Nurse Practitioner

special interest group newsletter

Volume 25, Issue 2, November 2014    
Survey to Be Mailed in Coming Months

Tamika Turner, MS, NP-C, AOCNP®
Indianapolis, IN

I hope the change of seasons find you well. I wanted to take this time to thank all of you who attended our SIG meeting at Congress this past spring. We had very interactive discussions. Our hope for next year’s Congress is to have a bigger room to spread out and network with one another. This will be an important time to get to know what other oncology nurse practitioners are doing in their practices.

We also will review the results from a nurse practitioner outpatient and inpatient staffing survey at Congress. This survey will be mailed out in the next couple months. Please check your email and take a few minutes to reply to the survey so we can help one another understand current issues in the inpatient and outpatient setting. We will add the results to last year's survey and keep an ongoing record of the trends for oncology nurse practitioners.

Lastly, I want to encourage you to get involved in our SIG leadership. We need help with newsletter content. I know many of you are talented and have skills that could greatly benefit our SIG. You always can write an article and email it to us for submission in the newsletter. The continued success of our SIG depends on the strength of our members. Please help us keep our SIG successful.


The Nurse Practitioner SIG Newsletter is produced by members of the
Nurse Practitioner SIG and ONS staff and is not a peer-reviewed publication.

Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Share Your Concerns by Contributing to
the Newsletter

Margaret Rosenzweig, PhD, APN-BC, AOCNP®
Pittsburgh, PA

Happy fall and upcoming holidays to all. This time of year always is busy, and 2014 is no exception. Thanks to Tina Harris, MS, FNP-C, a radiation oncology nurse practitioner who wrote “Use of Factor Xa Inhibitors in Patients With Cancer” in this issue. She is concerned that these drugs are being used too broadly in this population. Her article outlines her concerns so that everyone can be mindful of these drugs and the appropriateness of their use in patients with cancer.

If you have a concern, please share so everyone can become aware. I would be happy to help you with getting your concern into newsletter article format if that part feels like "one more thing.”

Enjoy the rest of the year, and remember to reward yourself a little for all of your hard work—you undoubtedly deserve it.

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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Use of Factor Xa Inhibitors in Patients
With Cancer

Tina Harris, MS, FNP-C
Chattanooga, TN

We work to provide the best care for our patients, and evidence-based practice is the best way to provide this care. Providers are bombarded with protocols, guidelines, studies, and complex care for patients. The perfect storm is when your patient presents to another provider or needs emergency care. Providers are not able to keep up-to-date on every protocol, guideline, or drug interaction. With current drug pathways and interactions, patients with cancer who are on treatment can be overwhelming for primary and emergency department providers. When patients undergoing cancer care are admitted to a local hospital for thrombus or pulmonary embolism, the risk for poor continuity of care and poor outcomes is heightened.

In the early 2000s, the idea of new antithrombotic medications becoming available was appealing to patients and clinicians because patients wouldn’t need to have frequent monitoring or need to limit their intake of vitamin K. Patients loved the ease, and once on these medications, they were not interested in changing back to their previous cumbersome drugs.

Direct factor Xa inhibitors are a class of anticoagulant drugs targeted to factor X in the coagulation cascade, without using antithrombin as a mediator. Patients with cancer now are placed on Xa antithrombin therapy, despite National Comprehensive Cancer Network (NCCN) guidelines not endorsing their use for all cancer populations (NCCN, 2014). Of concern are patients with cancer and concurrent renal insufficiency, those at the extremes (high or low) of body weight, and those at risk for bleeding due to recent surgery or thrombocytopenia. Novel oral factor Xa antithrombin therapy has no antidote to reverse major bleeding (NCCN, 2014).

The U.S. Food and Drug Administration (FDA) has fast-tracked an Xa antithrombin therapy antidote, andexanet alfa. This was done on the basis of preclinical animal studies and a randomized, double-blind, placebo-controlled, dose-escalation, phase 2 proof-of-concept study (Portola Pharmaceuticals, 2014) enrolling 27 "healthy adults" who received the antidote to Xa inhibitor therapy. Twenty-seven healthy volunteers were administered enoxaparin (a factor Xa antithrombin therapy) 40 mg subcutaneously once daily for six days and then randomized to andexanet alfa (the antidote) or to placebo. Results showed that with andexanet alfa, the anti-factor Xa activity was reduced quickly with no serious side effects or antibody formation. Andexanet alfa has been designated as a breakthrough therapy by the FDA and is targeted for fast-track approval. It continues to be studied in larger trials (Portola Pharmaceuticals, 2014).

