Psychosocial Issues

 Laurl at ONS 

Welcome to today's Hot Topic Chats. Today's speaker is Molly Loney, who will be talking to us about psychosocial issues. Unfortunately, she is experiencing technical issues today and cannot get into the chat. I will be relaying her comments, so whenever you see my postings from here on, consider them to be Molly responding to you!

 Laurl at ONS 

Welcome everyone- do you have any burning questions re: psychosocial issues?

 Laurl at ONS 

To start off, psychosocial covers such a broad area, but they are some of the most challenging issues that we face in meeting our patients' needs.

 Laurl at ONS 

Often times we look for the right thing to say or do and one of the best ways we can help is to just listen and be present.

 Laurl at ONS 

A lot of times it's hard to know what to say and when you are given an opportunity to talk like this with a pt, it's hard to know where to start.

 Laurl at ONS 

It's also hard to know where to start to open up questions like this with a chat!

 Laurl at ONS 

Do you have any difficult pt experiences you'd like to discuss?

 norissa 

Yes, it is a little hard to start. I have a couple of patients that just were admitted to the hospital with progressive disease and complications from their treatments. As this is at a teaching hospital, it is probably not the best time of year with new residents who do not exactly know what to say either.

 Laurl at ONS 

It sounds like the burden then falls on the nurses, not just finding what to say to the pts, but also guiding new staff like residents.

 Laurl at ONS 

Does your hospital offer the ONS Chemotherapy Course and would that be a starting point for the residents to join that course?

 Kristin 

I wondered if ONS has participated in the development of the NCCN practice guidelines in oncology regarding distress management. How can nurses be more directly involved in these guidelines?

 Laurl at ONS 

Or is there a team (Nurses or SWs) that would work together to orient that group?

 norissa 

It is a great idea. However, the patients do not always end up on the oncology unit. Often, it is the nurse practitioners that orient the new residents.

 Laurl at ONS 

RE: NCCN guidelines: I don't know if ONS has been involved in the NCCN guidelines, but we can check and add the response to this transcript when it is posted.

 Laurl at ONS 

Distress mgmt has become a focus in the last 5-6 yrs in a lot of centers. A lot of centers are using the distress thermometer as a way to screen.

 Laurl at ONS 

These centers are developing protocols for responding to the results.

 norissa 

It does seem that it would help patients and families cope by coaching them in how to talk to their providers.

 Laurl at ONS 

But I don't know of anything official ONS has done but will check.

 Laurl at ONS 

re: orienting: That's a great idea - again the burden falls on nursing but partnering with pts to help them partner with us re: asking for what they need is a great first step.

 Laurl at ONS 

Some institutions have an admission packet including a simple notebook with room for questions so that when the MD comes in they can ask questions already written down.

 Laurl at ONS 

And also the National Coalition for Cancer Survivors and the ACS (American Cancer Society) both have publications for pts on partnering with their physicians, which are great handouts.

 Laurl at ONS 

One of the best ways that you can help others on the team is by role modeling.

 Kristin 

Our institution has a psycho-social department as well as a pastoral service for patients who are interested.

 Laurl at ONS 

Having both of those resources is wonderful, so it's a team approach to meeting the pts needs, as well as added support for nursing.

 Laurl at ONS 

One of the challenges is that often meeting these kinds of needs falls on nursing without a lot of support for nursing.

 norissa 

We do have both available too. I suppose that should be part of the resident orientation packet and perhaps time to make introductions. And yes, that will most likely fall to nurses as the mediators.

 Laurl at ONS 

There is definitely a need to connect all the dots and have all of these depts together to provide a more holistic orientation - perhaps could be discussed with the med director to strengthen that orientation.

 Laurl at ONS 

One of the issue s we have as nurses is we have to go back and correct some of the communication gaps that occur between MDs (residents) and pts.

 Laurl at ONS 

If anyone has a model for this, we'd love to see this in CJON to share with the rest of the membership! :-)

 lorainebrenner 

The patients are often overwhelmed by the time they see the nurse for pt education. We nurses do the oral presentation leaving time for discussion. We too have the comprehensive patient education packet. The trouble seems to be when the patients get home with the packet. They often admit the packet was set down and not revisited because too voluminous. Wondering if there is a way to get everything on one page!

 Laurl at ONS 

There is a couple ways to reinforce all that info - follow up phone calls; also maybe develop a pt education introductory video, along with some verbal info, without the volumes of paper.

 Laurl at ONS 

Then a second visit for education is where the drugs are discussed, the actual nitty gritty stuff-what to expect with treatment, not as overwhelming.

 Laurl at ONS 

Pts. have said they feel less overwhelmed - ok to come in a second time to do this.

 Laurl at ONS 

Another thought if funding is available; put that info in a three ring notebook in sections and then cover certain sections at a time; first section the immediate info needed; then move on to other sections.

