Setting the Standard
As oncology research is developed, tested, reviewed, and published, new evidence is introduced and changes to the care environment are made. Nurses are no strangers to evidence-based practice changes, and they’re often leading the way when it comes to implementing new standards of care.
Oncology nurses are integral members of the cancer care team, and with their unique perspectives and ability to reach across disciplinary lines, they have the opportunity to identify gaps in care and address needs for standardization. Across the country, they’re implementing ONS standards at all levels of practice to create safe, cohesive care environments for patients, caregivers, and healthcare providers.
Addressing the Need for Standardization
ONS member Carrie Tompkins Stricker, PhD, RN, AOCN®, chief clinical officer at Carevive, Inc., and oncology nurse practitioner at the University of Pennsylvania Health Systems, has been working with standard implementation throughout her more than 20-year oncology nursing career.
According to Stricker, many standards have a life of their own. “Standards always have a spirit underlying them—a spirit for which they were developed. There’s always a need, gap, or patient care issue that drives the development of a standard, and that’s why it’s so crucial that they’re translated into practice.”
To create practice change, standards need to be developed from within the healthcare community. “By gaining the insight of healthcare constituents, including the patient and family community, administrators, clinicians, and members of the care team, a group of multidisciplinary professionals can take the exhaustive initiative to come up with what might be best practices based on the available knowledge, literature, and research and recommend what should be implemented into practice,” Stricker says.
ONS member Anna Vioral, PhD, MEd, RN, OCN®, BMTCN®, director of oncology education and research at Allegheny Health Network in Pittsburgh, PA, and her team noted the need to implement national chemotherapy safety standards from ONS and the American Society of Clinical Oncology (ASCO). To address the continual need to update and standardized chemotherapy safety, they set to work standardizing chemotherapy administration across 24 different locations.
“Our staff rotates between offices and hospitals, and trying to know what the standard was here and what the standard was there really defeated our purpose,” Vioral says. She and her team decided to address the safety gaps in a unified way.
“We started the implementation process of the ASCO/ONS Chemotherapy Safety Standards in 2009 but didn’t do our full implementation until 2011. It took two years to bring everything together between 18 outpatient offices and 6 hospitals. We weren’t going to just bring one place up. If we were going to do it, we were going to do it everywhere,” Vioral says.
The Implementation Process
A vital component of implementation includes staff education and engagement. Vioral’s team created 10 YouTube vignettes that educated staff on elements of the standards, including planning and consent, ordering and administration, hypersensitivity, safe handling, and more. They also offered a continuing education course and provided the opportunity for staff to take the course during work hours. And they didn’t stop there, continuing to find other ways for staff to get behind the change.
“We started doing what we call readiness rounds. Every week, we go into an office, and our staff can have one-on-one time with experts. They can ask questions about why we’re implementing these standards, and we can help staff understand why this is so important,” Vioral explains. “It also gives them the opportunity to understand where things are in the electronic medical record (EMR), which, if you build the EMR correctly, will almost carve you into practicing the standards.”
For Stricker, implementing standards of care begins with a map. “You really have to identify all the stakeholders that need to be part of the process of getting adoption into practice,” Stricker says. “I’ve learned a new term, people map, which just refers to all the players who are going to have a say in implementation of standards. You’ve really got to start there.”
Stricker notes that bringing together those on the healthcare team who are affected by new standards can allow for understanding and recognition of the positive components of the change. “If someone doesn’t recognize or perceive the benefit of a change, then there could be some resistance to adopting it into everyday practice.”
Overcoming Challenges Along the Way
Enacting change in an organization can be difficult. Between networks and institutions, many moving parts and individual concerns are involved. In Stricker’s previous experience of implementing mucositis standards, she’s approached change with a combined top-down and bottom-up formula. As part of her people map, she engaged staff nurses but recognized that she needed the support of the administration as well.
“We engaged nurse management on the principles and the need—while leveraging the knowledge of an expert researcher that I copresented the material with—and we got our leadership to buy in,” Stricker says. “Addressing changes from both sides, getting a groundswell of interest and adoption, and using the leadership infrastructure helped put policies in place to ensure that the standards were upheld.”
Another important component is including multiple disciplines in the process. Vioral notes that crossing disciplinary lines and creating an inclusive approach proved to be effective when integrating the chemotherapy safety standards into practice.
“The biggest challenge was getting the right people at the table, so to speak. In health care, we can become very discipline oriented. We get tunnel vision,” Vioral says. “So we have what we call our Chemo Council, and that’s our grassroots group from where it all starts. To make any changes or decisions, there must be representation of nursing, pharmacy, and physicians.”
Creating Positive Outcomes With Standards of Care
Ultimately, the goal of implementing new standards into practice is to see positive outcomes and increased patient safety and quality of care. However, results aren’t guaranteed immediately. Both nurses note that their outcomes improved over time.
“We track a lot of our outcomes on near misses and errors. It’s really important for people implementing new standards to know that often near misses and errors are going to go up immediately after the change,” Vioral says. “People become more vigilant when you make changes.”
“Give it six months and really track what the problems are—is it staff compliance, is it process, is it because it’s something different—I always stress this. Over time, our errors have gone down, because we’re catching things ahead of time,” Vioral adds.
According to Stricker, positive outcomes will show in pockets across practice. “It’s part of the model of early adopters and innovators versus late adopters. Focus on those who are engaged, and you will see early wins and positive outcomes immediately.”
She also notes the importance of organizations and industry leaders such as ONS continuing their work with practice standards. “I think it’s not to be underemphasized how crucial organizations like ONS and other professional societies are when providing the weight behind standards and the resources to support their implementation.”
Institutional practices must change and adapt to new research and evidence to ensure optimal care. Oncology nurses will continue find themselves at the forefront of this process and are key in transforming cancer care and should look to ONS and other organizations to provide best practices and standards of care to improve outcomes, close gaps in care, and increase patient safety throughout the cancer care continuum.