December 2014, VOL 5, NO 6

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Navigation Program Development

Sunrise, Sunset: Swiftly Go the Years

Many experienced oncology nurses who are retiring or approaching retirement possess knowledge about oncology patient care that comes from years of experience. They have seen a transition from general oncology to specialties in bone marrow transplant, genetics, hematology, medical oncology, palliative care and hospice, radiation oncology, as well as site-specific and surgical oncology. What used to be a limited number of treatment resources has exploded to multiple new methodologies, many of which are based on specific tumor markers. How does a practice ensure that the knowledge, skills, and abilities of its senior nursing staff are transferred to newer nurses joining the practice?

Background
The Toledo Clinic is a multispecialty physician organization, of which oncology is one of its specialties. The practice was established in the 1960s, when the first medical oncologist was recruited to Toledo, and grew with the addition of new partners who specialized in both medical oncology and hematology. Today, the practice has 6 locations in Ohio and Michigan, with 8 physicians, 9 nurse practitioners, and approximately 79 employees—including 17 registered nurses—staffing the offices.

Its founding members have retired, but the group continues to expand. Today, several senior partners in the clinic are approaching retirement, some are in the middle of their careers, and new partners have joined. The practice recognizes a need to provide the new partners with a mentoring process that provides historical perspective and practical knowledge. The mentor can help in the transition from student to practicing physician.

As more experienced nurses and nurse practitioners prepared for retirement, the need for role development was identified. With an explosion of new advances in diagnosis and treatment, newer nurses need a longer learning curve. We asked ourselves these questions: How does a practice ensure that its new nurses understand and appreciate the history of the practice, and how are ongoing learning opportunities provided for the nursing staff, especially in an era where there are competing priorities for nurses’ time?

Orientation
The process of educating new nursing staff has evolved over time. Today, the orientation program has been revised and extended to a minimum of 6 months, and includes mentorship and continuing education (CE) programs. Time is spent providing an orientation to the Toledo Clinic, as well as to overall practice operations. New registered nurses take a biotherapy/chemotherapy course online offered through the Oncology Nursing Society (ONS; www.ONS.org/online-courses). Because the practice is also very involved in clinical research, newly hired nurses complete a human protection course through the National Institutes of Health Office of Extramural Research (https://phrp.nihtraining.com).

During the first few months, orientation is designed around the practice’s policies and procedures, electronic medical record system, chemotherapy order writing process, and documentation of patient assessment and treatment. Time is also spent with the practice administrator learning about the history of the practice. As with new physicians, understanding the practice’s goals, mission, and contributions to the community is important.

Implementation of the new nurse training program has changed the schedule on the practice’s end. Formalized CE and pharmaceutical programs have been integrated into quarterly nursing meetings. In the past year, an event approved for nurses to earn CE units (CEUs) was also added.

Mentorship
New nurses are assigned a mentor who is responsible for initiating an orientation checklist (Table) that includes activities from the office observation period to the responsibilities related to chemotherapy administration and patient care in the infusion room. When the mentor completes the checklist, the nurse can begin taking patients independently, but the mentor and other experienced nurses remain available to answer questions.


Table

As nurses transition from orientation, they can continue their relationship with the mentor, or, if necessary, another nurse in the office. Experienced nurses are paid a differential because of the importance of their role in the orientation of the newer staff. Mentors are active participants in the initial orientation, and they complete the orientation checklist as well as a 90-day evaluation. Emphasis is also placed on chemotherapy safety, with mentors providing an assessment of skills and direct observation of performance in the mixing room.

Continuing Education Program
The practice has nursing personnel from all of its locations, including nursing staff and licensed nursing practitioners, attend quarterly meetings. Clinical topics are provided by one of the physicians, nurse practitioners, or nurses who brings back information from the national ONS meeting. However, none of these meetings have provided approved CEUs, which was an identified need. The agenda also includes updates on new drugs, legislative and reimbursement changes, as well as topics of interest, including practice updates, inventory management, safety topics, electronic medical record and documentation requirements, new drugs and updates from pharmaceutical representatives, as well as updates on quality initiatives, including depression screening.

To become a provider of approved nursing CEUs in Ohio, the Ohio Nurses Association (ONA) requires the following:

  • A clearly defined unit or department responsible for nursing CE
  • A nurse planner who meets the ONA’s specific qualifications
  • The organization to be functioning for at least 6 months, using accreditation criteria and the Ohio Board of Nursing’s rules, during which time at least 3 separate activities of at least 60 minutes in length must have been planned, approved by the ONA, implemented, and evaluated
  • The practice to submit a form and the required fees showing intent to apply as an accredited CE provider.

One of our nurse practitioners accepted responsibility for the role of nurse planner, and the practice has now received a preliminary CEU provider designation. Our first planned activity was a review of oncology drugs of the past, present, and future, which was presented by an oncology pharmacist. The objectives of the review were to state the mechanism, administration, and clinical pearls related to older, traditional chemotherapeutic agents, and to list a variety of targeted anticancer agents and explain their administration and common adverse effects.

The nurses who attended this session and completed an evaluation received 1.0 contact hour of CEUs. The first program was well-received by the staff, and evaluations will be used to develop future presentations. Assessment of the evaluations showed that nurses appreciated the pharmacist’s knowledge of chemotherapy and presentation of the information in a manner that enhanced their understanding of oncology drugs. Several individuals requested that the pharmacist attend the quarterly in-service meetings to review treatment regimens on an ongoing basis.

Based on the evaluations, programs are being developed on chronic lymphocytic leukemia, neuroendocrine tumors, genetic tests, and palliative care. A physician will provide clinical information on the topic and a nurse practitioner will provide nursing care–specific information.

Discussion
Developing an in-house nursing CEU program is beneficial to the practice. It demonstrates the practice’s commitment to CE and to staff development. For individual nurses, the program provides necessary information that is not readily available to them, and is an effective way for the practice to ensure nursing personnel have the information needed to care for patients. Other benefits include meeting the needs of busy nursing personnel, saving staff time, and minimizing travel time and expense.

In-house education programs should be customized to fit the needs of the nursing staff and the practice, which will keep doctors and nurses in tune with each other. The programs should provide the staff with updated information as changes occur and should provide a forum for responding to problems, issues, regulations, and new trends in a timely manner. These programs can offer an opportunity for knowledge transfer from experienced nurses to newer nurses, and can provide potential recruits with a reason to join the practice.

Conclusions
Using the above approach, our practice has developed a program to prepare for the sunset of retiring nurses and the sunrise of new nurses who will care for patients over the next decades. Orientation and mentorship programs allow newly hired nurses to learn about our clinic, including an overall understanding of processes, administrative procedures, the clinic’s role in the community, and expectations for the clinical care of patients. Educational programs and approved CE programs allow nurses to earn CEUs while maintaining clinical competency and helping to meet the practice’s clinical standards.

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