 Kristin 

NCCN has established algorithms that often recommend referrals to departments/experts etc., evidenced based. Of course there need to be resources. The guidelines/algorithms are available on the NCCN site.

 norissa 

I think it would be a good idea if there was someone assigned to make calls to  the patient home within a couple of days post discharge to see if there are questions. Once home, the reminder call can trigger their recollection of materials covered and one more time to coach in how to communicate to their providers in the ambulatory setting.

 lorainebrenner 

Good idea to follow up with phone calls and video. I do find the most important thing I do in my practice is to have the half hour or so at the beginning of treatment to outline symptom management with the patient and family.

 Laurl at ONS 

Yes, as everyone knows, education doesn't just occur in one sitting - that half hour before tx is a critical time to identify needs unaddressed yet. Great.

 Laurl at ONS 

All good comments!

 Laurl at ONS 

Another way that we found to reinforce is to develop a magnet that is called a "Red Flag" magnet - critical need to know-info - on a red three x five magnet, that tells family what to do if..... temp....bleeding...what to do...who to call....on their frig at home, easy to access.

 norissa 

One of the issues I wonder about are the patients in very rural areas where the resources are either very slim or non-existent. I like the magnet idea.

 Laurl at ONS 

Another resource that is helpful is if people have access to the internet - www.chemocare.com - free educational website service with a chat room. Also of course ONS's www.cancersymptoms.org - which is pt- friendly, easily printable, includes info on psychosocial issues as well as many other symptoms.

 Laurl at ONS 

These sites both really supplement each other. Both include an "Ask the expert" section too so pts can write a question and get a response. The ONS one is manned by a master's level RN at ONS.

 lorainebrenner 

I think the magnet idea is fantastic as well. The rural patients would benefit from a follow up phone call. What do you all think of involving the visiting nurses for the rural patients upon discharge?

 Laurl at ONS 

Great idea re: visiting nurses! We don't always think out of the box re: other resources that are available.

 Laurl at ONS 

Have you had any pts that were particularly challenging re: managing their psychosocial stress(es)?

 Laurl at ONS 

For example, one of the most difficult situations I've had was a pt with breast cancer, newly dx'd, telling me that she felt like killing herself - both mom and grandmom had died in early ages of breast ca, so she felt she had a death sentence already.

 Laurl at ONS 

My immediate reaction was to want to reassure her, but I realized that was from my frame of reference, not hers.

 Laurl at ONS 

What I tried to focus on was getting her to tell me about where she was coming from, her perception, feelings, so I told her I cared about her as a person...and asked her about previous times that she had had challenges and how she handled them (was trying to find out about her coping style).

 Laurl at ONS 

And I did a quick assessment to see how much of a suicidal risk she was, and asked her some hard questions, like "do you have a plan" and what would trigger that plan.

 Laurl at ONS 

She laughed, and told me that she had said it just to see what I would say!

 norissa 

That is what I was going to suggest. Assess.....

 Laurl at ONS 

And also to see if I was really there for her!

 lorainebrenner 

This is where I wonder if I should go back to school to become an NP with a focus in psychology. I often feel I could be more effective in helping the patient to surmount this sort of fatalistic thinking.

 Kristin 

Thanks very much, enjoyed the discussion.

 norissa 

Perhaps it comes out of the fear of what she experienced with her family members' cancer experiences.

 Laurl at ONS 

I always encourage anyone interested in continuing their education to do so, but we don't realize that it doesn't require a masters to be able to respond, and to listen...using critical thinking, picking up on important cues, whether psychosocial or physical - what I'm saying is that you probably have it in you already.

 Laurl at ONS 

RE: pt's suicidal ideation: I agree, her fear. I think she had actually considered suicide, but as soon as I paid att'n to it, she minimized it. But it was an opportunity for us to establish a relationship very quickly, and realized that I was tuning into her agenda, not mine.

 lorainebrenner 

Yes, and I think we all do a good job with our patients during these moments. Making sure they are safe, letting them know no one has a crystal ball and that we have better tools at our disposal then in previous generations...

 Laurl at ONS 

We were able to do follow up discussion (she and I) many times- I was staff nurse at the time - and focused on what was important in her life, what her goals were and how they changed, (or not) - in many ways, an opportunity to find new grounds for hope, re-negotiating hope in her life. Helped her quality of life and her coping.

 Laurl at ONS 

She found something to hold on to.

 lorainebrenner 

I think that is part of the training I am looking for. How best to consider the patient perspective rather than my own as a first response.

 norissa 

What do you say to people that tell you they don't want to offer false hope?

 Laurl at ONS 

RE: training - can relate to that - I got my Masters for the same reason - enhancing my ability and help them find hope - you do learn a lot of tools, etc but you learn that you are enhancing what you already have in side of you.

 Laurl at ONS 

RE: false hope - staff that don't what to offer false hope, or pts who don't want to hear it?

 lorainebrenner 

This is an important point, because hope is one of the indicators for how well patients will manage treatment.