The projected relatively short FDA approval time for andexanet alfa is concerning for large-scale dissemination of this medication because although an antidote to factor Xa antithrombin therapy is necessary, the impact of these drugs on patients with comorbidities (e.g., cancer) is largely unknown. The patients in the study were healthy (Crowther & Warkentin, 2008). Those taking care of patients with cancer are very aware that these healthy participants are not fully representative of patients with cancer. Although these medications are approved for atrial fibrillation, deep vein thrombosis, and pulmonary emboli treatment and prophylaxis, they are not recommended (per NCCN guidelines) for use in all patients with cancer (NCCN, 2014). All of us in cancer care will need to continue to monitor these drugs and side effects as factor Xa antithrombin therapy and its antidotes are put into widespread use in cancer care settings.

Crowther, M.A., & Warkentin, T.E. (2008). Bleeding risk and the management of bleeding complications in patients undergoing anticoagulant therapy: Focus on new anticoagulant agents. Blood, 111(10), 4871–4879.

National Comprehensive Cancer Network. (2014). Cancer-associated venous thromboembolic disease. Retrieved from

Portola Pharmaceuticals. (2014). Andexanet alfa: FXa inhibitor antidote. Retrieved from

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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Help Is Available With Orientation of Nurse
Practitioners New to Cancer Care

Margaret Rosenzweig, PhD, APN-BC, AOCNP®
Pittsburgh, PA

Nurse practitioners without previous cancer care experience are entering oncology positions requiring a high degree of autonomy and decision making. Orientation is widely variable to specialty content (Nevidjon et al., 2010). Without some additional education specific to cancer care, patient outcomes are susceptible, risk management is vulnerable, and high clinician attrition is possible. Orientation requirements vary for new oncology nurse practitioners at the level of the cancer providers in outpatient and inpatient facilities. Nurse practitioners enter oncology practice familiar with the tasks of nurse practitioners but often do not feel confident with the content knowledge of the specialty (Rosenzweig et al., 2012). Often, orientation is “on-the-job” training plus a random mix of web-based and on-site courses thought to be appropriate for an oncology nurse practitioner with or without formal mentoring. This type of orientation has limited oversight to curriculum structure, thoroughness, or quality, and the learning needs of the new nurse practitioner receive little attention.

ONS published specific competencies for entry-level oncology nurse practitioners in 2007.  The Oncology Nurse Practitioner Competencies (ONS, 2007) assume that nurse practitioners have completed graduate coursework and have had clinical experiences to provide quality medical care to patients and families. To meet the needs of nurse practitioners new to cancer care, a traditional 15-week, three-credit course designed for nurse practitioner students interested in cancer care was converted into a web-based resource. The course originally was designed as asynchronous lectures covering the “basics” of cancer care with text-based case studies. The curricular idea and delivery were enhanced through a better understanding of adult learning theory and principles of effective, quality online education (Koeckeritz, Malkiewicz, & Henderson, 2002; Merriam, 2001). These considerations resulted in the decision to abandon traditional presentation slides and create five interactive modules using life-like characters in clinical story settings unique to cancer care. As the cancer stories unfold, the resources needed to make decisions or gain more insight are provided to the learner. Feedback is immediate. The course was titled “Oncology Nurse Practitioner Web Education Resource” (ONc-PoWER). The five modules include

  • The new patient history and physical for cancer care
  • Presenting and documenting the new patient visit
  • Cancer visits across the cancer trajectory
  • Palliative care and hospice
  • Self-care and professional development.

The content features “Gina,” a new nurse practitioner in cancer care facing everyday challenges and tasks. Gina was designed to have the look and speak the words of a novice nurse practitioner. She is excited and nervous in her new position but quickly becomes discouraged with confusing cancer acronyms and patients sensing her inexperience. Within the module, she is assigned a mentor, Deborah, a purposefully older, wiser-looking woman who provides support, direction, and encouragement. The course then “solves” Gina’s dilemmas through an introduction of content that traditionally would have been introduced via slide presentations. For example, instead of providing slides of information about how to assess a new patient in cancer care, Gina is faced with Mr. Cole, a new patient. His chart is made available, and she needs to make decisions with the information provided. Outside resources are provided and used as Gina needs them.

The new nurse practitioner in cancer care will work through problems with Gina in a supportive and engaging fashion. Each module is organized into “Content,” “Challenges,” and “Resolution.” The Content portion features the lesson of the module with the introduction of outside resources. The Challenges section features interactive situations in which the nurse practitioner is asked to use the content or resources just presented to make decisions regarding patient situations. Immediate feedback is provided. Each module ends with Resolution, in which the patient or colleagues acknowledge Gina for the work she has done. Empathic communication is modeled throughout.

