10 joyce neumann
Transcript of 10 joyce neumann
JOYCE NEUMANN, APN, PH.D.
Houston, USA• Clinical Nurse and Program Manager, Bone Marrow
Transplant Unit at The University of Texas MD
Anderson Cancer Center
• Major professional experience has been as advanced practice nurse
and manager of advanced practice nurses as Program Director in
Stem Cell Transplantation at a major US comprehensive cancer
center. Professional presentations on nursing, nursing ethics, SCT
nursing have been given nationally and internationally (Japan,
Saudi Arabia, Brazil, Korea, and Australia). Research and
publications focus has been on ethical issue in oncology care, SCT
patients’ quality of life and experience, patient treatment for
GVHD, and moral distress, compassion fatigue and burnout of SCT
care providers. Currently principle investigator on a protocol with
the National Marrow Donor Program examining the prevalence of
work-related distress, work-life balance and career satisfaction
among nurses, NP/PA, pharmacists, physicians, and social workers.
Dr. Kian Ang Memorial Lecture
Dr. Ang exceptional physician,
scholar, scientist, researcher,
mentor, supporter of
nurses/nursing
Nurses who worked with him
described him as “loved to teach”
“loved by patients” “empowered
nurses to do their best” “shared
vision – patient safety” “concerned
about what nurses thought”
Nurse’s role in the Interprofessional Team
Caring for the Hematologic Malignancy
Patient
Joyce Neumann PhD, APN, AOCN, BMTCN
Program Director, SCTCT
Roles of Nurse in Care of Hematological
Malignancies to Improve Patient Care
Clinical nurse - inpatient, outpatient
Research nurse – outpatient, inpatient
Nurse Researcher, faculty School of Nursing –
provide the evidence to improve symptom
management, quality of life
Advanced Practice Nurse - Clinical Nurse Specialist,
Nurse Practitioner, Clinical Nurse Leader
Nurse Administration – manager, director to improve
quality of care by providing resources for nurses to
provide “best care”
Traditional Role of the Oncology NurseDirect patient care -
Assessment, Plan, Intervene, Teach, Evaluate
“First line” of interaction with the patient
Patient Advocate – Ethical IssuesExamine Quality of Life Issues –
impact of the medical diagnosis Maintain standard of nursing careMember of nursing team(nurses on
unit, professional organization) and medical team (carries out orders to achieve the medical plan of care)
Advanced Practice Registered Nursing
(APRN) Nurse Practitioner – expanded scope of practice allow for
diagnosing, devise plan of care, order blood, tests, prescribe
and treat (symptoms, side effect of trx) within department and
institutional guidelines and state rules and regulations
Clinical Nurse Specialist and Clinical Nurse Leader (newer)
following nursing model of expert care provider.
Methods for Nurses to Prepare for Roles
Education (US) – (mid Associate – China), Associate degree,
baccalaureate degree, masters degree, doctorate in nursing
practice (DNP), PhD - research focused
Certification – Oncology Certified Nurse (OCN); Advanced
Oncology Nurse Practitioner/Clinical Nurse Specialist,
Board Certified – Medical Surgical; and subspecialty
certification - BMTCN
Continuing education – conferences, professional meetings.