 Laurl at ONS 

Yes, indeed

 norissa 

I have had patients tell me that but more importantly, I have heard it more from staff.

 Laurl at ONS 

RE: false hope - it's hard to know how to offer hope to others - yes, important indicator for coping- but no one can "give” us hope. Sometimes we think we can't say anything without saying it as false reassurance... what we can do is listen to the pt’s story, and help the pt identify what is meaningful in their life.

 norissa 

Staff that are not dedicated to oncology but are caring for the patient on another unit.

 lorainebrenner 

I like to come at treatment from a shifting of focus. Sometimes putting on the blinders isn't a bad idea. Seeing a small part of the picture rather than the whole so as to get through treatment and then evaluate what that does for the person. So I emphasize going about things in small steps.

 Laurl at ONS 

And through that process can help the pt hold onto hope and find ways to redefine their hope in terms of their current situation. Sounds abstract, but if pts can find ways to meet their needs, family…

 Laurl at ONS 

....sorry....family's needs, they can redefine hope without false reassurance.

 Laurl at ONS 

Re: small steps- good strategy as long as you able to inform the pt adequately so there is informed consent.

 lorainebrenner 

I think there is an understanding intrinsic to oncology nursing that we have to impart to others out of our discipline. I remember a situation when one of our people got in an accident. The radiation oncologist wanted him to continue treatment and have him brought in for xrt  (radiation) daily, much to the ICU's chagrin. But I think I kind of got through to them the rationale for continuing daily, and especially since the patient was going to go on and have life after this very rough patch.

 Laurl at ONS 

Great advocate because you tuned into what the pt needed/wanted and not the staff agenda. Critical.

 Laurl at ONS 

This sounds like a strong example of nursing's intuitive "knowing", based on knowing the pt.

 norissa 

Keep on advocating, teaching colleagues in other areas~

 Laurl at ONS 

Nursing truly is holistic in its approach - some other disciplines are not.

 Laurl at ONS 

There is a large study I just learned about underway to look at the impact of nursing empathy on their own caregivers' burden...so there is a double edge sword - as much as we care, there is a burden for caring.

 Laurl at ONS 

We have a little more than 10 minutes left- any other challenging pt situations you'd like to discuss?

 lorainebrenner 

This is one of the things I wanted to see about. What are other nurses doing to process the care we give and fortify ourselves to come back another day? And how often is this done?

 Laurl at ONS 

First, there was a recent series of hot topics on this issue- check the past transcripts page of the hot topics webpage on ONS/ CNE Central to read some great suggestions. Also, it's important for all of us to recognize the difference between the pts’ experiences and our life experiences - bearing witness means we get pulled into their roller coaster ride.

 Laurl at ONS 

Tuning in /being empathetic puts us at risk for feeling what they are feeling.

 Laurl at ONS 

A lot of times if day is busy, we go home thinking of what we haven't accomplished, instead of reflecting on what we have done, in small ways.

 norissa 

Some institutions sponsor retreats for staff...1/2 to a 1 day to a weekend. Discussions and activities focus on…

 norissa 

…reflecting on why we do what we do as oncology nurses and how to recharge and stay empathetic without bearing the entire burden.

 lorainebrenner 

Are the retreats on a regular predictable basis? And who leads the discussion?

 Laurl at ONS 

This is also a project that your ONS chapter might be interested in taking on. Our chapter has done this a few times along with our local wellness center…could be an evening, complimentary therapies, etc.

 lorainebrenner 

I know that would help me. It is good to decompress with colleagues, which we do, but it would be better to make it constructive.

 norissa 

There have been special speakers that have been invited to facilitate the retreats and there have been other times that it is more of a social function to celebrate nurses.

 Laurl at ONS 

The first retreat we offered was facilitated by special project funding; contracted Deforie Lane, music therapist, and Judy Johnson, former ONS president, to facilitate the group.

 Laurl at ONS 

With lots of experiential activities.

 norissa 

These are really good examples!

 norissa 

Funding certainly helps

 Laurl at ONS 

The important thing is to find ways to express, renew yourself, whether in a retreat, or friends outside of work.

 Laurl at ONS 

Just about out of time - any other questions?

 lorainebrenner 

Thank you so much for facilitating this discussion. It has been very helpful.

 norissa 

Thank you

 Laurl at ONS 

ONS has a great new edition - encourage you to look for this book - new edition of Psychosocial Issues in Oncology Nursing, soon to be published by ONS press. User friendly, tangible strategies to use. I have a chapter in it  re: death, dying, grief.

 Laurl at ONS 

I appreciate everyone sharing their experiences in today's chat. Hopefully tomorrow I will be online myself!

 Laurl at ONS 

Thank you for attending. This concludes today's chat - please join us tomorrow at 6pm Eastern for the next hot topic chat! Have great day!