The onsite mentor is critical to the success of this program. First, the new oncology nurse practitioner must establish a mentor, reinforcing that relationship. The onsite mentor has access to all content and receives reminder emails as the nurse practitioner works through the modules. Knowing the focus of the content helps the onsite mentor tailor or emphasize certain aspects of clinical care so the content has immediate local and clinical applicability. If the new oncology nurse practitioner is working through the patient with nausea and vomiting, that is an ideal time for the mentor to review the symptom management protocols in place at that clinical site, resources available to help with challenging symptom issues, or where to look for a clinical trial related to symptom management. Some cancer centers may have a multitude of resources, and others may have virtually none. The onsite “this is how we do it here” is critical to the success of this orientation.

The ONc-PoWER course is funded through the National Cancer Institute and is being disseminated and evaluated as an educational product for adoption and use by cancer care facilities employing nurse practitioners. The free course is embedded into the University of Pittsburgh School of Nursing course web structure as a continuing education module. Nurse practitioners receive 30 continuing education contact hours for completing the course, and mentors are paid $1,000 as an honorarium for participation. Get more information or register.

Koeckeritz, J., Malkiewicz, J., & Henderson, A. (2002). The seven principles of good practice: Applications for online education in nursing. Nurse Educator, 27(6), 283–287.

Merriam, S.B. (2001). Andragogy and self‐directed learning: Pillars of adult learning theory. New Directions for Adult and Continuing Education, 2001(89), 3–14.

Nevidjon, B., Rieger, P., Miller Murphy, C., Rosenzweig, M.Q., McCorkle, M.R., & Baileys, K. (2010). Filling the gap: Development of the oncology nurse practitioner workforce. Journal of Oncology Practice, 6(1), 2–6.

Oncology Nursing Society. (2007). Oncology nurse practitioner competencies. Retrieved from

Rosenzweig, M., Giblin, J., Mickle, M., Morse,A., Sheehy,P., & Sommer, V.(2012). Bridging the gap: A descriptive study of knowledge and skill needs in the first year of oncology nurse practitioner practice. Oncology Nursing Forum, 39(2), 195–201.

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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Exclusive Articles Available Before Print

The Oncology Nursing Forum (ONF) and the Clinical Journal of Oncology Nursing (CJON) have unveiled advanced print exclusive articles to give our readers access to important, cutting-edge content ahead of print. Articles from the journals are available on the main ONF and CJON pages. These articles are open access, meaning they are available to members and non-members alike, until they appear in print at a later date. At that time, the content will become password-protected like other articles that appear in print as online exclusives in the journals.

The latest article to receive the advanced print exclusive designation is “Round and Round We Go: Rounding Strategies to Impact Exemplary Professional Practice” by Nicole Reimer, BSN, RN, OCN®, and Laura Herbener, BSN, RN, OCN®. The purpose of this CJON article is to detail diverse rounding methods as implemented on a 26-bed hematology/oncology unit. Check out this timely and informative article today.

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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Check Out the ONS Connect Blog

The official blog of ONS is written by oncology nurses for oncology nurses on a variety of topics of interest, including facing day-to-day challenges at work, juggling busy lives at home, and keeping up to date with the magnitude of information available for practicing nurses.
This month, you’ll find the following new discussions.

As a reader, join in on the conversation and connect with other oncology nurse readers by posting your own stories, tips, ideas, and suggestions in the comments section at the end of each blog post.

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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Five-Minute In-Service

The latest Five-Minute In-Service explains how a Reference Tool Helps Nurses Monitor Patients Receiving Oral Oncolytics.
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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Ask a Team Member

The latest Ask a Team Member column answers the question How Do You Teach Students About Oncology in Clinicals?
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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Membership Information

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Join a Virtual Community

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Participate in Your SIG’s Virtual Community Discussion Forum

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Nurse Practitioner

Special Interest Group Newsletter  November 2014  

Nurse Practitioner SIG Officers

Coordinator (2012-2015)
Tamika Turner, MS, NP-C, AOCNP®
Indianapolis, IN

Coordinator-Elect (2014-2015)
Aaron Begue, MS, RN, FNP
Alexandria, OH


Margaret Rosenzweig, PhD, APN-BC, AOCNP®
Pittsburgh, PA

ONS Copy Editor
Jessica Moore, BA, BS
Pittsburgh, PA

Know someone who would like to receive a print copy of this newsletter?
To print a copy of this newsletter from your home or office computer, click here or on the printer icon located on the SIG Newsletter front page. Print copies of each online SIG newsletter also are available through the ONS National Office. To have a copy mailed to you or another SIG member, contact Membership/Leadership Specialist Carol DeMarco at or 866-257-4ONS, ext. 6230.

View past newsletters.

ONS Membership & Component Relations Department Contact Information

Brian K. Theil, CAE, Director of Membership and Component Relations Department

Diane Scheuring, MBA, CAE, CMP, Manager of Member Services

Carol DeMarco, Membership Specialist—SIGs

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

Oncology Nursing Society
125 Enterprise Dr.
Pittsburgh, PA 15275-1214

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