itself. The NCLEX is like the breaking point. So many thoughts are running through my head!!! Did I actually learn everything I needed to in nursing school to prepare me for this scary test? Did I do enough review questions? Will I make a great nurse? Will I be that 1% in my graduating class that has to repeat the test? Even though I have all of these very common anxieties, I have to have faith and confidence in my abilities that I will be a great nurse and I will pass the test! I will have 6 hours for a little computer to test my abilities. I could have the minimum of 75 questions or the maximum of 250 questions.

So, for those of you who have taken the NLCEX and lived to tell about it, what did you think of the test? For those of you who took the NLCEX a very long time ago, how has the NLCEX evolved throughout the years? And, any helpful hints to prepare for the test?

Chemo Spill Simulation

Hello again to all!

While we are discussing safe handling, I will bring up another related topic - spills.

I am an ONS Chemotherapy/Biotherapy trainer and always discuss chemo spills during the course.  I usually have one of the box kits with me and allow the class to pass it around and look at the contents. 

As you all know, the course does not designate a nurse as "chemo-competent", as each organization is responsible for establishing criteria for competency.  I am employed by an organization that is CoC accredited.  With this accreditation comes the requirement that competency will be assessed on an annual basis.  We complete an annual "competency renewal session" that is mandatory for all nurses who desire to remain chemo-competent.  I usually go over new FDA indications, new or updated policies/procedures, and offer webcasts or other interactive programs related to chemotherapy.  One year, our interactive activity was the Chemotherapy board game sold by ONS.  It was a hit!  Well, to get back to my post topic, I offered a different activity this year.

I did not include a webcast for the renewal sessions this year.  Instead, the chemo nurses participated in a simulation in which they had to manage the care of a chemo-naive AML patient - from identification of appropriate education topics/level to completion of the chemo flowsheet and identification of missing/inappropriate orders.  We ended the simulation with a chemo spill.  Control of the spill varied as the scenario progression was dependent upon whether or not the patient & family were instructed on "what to do if the IV leaks".  For example, I asked some of the nurses on the team to portray the part of helpful family members who decided to help the "busy" nurses by cleaning the spill themselves.  We managed the patient in teams, ideally the teams were comprised of the nurses who worked together routinely.  Each "team" was required to open and use the spill kit appropriately on an actual "chemo" (normal saline) spill.  

The nurses appreciated the opportunity to practice this procedure before an actual occurence.  Many said that the spill-handling was the most beneficial aspect of the simulation. 

Although we had discussed the procedure many times, there is no replacement for experience.  Many adults are tactile learners and I realized after the sessions that this was something that I should have made available to them long ago. 

Chemo Gowns: To wear or not to wear?

     After reading Kimberly's previous posts about chemo gloves I decided to write about a safe handling issue I am experiencing at my own institution........

     In August 2008 the ONS Connect cover story was titled Safe Handling of Chemotherapy: Developing and Implementing Institutional Guidelines.  For a long time my institution had planned to mandate that gowns be worn when handling or disposing of chemotherapy.  In July 2008 we began to educate the staff about the change which included the OSHA and ONS guidelines and the added protection that a gown would provide to the RN.  A group of nurses from each chemotherapy area collaborated to select the gown that would be worn.  In November 2008 we implemented wearing chemo gowns.

     I have to be honest and say that the gowns have not been a hit with the nurses.  Some of the negative feedback we’ve heard about the gowns are that they’re too hot, constricting, small, and cumbersome.  Some nurses have even asked to opt out of wearing the gowns, needless to say we have not allowed this.  One stated to me that she was finished having kids so she wouldn’t need the protection for fertility reasons.  Clearly there is a knowledge deficit here but still a very interesting thought.   There has also been some positive feedback about the gowns.  During the education many nurses said that any additional measures taken to protect them would be greatly appreciated.

    At the end of the day the nurses are not 100% compliant with wearing the gowns.  So I guess my questions to you all are:

Are the RN’s at your institution required to wear gowns? If so, how compliant are they?

What have you done (past/present) to encourage the nurses to wear gowns?

Lastly, if you’re a chemo RN please provide me with your own feedback (positive/negative) related to your gown usage (or lack thereof).

Happy Holidays!!!!!
j :-)

The Nurse Pinning Ceremony

This past week has been surreal. For the past past 5 years, I have focused on finishing school in order to become a nurse. My mother and I joke around that I am on the "road to success." This past weekend I finally reached the end of that road and to tell you the truth, it's just plain weird. I don't quite know what to do with myself! On Thursday night, in front of my closest friends and family members, my mother had the opportunity to pin me. The nurse pinning ceremony dates back to the times of Florence Nightengale. The ceremony is given for graduating nursing students, family and friends and is a symbol of welcoming graduate nurses into the professional nursing world. The nursing pin was once proudly worn by all registered nurses on their crisp, white uniforms. Today, it is rare to see nurses wearing their nursing school pins, but nonetheless, the pinning ceremony remains close to their hearts. I am sure that each nursing schools' pinning ceremony is slightly different, but Belmont University's ceremony ended with the lighting of candles and each nursing student reading the nurses pledge in front of our friends and family. It was an honor to stand in front of my family pledging to take care of each patient with dignity and to uphold the highest standards of practice. I would like to hear from you all what you remember of your nursing schools pinning ceremony. Did anyone special have the opportunity to pin you and what does the nursing pledge mean to you?

