Tips for Learning Chemotherapy Administration

I attended a chemotherapy and biotherapy course. Most of the nurses attending had administered chemotherapy for years, but a group of nurses new to oncology sat at the far end of the table. By the end of the first day of class, none of them had spoken a single word after the morning’s introductions.

photo by jparadisi

photo by jparadisi

Concerned, I approached the instructor. She had noticed their lack of participation too and told me these nurses had expressed feeling overwhelmed by the amount of knowledge needed to safely administer chemotherapy.

I can relate. I recall, years ago as a pediatric ICU nurse, admitting a patient in anticipation of tumor lysis syndrome (TLS). Although chemotherapy certified nurses administered the chemo, I was responsible for the patient’s well-being in the ICU. I asked a lot of questions, probably too many. Weary of me, the oncology nurse coordinator remarked, “You worry too much. It’s just chemo.”

Somewhere between this coordinator’s cavalier attitude and the paralyzing fear of a nurse unfamiliar with oncology is the middle ground for teaching chemotherapy and biotherapy administration. Here are some suggestions:

Fear is the nurse’s friend. Fear makes you look up medications and regimens you are unfamiliar with administering. It makes you ask a more experienced coworker for help. It makes you call the oncologist for clarification of orders when you are unsure, but don’t let it paralyze you. Fear is your friend. Embrace it.

Build on what you already know. Safe administration of all medications, including chemotherapy, is founded on the cornerstone of The Five Rights:

  • Right Patient
  • Right Medication: In oncology, this includes becoming familiar with the overarching chemotherapy regimen ordered.
  • Right Dose
  • Right Route
  • Right Time

Right Now is what my husband, a hospital pharmacist, jokingly refers to as the “sixth right,” as in, “the doctor wants the chemotherapy given right now.” While promptness is a virtue, chemotherapy administration is similar to teaching a small child to safely cross a street: “Green means go when safe.” Don’t give the chemo until all the double checks are completed to satisfaction.

Teach evidence-based practice, not your old war stories. None of us older nurses are as entertaining to new nurses as we think we are. As a preceptor, keep your pearls of wisdom short and relevant to the teaching situation.
“Knowledge isn’t knowing everything but knowing where to find it,” said my ninth grade algebra teacher. Teach new oncology nurses the value of looking up medication administration information in your facilities’ policies and up-to-date references. Assuming the information provided by a coworker is reliable instead of looking it up yourself is unprofessional, and won’t hold up as your defense in a sentinel event review.
What helpful advice would you offer new oncology nurses?
What oncology references do you find particularly helpful?

How I Became a Nurse Part II: Gatekeepers

Gate Keepers by jparadisi 2011

“Jules, you need to quit wasting your talents working with Sister Sebastian up there on the Pediatric unit. I want you transfer to Pediatric Intensive Care so I can train you. You’re a natural,” said Roz, when we finished our shift.

Roz found a way for me to float to PICU at least once a week. Soon, I was caring for stable patients with her backup. It was complex work, and I had a lot to learn. I loved it. I wondered what it would take to become staff. Roz encouraged me to ask Barbara, who managed both pediatrics and the PICU.

Barbara worked her way into nursing administration first as a pediatric RN and then in PICU. She and Roz had worked side by side in both units before Barbara became manager. They were friends. Roz and I sat in her office, discussing my transfer.

“Roz can’t say enough good things about your nursing, Juli. I’m happy to hear you’re doing well and I’m grateful for your help in the PICU. I think you will make an excellent PICU nurse, however, I’m reluctant to transfer you there so soon after graduation. You’ve been a nurse for less than six months, and I’m afraid that getting in over your head is a real possibility. I will feel more comfortable with the idea after you gain more experience. I don’t mean to discourage you, but for now the answer is no. Let‘s talk about it again after you‘ve been here a year.”

I was already in over my head on the pediatric unit, but I understood Barbara’s concerns. Since I floated so often, I knew it wouldn’t be long before she changed her mind. I decided not to push for the transfer at present.

What I didn’t count on was interference from Sister Sebastian. One evening I checked in on Peds before floating to PICU when once again she stopped me at the nurse’s desk.  “I see they scheduled you in the PICU tonight, however, it is not fair for them to have favorites. You cannot always be the nurse who goes down there. I am keeping you here tonight and I have sent Leah down to them instead. I have told Roz no.” Her wimpled face radiated with satisfaction as she spoke. She found pleasure in the self-assigned role of gate keeper. Her personal disappointments compelled her to block the way of others pursuing happiness. Now I know life is full of such people.

I wanted to argue with her that the other Peds nurses hated floating to PICU, but I knew it wouldn’t help. I took report on my assignment, realizing I was going to stay a Peds nurse for a very long time. During my break in the staff lounge, Roz called from PICU. “This isn’t the end of it,” she said.

Three days later, Barbara called me back to her office. Roz was already there, seated. Barbara started the conversation.

“Juli, Roz requests I transfer you to PICU. I have already explained my concerns. I still feel the same, but Roz has agreed that if I transfer you, she will take responsibility for your training in the PICU. She has committed to working the same schedule as you every shift for a year, to make sure that both you and your patients are safe. Do you still want to transfer?

