Partial Breast Irradiation: A Longitudinal Study of Symptoms and Quality of Life.

BACKGROUND: In many women with early-stage breast cancer, breast-conserving surgery (BCS) with partial breast irradiation (PBI) has similar overall survival and local recurrence rates compared to BCS with whole-breast irradiation (WBI). A better understanding of the quality of life (QOL) outcomes during and following BCS with PBI versus BCS with WBI is needed. OBJECTIVES: This study was conducted to examine symptoms, symptom distress, cosmesis, QOL, and perceived body image in women during and after BCS with PBI. METHODS: A convenience sample of 31 women completed self-reports pre- and post-PBI over six months. Descriptive statistics and repeated- measures analysis were performed at baseline and three times post-PBI. FINDINGS: Most women reported satisfaction with body image and good QOL, despite a small decline in social well-being. Fatigue and mild to moderate symptom distress persisted over time.

Chemotherapy Extravasation: Establishing a National Benchmark for Incidence Among Cancer Centers.

BACKGROUND: Given the high-risk nature and nurse sensitivity of chemotherapy infusion and extravasation prevention, as well as the absence of an industry benchmark, a group of nurses studied oncology-specific nursing-sensitive indicators. 
. OBJECTIVES: The purpose was to establish a benchmark for the incidence of chemotherapy extravasation with vesicants, irritants, and irritants with vesicant potential.
. METHODS: Infusions with actual or suspected extravasations of vesicant and irritant chemotherapies were evaluated. Extravasation events were reviewed by type of agent, occurrence by drug category, route of administration, level of harm, follow-up, and patient referrals to surgical consultation.
. FINDINGS: A total of 739,812 infusions were evaluated, with 673 extravasation events identified. Incidence for all extravasation events was 0.09%.

Self-Administered Premedication: Improving Taxane Chemotherapy Treatment
.

BACKGROUND: Patients receiving taxane therapy are at risk for hypersensitivity reactions without appropriate premedication management. Patients must understand the importance of taking premedications as prescribed to prevent reactions.
. OBJECTIVES: The objectives of this study were to implement and evaluate a multidisciplinary practice protocol comprised of standardized nursing documentation of premedication regimens, teaching, and patient adherence to at-home premedication in an electronic health record (EHR).
. METHODS: A new process was developed to provide standardized prescriptions, a personalized instruction sheet for patients and families, and a standardized approach to document adherence and teaching in the EHR. Pre- and post-EHR audits were used twice to evaluate the practice changes.
. FINDINGS: The findings of the first audit suggested improvement in all practice changes. After the first audit, reinforcement of the changes occurred within the group and with one-on-one meetings. The goal of 90% adherence was met at the second audit.

Assessment of Multiple Co-Occurring Cancer Symptoms in the Clinical Setting.

OBJECTIVES: To discuss multiple co-occurring cancer symptoms, review symptom assessment instruments, identify innovative methods to integrate symptom assessment and management in the clinical setting, and examine barriers and facilitators for implementation of symptom assessment and use of clinical practice guidelines. DATA SOURCES: Peer-reviewed articles, guidelines, systematic reviews, and web-based resources. CONCLUSION: Despite the availability of brief, reliable, and valid instruments, symptom assessment has not been integrated as a routine aspect of clinical care. New technologies and changes in health policy provide an optimal environment to integrate electronic symptom assessment and management into cancer care. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses play a key role in early identification and management of distressing symptoms.

Using Data to Strengthen Ambulatory Oncology Nursing Practice.

BACKGROUND: Efforts to measure quality of care do not capture the unique aspects of ambulatory oncology settings. To retain nurses, ensure a safe practice environment, and encourage behaviors that support high-quality care, there is a need to identify factors associated with job satisfaction and turnover with measures that reflect the ambulatory setting. OBJECTIVE: The objective of this study was to examine the patterns and correlates of the work environment for nurses and nurse practitioners working in a National Cancer Institute-designated Comprehensive Cancer Center. METHODS: Web-based questionnaires were disseminated to employees with a registered nurse license in ambulatory settings and related support services and included 3 affiliated satellite locations. Participants completed the Practice Environment Scale of the Nursing Work Index, revised for ambulatory oncology settings, the Safety Organizing Scale, and items to assess job satisfaction, perceived quality of care, and intention to leave their current position. Logistic and linear regression models were used to examine factors associated with these outcomes. RESULTS: From 403 individuals, 319 (79.2%) participated. The majority of respondents endorsed excellent quality of care (57.7%), job satisfaction (69.3%), and intention to stay in current position (77.4%). Endorsement of favorable collegial nurse-physician relationships was significantly associated with all 3 outcomes and increased performance of safety organizing behaviors. Nurses reported variations in practice environments and safety organizing behaviors across units. CONCLUSIONS: Work environment assessments are useful to retain experienced nurses and support the delivery of high-quality patient care. IMPLICATIONS FOR PRACTICE: Routine assessment of the work environment for registered nurses and advanced practice nurses is feasible and informative.