A Happy Year for Hematological Disorders: An Overview of Hem/SCT Treatments FDA-approved in 2008 (PART 2)

In my previous post, I mentioned that the FDA approved a total of 6 new treatments for Hematologic disorders in 2008. In PART 1 of this post, I discussed Nplate™ and Promacta® for chronic idiopathic thrombocytopenic purpura (ITP) and Mozobil™ to facilitate more reliable peripheral blood stem cell collection.

Also in 2008, the FDA approved TREANDA® (bendamustine) both for the treatment of chronic lymphocytic leukemia (CLL) and later in the year for the treatment of B-cell non-Hodgkin’s lymphoma (NHL). Specifically, TREANDA®’s NHL indication is for patients with indolent B-Cell NHL who have progressed within <6 months of receiving rituximab.  In a single-arm study that evaluated the use of TREANDA® for the treatment of indolent B-cell NHL, the overall response rate (ORR) was 74% with a 9 month duration of response.  In a study of over 300 CLL patients, half the group received TREANDA® and the other half received chlorambucil. The ORR for the TREANDA® arm was 59% vs. 26% for chlorambucil arm. 

Ontak®( denileukin diftitox) received accelerated FDA approval in 1999 and regular FDA approval in October for the treatment of  persistent or recurrent CD-25+ cutaneous T-cell Lymphoma. A three-arm study compared treatment response of patients on Ontak (at 18mcg/kg/dose or 9mcg/kg/dose vs. placebo). In the two-treatment arms Ontak the higher dose the ORR was 46% and in the lower dose treatment arm, the ORR was 37%. Also this year, Velcade® (bortezomib) which was originially FDA approved for the treatment of refractory Multiple Myeloma (MM) was approved in June as an initial treatment for patients with symptomatic MM.

If you would like additional information on FDA approvals and other cancer drug press releases, please visit http://www.ons.org/news.shtml. If would like to receive FDA approval notices from ONS via email, you may edit your email preferences by logging into your profile at https://profile.ons.org and then selecting "Preferences."

A Happy Year for Hematological Disorders: An Overview of Hem/SCT Treatments FDA-approved in 2008

This has been an exciting year for Hematological Malignancies and stem cell transplant with the introduction of over 7 newly FDA-approved treatments during 2008. I will discuss three of these today and plan to discuss the other 4 treatments later this week.

In 2008, FDA approved two different drugs the treatment of chronic immune (idiopathic) thrombocytopenic purpura (ITP) for patients who have had poor responses to corticosteroids, immunoglobulins, or splenectomy. Nplate™ (romiplostim), manufactured by Amgen, is administered by weekly SQ injection and was approved in August. Promacta® (eltrombopag) which is administered daily by mouth is manufactured by GlaxoSmithKline, Inc. and was approved in late November. Both drugs act as thrombopoietin (TPO) receptor agonists which stimulate bone marrow megakaryocytes to produce platelets. Because of the risk for overstimulation of the megakaryocytes in the marrow, there is a risk for bone marrow reticulin formation. Other risks include worsened thrombocytopenia (compared to baseline) following discontinuation of therapy or thromboses due to excessive platelet increases.

This past week, Mozobil™ (plerixafor) was FDA approved for use in combination with GCSF (Neupogen®) to mobilize peripheral blood hematopoietic stem cells (PBHSC) prior to autologous transplantation. Mozobil™ is administered by SQ injection on the same days as GCSF injections. In a study of 298 Non-Hodgkin Lymphoma patients, 59% of patients who received Mozobil™+GCSF collected >5 million stem cells in <4 apheresis sessions compared to only 20% of patients who were mobilized using GCSF alone. In a study of 302 Multiple Myeloma patients, 72% of patients who were mobilized with Mozobil™+GCSF collected >6 million or more stem cells in <2 apheresis sessions compared to only 34% of patients who were mobilized using GCSF alone.

Chemo Glove Follow-up

Hi again everyone!!

I posted a question in an earlier blog about how chemo gloves are selected at your facilities.  Thanks for the comments!  I mentioned this topic because my organization received notice from the manufacturer of our gloves that the production process was changing and that the gloves would no longer be safe for use with many of the chemo agents we administer.  FYI:  Gloves can receive a chemo rating by completing testing on select chemo agents; however, many chemo agents are not tested at all.  I am continuing to research our options and our nurses are comparing products now - I've given them a form to document their subjective opinions about each glove, i.e. strength; puncture resistance; fit; comfort; elasticity, etc.