I couldn’t believe Roz would commit herself like that for me. I agreed to the transfer, resolute that she would not regret her choice. Years later, after mentoring many new nurses myself, I fully understand Roz’s gift.  Her generosity is more overwhelming than the nursing unit she rescued me from. Life should be full of such people.

I thrived as a nurse in the PICU. I learned rapidly in the fast paced environment. Roz gave me a Pediatric Intensive Care Nursing textbook. I studied it at home and on breaks.

Roz was well respected by the PICU intensivist. Eventually, he trusted my nursing judgment nearly as much as hers. I was proud when he nicknamed us “The A Team.” I was going to stay in nursing after all.

Next week: How I Became a Nurse Part III

Whistle Blowers & Patient Advocates: When the Nurse Stands Alone

oil on unstreched canvas (detail) 2009 JParadisi

A colleague and I discussed the Winkler County Whistle Blowers case and our admiration for Registered Nurses Vicki Galle and Anne Mitchell. They brought the nurse’s role of patient safety advocate into the national spotlight.

My colleague is also a force to reckon with when it comes to patient advocacy. During our conversation she grew quiet and told me once, she had advocated for a patient without the support of her peers or administration.

The event occurred early in her nursing career, before she gained the skill and knowledge, which now empower her ability to act confidently as an advocate. In the end, she followed orders, even though they conflicted with her ethics. Decades later, she still regrets her choice.

I listened to her story, and tried to imagine her as a young nurse, uncertain and faced with a situation nursing school had not prepared her for. I imagined her alone and isolated, the only one in a nursing unit who felt, or more likely, spoke out loud the feeling that what was happening might not be best for the patient.

The Winkler County Whistle Blower case demonstrates that this kind of moral isolation still happens to nurses. However, it also demonstrates that nurses have developed resources for themselves and learned how to access them. These days, many hospitals have ethics committees and safety committees for reporting unsafe systems and behavior. Many hospitals have policies protecting nurses who refuse to administer treatments that conflict with their moral beliefs. Winkler County Memorial hospital fired Anne Mitchell and Vicki Galle when they used the hospital’s safety chain of command to protect patients, but the hospital and the doctor bringing charges against them found out this kind of punitive behavior is no longer tolerated by the court system or a majority of health care professionals. The Texas Nurses Association and the American Nurses Association said, “We are watching,” as did the Texas Medical Board. I’ve heard the conversations of doctors who ask why Dr. Arafile’s colleagues didn’t report his behavior. Why was the responsibility left to nurses? If any of these resources were available for my nurse colleague when she faced her dilemma decades ago, I would be surprised.

My heart breaks for that young nurse, facing an ethical dilemma alone and unsupported, with nowhere to turn. I told my colleague I hope she has forgiven that young, inexperienced, and frightened version of herself, with  her older, more experienced self’s compassion. I suggested that what she learned from that episode long ago has forged her into the warrior nurse advocate she is today, benefiting hundreds of patients during her long career as their advocate.

Advanced Precepting, Part II

In my last post, I promised to tell the story of another preceptee who didn’t remain in the PICU after orientation.

A new grad, this preceptee showed lots of promise. She was smart, detail oriented, and learned quickly. She was also independent. So independent, that fresh out of school, she would assess her patient, decide what was needed, and call the intensivist for orders without discussing anything with her preceptor first. Sometimes, she was right. Sometimes, she focused on a symptom without looking at the larger picture of the patient’s overall status. And that would lead to another phone call  to the intensivist, in which the preceptor had to explain why the previous order needed revision. You can imagine how well that went over, when it became a pattern. Her tendency to act without notifying her preceptor also precluded the opportunity to group questions for the intensivist, and asking the other nurses on the shift if they needed to call with questions too. In our unit, we worked effectively with the intensivists by grouping questions together as often as possible, facilitating work flow between medicine and nursing. In return, the physicians agreed not to call with new orders or questions during change of shift report, unless it was necessary. Suddenly, nursing wasn’t holding up its end of the bargain.

Because I was a mentor in our unit, my colleagues came to me with their complaints about this preceptee. Her behavior was interpreted as contrary to a team approach, and it was. I had trouble getting nurses to precept her. She was aware of the growing hostility of the other nurses towards her, and in turn, became withdrawn, acting out with more Lone Ranger behavior and creating a vicious circle for herself.  She tried, really she did, but it was difficult for her. She was intelligent and competent enough, but her inability to work with a team hindered her success.

The difference between  problems and  dilemmas is:  problems have a resolution; dilemmas are ongoing and unresolvable. I was beginning to think I had a dilemma on my hands.

I took over her orientation. Each shift I outlined what our goals were, and reinforced the expectation I be notified before every phone call to the intensivist. If I was in the bathroom, momentarily unavailable, and she thought there was an emergency, she was to notify the charge nurse first.  It was difficult for her, but she tried. Conversely, I included her in every discussion I had with the intensivist, explained the rationale for changes in the care plan, and took lunch breaks with her. I reinforced I respected her as a colleague and friend. She needed to trust me too. It didn’t take long before I saw improvement.

Shortly after that, she came to me requesting a letter of recommendation. She was applying for an advanced practice nursing program. Completing the program would give her a position of autonomy I believe suited her. I wrote the letter. She was accepted into the program. I don’t know what became of her, but I respect her for following her heart.