Professional organizations – as member, officer, and content
expert
Methods to measure quality care
National standards – National Database Nursing Quality Indicators
benchmark for CLABSI, falls, pressure ulcer, catheter UTI,
nursing hours per patient day; Oncology Nursing Society
guidelines for oncology nursing practice; NCCN Guidelines
Unit based/institutional standard – time until first dose of antibiotics
patients with neutropenic fever, review medication errors –
corrective action (communication, education), patient safety net
errors and near misses
Patient satisfaction – pain control, communication
Retention rates – turnover
NATIONAL STANDARDS: Total RN Hours/Patient Day(National Database Nursing Quality Indicators [NDNQI] Data)
11.14
10.56 10.7010.38 10.31
10.05 10.24
10.4810.29
10.58
10.01 10.119.92 9.90
9.639.43 9.51 9.59 9.55
9.55
9.919.54
9.51 9.23 9.41
9.09 9.119.34
9.12
9.43
7.00
8.00
9.00
10.00
11.00
12.00
13.00
1Q12 2Q12 3Q12 4Q12 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14
G18/G17W SCT NCI AMC
Total Falls Per 1,000 Patient Days
(National Database Nursing Quality Indicators [NDNQI]
Data)
1.80
3.13
1.20
1.692.10 1.95
2.85
3.66
2.82
2.442.60
3.25
2.39
3.01
3.35
2.35
2.74
2.26
3.303.35
2.97
2.95 2.732.48
3.13 2.672.85
2.24
3.303.28
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
1Q12 2Q12 3Q12 4Q12 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14
G18/G17W SCTCT NCI AMC
PerSurveyed Patients with Unit Acquired Pressure Ulcers
(National Database Nursing Quality Indicators [NDNQI] Data)
0 0 0 0 0 0 0
1.06 1.09
1.39
00 0 0 0 0 0 0 0 0 0
0.32
0 0 0 0 0 0 0 0 0 0 00
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
4Q11 1Q12 2Q12 3Q12 4Q12 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14
G18/G17W SCT NCI AMC
Hematology CLABSI Rate
(Per 1000 CVC Line Days – Intellechart Data)
FY 2013
CVC & Lab EducationCHG Showers &
Curos Caps
Push-Pause Education
87%93%
96%91%
86%
93%
0%
20%
40%
60%
80%
100%
120%
July - Nov. 2008
(Cultures draws
exclusively by lab
techs)
April- May 2009
(start of central
line culture draws
by RNs)
June 2009
(Central line
culture draws
standardly drawn
by RNs)
Oct - Nov 2009 Aug- Oct 2010 Sep - Oct 2011 Apr- Aug 2014
<60 minutes
61-90 minutes
91-120 minutes
>121 minutes
UNIT BASED: Neutropenic Order Activation
Time and Trends from Order Activation to Time of First
Medication Given
Unique areas of nursing practice in
Hematologic Malignancies – Oncology
Research nursing - evaluate appropriateness of
patient for research study, teach, facilitate
informed consent, observe toxicity, coordinate
study documentation, work with sponsor
Survivorship program – APRN
GVHD program - APRN
Survivorship CareRisk Reduction and Early Detection
Wellness promotion
Nutrition
Exercise
Sun protection
Meticulous self exams: oral and skin
Weight control
Control of co-morbid conditions
Re-vaccination
Risk factor and age related screening
Cancer
Blood pressure
Lipid
Psychosocial factors
• Fatigue
• Sleep disorders
• Body image disturbance
• Anxiety disorders, depression
• Post traumatic stress disorder
• Post traumatic growth: positive changes in quality of life – new appreciation for life
Nancy Tomczak, RN, OCN
Nicholas Szewczyk RN, MSN, NP-C
Joyce Neumann, PhD, APN, AOCN, BMTCN
Kelly Brassil PhD, RN, AOCNS
The Problem Weakness and fatigue post Stem Cell Transplantation
Prolonged and Multiple Hospitalizations
Anorexia/Cachexia syndrome
Long term use of Glucocorticoid Steroids
Physiologic and Psychological barriers
Failure to Thrive, Depression
Co-morbidities, advanced ages
Nursing and Ancillary Staff often takes early lead in identifying patients with increase risk of developing major debilitative states
Early Interventions Rehabilitation Success group Formed
Motivated and Moving (M&M’s ®) Program Developed Encourage patients and staff in meeting the goal of
physical activity
Activities include: Exercise class, walking on unit
using exercise equipment
social activities outside of room
Motivated and Moving Program Patients place marker on their door upon physical activity
completion Bandana - Earned for every 15 Motivated and Moving
markers Impact:Popular with patients andStaffUnclear Benefit
Motivated and Moving (M&M’s ®) Research Grant Funded
Permission from Mars® Corporation to use M&M’s ® name and Characters
Aim of Study:
Evaluate if participation in an incentive-based mobility program (Motivated and Moving) impacts fatigue, physical conditioning, performance status and quality of life in adults undergoing allogeneic SCT.