Evidence-based practice beliefs and implementation before and after an initiative to promote evidence-based nursing in an ambulatory oncology setting.

BACKGROUND: The purpose of evidence-based practice (EBP) in nursing is to improve patient outcomes, providing the best and most up-to-date care practices. In 2011, a nurse-led committee convened to develop an institute-wide initiative to promote EBP with oncology nurses at the Dana-Farber Cancer Institute. AIMS: Compare and describe oncology nurse beliefs and perceived implementation of EBP and explore beliefs and implementation before and after implementing an institutional EBP initiative. METHODS: Based on the Advancing Research and Clinical practice through close Collaboration (ARCC) Model, the Evidence-Based Practice Beliefs (EBP-B) and Implementation (EBP-I) scales were distributed to all Dana-Farber Cancer Institute registered and advanced practice nurses through an online survey in 2011 (T1) and again in 2013 (T2) after the implementation of an institute-wide nursing EBP initiative (orientation, poster presentations, education). Descriptive and correlation statistics were completed on total scores and demographics. Differences in beliefs and implementation scores based on demographics were analyzed with Mann-Whitney U tests. Open-ended item responses at each time point (T) were summarized for EBP barriers and promoters. FINDINGS: Thirty-two percent (n = 112 at T1; n = 113 at T2) of 350 nurses began the survey. A history of formal EBP education and nurse role were associated with higher EBP-B and EBP-I scores (p < .05). Highest level of education was significantly correlated with both EBP-B (r = .25; p = .03) and EBP-I (r = .32; p = .01). Narrative responses to open-ended questions described perceived personal and environmental barriers to engaging in EBP. LINKING EVIDENCE TO ACTION: Although no significant differences were noted in beliefs and implementation after the EBP initiative, nurses reported valuing EBP. Respondents acknowledged a lack of full preparation in the EBP process to engage in and implement EBP consistently. Nurse role, formal EBP education, and highest level of education were associated with perceptions of EBP beliefs and implementation. Nurses should be provided the mentorship and support to obtain continuing education about how to engage in EBP and about implementing EBP change.

Symptom-related emergency department visits and hospital admissions during ambulatory cancer treatment.

BACKGROUND: People with cancer experience symptoms related to the disease and treatments. Symptom distress has a negative impact on quality of life (QoL). Attending to symptoms and side effects of treatment promotes safe and effective delivery of therapies and may prevent or reduce emergency department visits (EDVs) and unplanned hospital admissions (HAs). There is limited evidence examining symptom-related EDVs or HAs (sx-EDV/HAs) and interventions in ambulatory oncology patients. OBJECTIVE: To examine factors associated with sx-EDV/HAs in ambulatory oncology patients receiving chemotherapy and/or radiation. METHODS: This secondary analysis used data from a randomized controlled trial of ambulatory oncology patients (n = 663) who received the web-based Electronic Self-Report Assessment ­ Cancer intervention (symptom self-monitoring, tailored education, and communication coaching) or usual care with symptom self-monitoring alone. Group differences were described by summary statistics and compared by t test. Factors associated with the odds of at least 1 sx-EDV/HA were modeled using logistic regression. RESULTS: 98 patients had a total of 171 sx-EDV/HAs with no difference between groups. Higher odds of at least 1 sx-EDV/HA were associated with socioeconomic and clinical factors. The multivariable model indicated that work status, education level, treatment modality, and on-treatment Symptom Distress Scale-15 scores were signifcantly associated with having at least 1 sx-EDV/HA. LIMITATIONS: This is a secondary analysis not sized to determine cause and effect. The results have limited generalizability. CONCLUSION: Most patients did not experience a sx-EDV/HA. Demographic and clinical factors predicted a sx-EDV/HA.