Stay tuned - more to come.......

   

Why Are You Where You Are Now?

When I was a child, my family moved frequently.  Such is the life of a military brat!  My sister Shannon and I always looked forward to our visits with extended family as these didn't happen very often.  My dad was one of nine children, so there are quite a few relatives out there who I probably don't even know today. 

My Aunt Betty can bake a pecan pie!  That's one of the things I remember about being at her home in Paris, Texas.  It was so delicious that my mom wanted to make pie just like her.  She didn't know that the pecans would "float" to the top of the pie when cooked, so she took great care in arranging all of the pecans on the top before she baked it.  When my mom told her about this, my Aunt Betty just giggled and said "Well sugar, you know they 'll float all by themselves?!"  I also remember that Shannon and I discovered an interesting contraption at her home one year.  Remember those "exercise machines" that had the belt you put around your waist and it shook you like crazy?  Well, Shannon and I played with that silly thing tirelessy!  We would get the giggles and couldn't stop laughing at how weird it was - it was so much fun for a kid!  One of the most important things I remember about my Aunt Betty was that she was a nurse and she worked with cancer patients.  I'm sure she was a GREAT nurse.  I thought that she had a gentle soul and a "touch" with people.  Although it is "frowned upon" now, I still have a hard time not referring to my patients as "honey" or "sugar" because my Aunt Betty called EVERYONE "sugar".  It is a term of endearment in the South - kind of like saying "sir" and "ma'am" or using first and middle names together, i.e. "Betty Jane" or "Kimberly Michelle".  It is heartfelt when I say "dear" or "honey" and not intended to be pretentious or insincere.  

My mom says I knew when I was 4 years old that I wanted to be a nurse.  When I was in nursing school, I began a job as a clinical assistant on the oncology unit at the local hospital; school in the daytime and CA on the night shift.  Isn't it amazing what we can do when our bodies are young?!  Ha!  After working on the unit, there was no turning back.  Just like you, I loved my patients!  I worked with incredible people on both shifts who mentored and supported me.  My path in life, inspired by my Aunt and further encouraged by wonderful nurses and co-workers, has been an adventure that I will never regret.

We all have a story about why we became a nurse and why we chose oncology as our specialty.  Who inspired you?  Why are you where you are now?

Translational Research

In the December edition of ONS Connect, Kristen Fessele wrote about the topic of translational research. "Translational research is the application of a discovery to practice", or the process of taking information from the laboratory (benchside) to the clinical setting (bedside) and back again. In our practice at CancerCare Manitoba we have a growing translational research program, and a tumor/tissue/blood bank that banks samples from the prostate, breast and CLL disease site groups. In the CLL clinical setting we have over 450 blood samples. Patients consent to have their blood samples banked at each visit and allow scientists and graduate/doctoral students to use their specimens to determine mutational status, FISH analysis and for the development of clinical trials. As the patient's condition changes and they develop symptoms, our researchers are able to compare and analyze blood samples at the molecular level to better understand the true nature of the disease.

Translational research can be confusing for patients and families to understand. Our clinic employs a translational research nurse who has the time to sit down and explain the process and the benefits to them. Consenting to participate means that patients must give extra blood samples every visit. This can be upwards of an extra 60mL of blood. Once patients understand that by simply donating some of their blood they are helping researchers and clinicians better understand how their cancer behaves, and perhaps develop new treatments and clinical trials, individuals are eager to participate. Participation in tumor/blood banking allows individuals to be involved in moving research forward and perhaps finding a cure for their disease. The next step is developing nursing research studies based on the scientific/medical information and implementing them in the clinical setting. 

"What will your colleagues say about you?"

    As a Nurse Manager I am responsible for hiring nurses to staff the Ambulatory Chemotherapy unit that I manage.  When interviewing, my favorite question to ask a candidate is “What are three things your colleagues would say about you?”  The question has been known to stump some candidates and produce a variety of confused facial expressions in others.  The answers provided are very enlightening.  You can tell a lot by how fast or slow a candidate responds, if they provide specific examples of things their colleagues have told them or use one word adjectives without elaborating.  Of course it’s possible that the candidate might not know or want to tell what their colleagues think about them, and just answer the question with what they think of themselves, or what they think I want to hear. Nevertheless, I still like to ask the question. After all, your colleagues are the ones that really know what kind of nurse you are.  They know if you’re a hard worker and care about your patients and their families, if you practice safely, if you possess good critical thinking skills and if you can communicate effectively. 

So I challenge you all to answer the question “What are three things my colleagues would say about me?”  Write me back with your responses.