Methodology DESIGN: One-group repeated measures
Randomized control trial ruled out
SAMPLE: N=83 provides .80 power to detect fatigue score changes
90 subjects accrued, 85 completed; 2 withdrawals and 3 treatment related deaths
INCLUSION CRITERIA:
Adult, Admitted for allogeneic SCT
EXCLUSION CRITERIA:
Autologous SCT admission
Previous SCT(s)
Non-SCT related chemotherapy or post SCT complications admission
INSTRUMENTS INSTRUMENTS:
Functional Assessment of Cancer Therapy (FACT-BMT)
ECOG Performance Status
Brief Fatigue Inventory (BFI)
Six-Minute Walk Test
Multidisciplinary Team Members Advanced Practice
Nurses:
Nursing
Clinical Nursing
Statisticians
Physical Therapist
PROCEDURESConsent
Oriented to Motivated & Moving
Six minute walk test and administration of instruments
Patients logged activity using a time clock
Instruments administered at three points
Staff follow-up of points and distribution of rewards
Age Mean = 53.0 SD 10.1 Range: 26.0-68.0
N %
Gender MaleFemale
4540
52.9447.06
Race CaucasianAfrican AmericanHispanicAsianOther
685822
80.005.889.412.352.35
Type of Stem Cell Transplant
Matched Related Donor (MRD)Matched Unrelated Donor (MUD)Haploidentical Donor (HAPLO)Umbilical Cord Donor (CB)
314653
36.4754.125.883.53
Scores Between Time PeriodsAssessment Mean (SD) Min-Max
Mean Difference
(95% CI) p-value
BFI
Discharge - Admission 2.8 (2.0) 0 - 8.7 0.7 (0.2 - 1.2)* 0.0059
Day-1 - Admission 4.4 (2.4) 0 - 9.4 1.6 (1.2 - 2.1) ϯ <0.0001
Discharge - Day-1 3.5 (2.3) 0 - 9.4 -0.9 (-1.4 - -0.4) ѱ 0.0012
6 Minute Walk
Discharge - Admission 337.5 (117.1) 61.2 - 647.9 -12.9 (-38.2 - 12.3) * 0.3107
Day-1 - Admission 313.0 (119.8) 63.3 - 640.5 -33.0 (-55.9 - -10.1) ϯ 0.0052
Discharge - Day-1 332.2 (124.8) 108.2 - 633.7 23.4 (0.6 - 46.2) ѱ 0.0447
FACT-G
Discharge - Admission 81.1 (13.2) 40 - 102 -3.6 (-6.2 - -1.1) * 0.0058
Day-1 - Admission 71.0 (14.1) 38 - 104 -10.1 (-12.3 - -7.9) ϯ <0.0001
Discharge - Day-1 77.5 (15.0) 34 - 106 6.6 (4.1 - 9.1) ѱ <0.0001
FACT-BMT
Discharge - Admission 109.1 (17.2) 59 - 139.8 -6 (-9.3 - -2.8) * 0.0003
Day-1 - Admission 95.6 (18.2) 58 - 138.0 -13.1 (-15.9 - -10.4) ϯ <0.0001
Discharge - Day-1 103.0 (19.3) 47 - 136.7 7.8 (4.6 - 10.9) ѱ <0.0001
• ECOG: No Significant Changes
Six Minute Walk Results
280
300
320
340
360
380
6 M
inu
te W
alk
Adm
ission
Day
-1
Disch
arge
Assessment
Low Minutes Med Minutes High Minutes
6 Minute Walk scores for low,
med, and high values of
minutes
BFI & FACT-BMT - NS
difference related to time
spent in activity
Beta P-value 95% LB 95% UBAverage
Minutes
Admission
through Day-1 0.76 0.002 0.28 1.24Average
Minutes Day-1
through
Discharge 0.97 0.000 0.45 1.49
Assessment
Day-1 (ref:
Admission) -74.08 <0.001 -109.76 -38.39Discharge
(ref:
(Admission) -56.38 0.001 -89.84 -22.92
Length of Stay After Transplant
As time spent walking increased by 10 minutes, days until discharge
decreased by 10 percent, p = 0.026
Summary During hospitalization, fatigue increased and QOL
decreased, but improved from Day – 1 through time of Discharge
Improved 6 minute walk scores for participants with greater activity time
Pilot data supports decreased length of stay for those who engage in higher levels of activity
Future Studies include RCT
Motivated and Moving Project has been implemented across institution
Like A Bridge I Never Crossed Before: African-
american, Latino, And Caucasian Patients’
Experience Before, During And After Stem Cell
Transplantation- Phenomenological Study
Joyce Neumann
LITERATURE REVIEW
An integrative review was conducted. Time limits
were January 1988 and December 2012.