Patient and clinician communication of self-reported insomnia during ambulatory cancer care clinic visits.

BACKGROUND: Insomnia, the most commonly reported sleep-wake disturbance in people with cancer, has an adverse effect on quality of life including emotional well-being, distress associated with other symptoms, daily functioning, relationships, and ability to work. OBJECTIVE: The aim of this study was to describe the content of discussions between clinicians and 120 patients with self-reported insomnia and to examine the associations of sociodemographic, clinical, and environmental factors with insomnia. METHODS: A secondary analysis was conducted with self-reported symptom data and sociodemographic, clinical, and environmental factors. Recordings of clinician and patient discussions during clinic visits were examined by conducting a content analysis. RESULTS: Severe insomnia was more likely to be reported by women, minority, and lower-income individuals. Seven major topics were identified in the discussions. The clinicians did not always discuss insomnia; discussion rates differed by diagnosis and clinical service. CONCLUSIONS: Reporting of insomnia by the patient and clinician communication about insomnia may have differed by demographic and clinical characteristics. Clinicians attended to insomnia about half the time with management strategies likely to be effective. Explanations may be that insomnia had a low clinician priority for the clinic visit or lack of clear evidence to support insomnia interventions. IMPLICATIONS FOR PRACTICE: A better understanding is needed about why insomnia is not addressed even when reported by patients; it is well known that structured assessments and early interventions can improve quality of life. Research is warranted to better understand potential disparities in cancer care.

Fatigue, pain, and functional status during outpatient chemotherapy.

PURPOSE/OBJECTIVES: To examine the relationship of fatigue and pain with functional status and the pattern of the two symptoms' occurrence over time in individuals with cancer who were receiving outpatient chemotherapy. The aims were to describe the levels of fatigue and pain with functional status and the inter-relationships with each other and with demographic and clinical variables over time. DESIGN: Descriptive, correlational. SETTING: Outpatient chemotherapy clinic in the New England region of the United States. SAMPLE: Total available population of 70 consecutive adult patients with breast cancer (n = 9), colorectal cancer (n = 21), lung cancer (n = 21), or lymphoma (n = 19). METHODS: Retrospective data were extracted from the medical records; descriptive, correlational, and mixed-modeling methods were used to describe the sample and to examine the relationships of the symptoms and functional status. MAIN RESEARCH VARIABLES: Fatigue, pain, functional status, and demographic and clinical factors. FINDINGS: Fatigue was the most frequently reported symptom; pain was rarely and almost exclusively reported by patients with lung cancer or lymphoma during their early treatments. Fatigue and functional status impairment were highly associated with each other and had similar relationships with the other variables. CONCLUSIONS: The patterns and relationships of fatigue and functional status reported by this fairly healthy sample provide useful information to help guide early assessments and nursing interventions for people receiving outpatient chemotherapy. IMPLICATIONS FOR NURSING: The patterns and severity of symptoms and functional status impairment in people with colorectal cancer or lymphoma warrant further investigation. Targeted exercise interventions for specific outpatient populations should be developed and tested to address specific patterns of symptoms and functional status impairment in individuals with cancer.

Patterns of symptoms in women after gynecologic surgery.

PURPOSE/OBJECTIVES: To explore patterns of symptoms over time and the relationships between selected demographic and clinical characteristics. DESIGN: Secondary analysis of longitudinal data. SETTING: A hospital and comprehensive cancer center in the northeastern United States. SAMPLE: 66 women with gynecologic cancers, postsurgical, and scheduled to receive chemotherapy. METHODS: A secondary analysis using descriptive and general estimating equation statistical procedures was conducted on symptom and disease data in a subset of a larger nursing intervention study. MAIN RESEARCH VARIABLES: Demographic and clinical variables including cancer site, new diagnosis or recurrence, stage, treatment, comorbidities, emotional distress, use of a symptom management tool kit, and 10 symptoms over time. FINDINGS: Two patterns of symptoms were identified. The first pattern (pain, bowel dysfunction, disturbed sleep, depression, nausea, and lack of appetite) decreased, and the second pattern (fatigue, anxiety, hair loss, and numbness) remained constant over time. The total number of symptoms decreased over time. Factors associated with symptoms, such as the use of a tool kit and emotional distress, were identified. CONCLUSIONS: Tool kit use by women who experienced fatigue, bowel dysfunction, and anxiety suggests its usefulness as a self-care guide. Explanations for the two patterns of symptoms are discussed. IMPLICATIONS FOR NURSING: Postsurgical management should include management and monitoring of symptoms associated with treatment. Screening for emotional distress is recommended in this population. Use of the tool kit could be an effective postsurgical management strategy for women with gynecologic cancers.

Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers.

OBJECTIVE: Women with gynecological cancers have reported poor health-related quality of life (QOL), with complex physical and psychological needs post-surgery and during chemotherapy treatment. There are no studies reporting interventions addressing these needs post-hospital discharge in this population. METHODS: Patients were randomized into two groups. The intervention group received 6 months of specialized care by an Advanced Practice Nurse (APN); in addition, women with high distress were evaluated and monitored by a psychiatric consultation-liaison nurse (PCLN). The attention control group was assisted with symptom management by a research assistant. The effects of the 6-month intervention were evaluated using self-report questionnaires at baseline (24-48 h after surgery), 1, 3, and 6 months post- surgery. QOL assessments included the Center for Epidemiological Studies-Depression Scale , the ambiguity subscale of the Mishel Uncertainty in Illness Scale , the Symptom Distress Scale, and the Short-Form Health Survey (SF-12). The sample for the longitudinal analysis included 123 who completed QOL outcome measures across three occasions post-surgery. RESULTS: The APN intervention resulted in significantly less uncertainty than the attention control intervention 6 months after surgery. When the sub-group who received the APN plus PCLN intervention was compared with the total attention control group, the sub-group had significantly less uncertainty, less symptom distress, and better SF-12 mental and physical QOL over time. CONCLUSION: Nurse tailored interventions that target both physical and psychological aspects of QOL in women recovering from cancer surgery and undergoing chemotherapy produce stronger outcomes than interventions that target solely one QOL aspect.

The caregiving experience in a racially diverse sample of cancer family caregivers.

The literature supports a variety of predictor variables to account for the psychological and stress burden experienced by cancer family caregivers. Missing among the predictor variables are the differences by or influence of race/ethnicity. The purpose of this study was to describe the sample, explore differences in outcomes by patient and family caregiver characteristics, and determine if any of the patient and family characteristics, including race/ethnicity, predicted outcomes. Cross-sectional surveys were used to determine sociodemographics, psychological and physical health, and burdens of caregiving among 54 caregivers. The analysis consisted of descriptive methods, including frequencies and t tests, and regression modeling. The sample was 35% African American or Hispanic. African American and Hispanic caregivers were younger than white caregivers and more often women, were rarely the spouse of the patient, and frequently had other dependents, including children and older parents. African American and Hispanic caregivers reported lower incomes and more burden related to finances and employment than did white caregivers. When controlling for sociodemographic factors, there was no difference by race/ethnicity on the outcome measures. The experience of caregiving may supersede race/ethnicity and may be its own cultural entity. Areas of concern include the interrelationship between socioeconomic status and race/ethnicity, the absence of cultural frameworks to direct caregiver research, and the question of cultural relevance of measurement tools.

Effects of advanced practice nursing on patient and spouse depressive symptoms, sexual function, and marital interaction after radical prostatectomy.

A secondary analysis of a prospective randomized clinical trial with repeated measures was conducted to examine the effects of a standardized nursing intervention on patient and spouse depressive symptoms, sexual function, and marital interaction. Another purpose of this study was to determine if, over time, differences existed in men and their spouses' levels of depressive symptoms, sexual function, and marital interaction following radical prostatectomy. Spouses reported significantly higher levels of depressive symptoms and significantly more marital interaction distress compared to patients. Patients reported significantly more distress pertaining to sexual function than their spouses.

Concept analysis of comfort.

TOPIC: The concept of comfort, although used frequently and throughout the nursing literature, has not been clearly or consistently defined. PURPOSE: To clarify the meaning of comfort by employing the systematic approach of an evolutionary concept-analysis method. SOURCES: Books, journals, professional organization position statements, electronic searches. CONCLUSIONS: A clear definition and meaning of comfort is needed, and thus the ability to use this concept empirically in order to further nursing knowledge development.