Of approximately 200 studies search identified 27
were selected that met the criteria.
Distressingly little is know about the experience of
ethnic minority patients undergoing SCT.
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RATIONALE FOR STUDY
Significance: understanding patients’ lived
experiences will guide strategies that provide
psychosocial support, enhanced communication, and
educational opportunities to better meet the needs of
SCT patients
Researcher’s relationship to topic:
collaborator on parent study (R01 NR05188),
APRN in area of SCT for 25 years.
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PHILOSOPHY AND METHODOLOGY (2)
Analytic process involves naïve reading, structural
analysis, and critical analysis in order to discover the
“matter” (the world it opens up and discloses) of the
text and not the psychology of the author (Ricoeur,
1983, 2007).
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Characteristic Totals
(n=60)
African
American
(n=20)
Latino
(n = 20)
Caucasian (white
non-Hispanic)
(n = 20)
Gender:
Male 29 7 13 9
Female 31 13 7 11
Mean age years (range years) 47
(22-71)
45
(22-64)
48
(22-65)
49
(32-71)
Marital status:
Married 36 8 15 13
Single / Widowed /
Divorced 24
12 5 7
Survival
< or = 100 days 50 17 15 18
6 months 41 16 13 14
1 year 38 15 11 12
3 years 30 11 9 10
5 years 26/59 8/19 8 10
10 years 21/57 (37%) 5/19 (26%) 7 /19 (37%) 9/19 (47%)
Lost to follow-up 3 1 > 3 yrs 1 > 5 yrs 1 > 5 yrs
Education:
Some High School or Less 6 2 4 0
High School Graduate 19 6 4 9
Some College/College
Grad 22
9 9 4
Post-baccalaureate 13 3 3 7
Type of Transplant:
Allogeneic 26 6 10 10
Autologous 34 14 10 10
Intent of Transplant:
for disease control / cure
18/43 11/9 4/16 2/18
INFORMANTS’ DEMOGRAPHIC INFORMATION
NURSING IMPLICATIONS
Consistency in assignments of nurses to patients.
Start every shift by asking patients what their major concerns are, how their family is, and their current expectations for SCT treatment, spend a few minutes of uninterrupted patient-centered time.
Assist nurses to understand the significance of SCT for patient and their likely hopes and fears for their future. Many informants described SCT as a life-changing event.
Assisting patients to have realistic expectations is exceedingly important – advance care planning
Educating patients on nursing roles and cultural differences in nurse roles is likely to be helpful in establishing realistic expectations.
Staff stress and burnout, noted by one informant, suggests that it may be important to address staff members’ compassion fatigue/moral distress by providing support for nursing staff.
CONCLUSIONS
These findings provide guidance for caring for SCT patients and their families and they provide direction of ongoing research.
Implications for care, most convincing is the need for patient-centered care based in an understanding of the contextual factors that affect patient and family coping.
Implications for research, perhaps most compelling is the need for research related to education to ensure informed consent and preparation for treatment related experiences, in accord with patient needs.
References available on request.