The seventh floor of the Wilmot Cancer Center, with its panoramic views and 31 private, light-filled hospital rooms, hums with a calmness that contradicts the reality of life-threatening emergencies that can take place at any minute. Nearly every room is filled with people whose conditions can fluctuate by the hour; 55 skilled nurses monitor and care for them with compassion during high-risk treatments and for serious complications from cancer or the therapy they received.
WCC7 is also the research “bench” for investigations to improve patient care and nursing practice.
The up-and-coming research champions on the unit, Sara Luzunaris, B.S., R.N., a WCC7 nurse manager who’s been a nurse for eight years, and Shannon O’Leary, B.S.N., R.N., OCN, an assistant nurse manager who’s been a nurse for five years— proudly call themselves “the research nerds.”
“We’re determined to get past the theory that, ‘We’ve always done things this way,’ ” Luzunaris says. “Nursing in general is becoming evidence-based in nearly every way and this means taking into account not only clinical experience and patient desires, but the current findings from data and the literature.”
Their data helps to manage the intensity of taking care of very sick patients.
The questions today are so complex and the problems so numerous that all team members need a seat at the table.
Recently O’Leary led a project known as the acuity study, which was presented at this year’s national Oncology Nursing Society’s annual meeting. The goal was to capture in detail and with precise accuracy the level of sickness for each patient on WCC7, improving the ability to assign a proper nurse-to-patient ratio.
When patients arrive they’re usually assessed in standard ways: by their vital signs, medications, and the professional but subjective judgment of a nurse. O’Leary wondered if the standard method was accurate enough. As part of a nursing practice research internship, she reviewed the scientific literature and found an oncology-specific acuity tool that was deemed valid and reliable.
O’Leary then designed a study to investigate the acuity tool’s value for WCC7. Co-workers agreed to test the new assessment and they were able to chart trends in the health of patients, as well as how well the tool predicted fluctuations during a nurse’s assignment. O’Leary further broke down the data to find trends in the numbers of patients per nurse. As a result, she was able to create a graphic that visually demonstrated the sharp turns in patient sickness each day, from shift to shift, and throughout their hospital stay.
“This is not only hard on patients but it’s hard on nurses,” O’Leary says. “Ultimately we wanted to show with real data how sickness impacts the patient, the whole unit, the flow of work, and how nursing assignments could be altered.”
“I love research and finding my niche has been wonderful,” O’Leary adds. “We have a group here that really appreciates data, and if they know that our research will benefit patients, they’re all for it.”
Next up: Luzunaris says the Wilmot Nursing Research Committee, a group comprised of nurses from various inpatient and outpatient locations, will evaluate ways to improve communication by using technology similar to a smart phone. Designed for the medical community, these types of devices stream vital signs, send alarms, and notify appropriate team members. They also have a text message-like feature while keeping information secure.
Luzunaris believes the technology will simplify and speed up decision-making. “Sometimes all that’s needed is a quick ‘yes’ or ‘no,’ ” she says. But, as scientists, she and O’Leary know it’s important to first take a step back and investigate the effectiveness, costs, and efficiency of the communication devices.
“We have a lot of nurses who question things here, and that’s good,” Luzunaris says.
Sara Luzunaris, B.S., R.N., and Shannon O’Leary, B.S.N., R.N., OCN, are leading data-driven nursing on WCC7.
Invasion of the “research nerds”
Cancer research is often described as a “bench to bedside” process, starting in a controlled laboratory with fundamental science to understand the roots of the disease and ending, ideally, closer to the patient’s bedside with a new discovery about cancer or how a treatment might impact an entire population of patients.
When nurses do research, their benches look a lot different.
They work on the front lines, and they’re educated to see the whole person, from the biological to the spiritual side. Nurses bring a different perspective to the complex world of cancer research—one that focuses on patient experiences and quality of life.
“My lens is different than that of a radiation oncologist or a molecular geneticist in a basic science lab,” says 13-year cancer survivor Kathy Rideout, Ed.D. P.P.C.N.P.-BC, F.N.A.P., dean of the University of Rochester School of Nursing. “The scope of research has changed and it’s important that research is being done on every front. Being able to provide the tools to live with a chronic disease is just as important as a cure.”
The possibilities are endless. Nurse scientists resolve urgent clinical problems such as preventing medication errors or infections; they investigate tools and systems to manage care; and they tackle behavioral issues related to cancer prevention, coping with getting sick, and living well beyond the diagnosis. In the end, nurse investigators have the same goals and objectives as other researchers: To supply valid and meaningful evidence to every decision made in an outpatient clinic or at the bedside.
Wilmot nurses are formalizing their approach by launching a nursing research committee and encouraging collaboration across disciplines.
As Rideout notes, a key distinction for an academic facility is that every member of the care team— from the physician, to the nurse, to the social worker—brings not only their individual expertise but “their own body of evidence to support decisions and a respect for team science. And when patients know what the latest evidence shows, it really resonates.”
“The day of the lone researcher is really past us,” adds Jamie Oliva, Ph.D., A.N.P-C, B.M.T.C.N., a researcher, nurse practitioner, and teacher. “The questions today are so complex and the problems so numerous that all team members need a seat at the table.”
Marie Flannery, Ph.D., R.N., AOCN, and Jamie Oliva, Ph.D., ANP-C, BMTCN, study patient-reported outcomes and ways to improve care.
Making things happen
Marie Flannery, Ph.D., R.N., AOCN, has been part of Wilmot’s rich history of nursing research since the 1980s. She built on those early opportunities to advance her own studies and initiatives, and now as a nursing faculty member has the responsibility of training the next generation of nurse scientists.
“By becoming a researcher, I could help more than one patient at a time,” says Flannery, who has presented her research nationally and internationally.
Some of her past projects looked at ideal nurse ratios for patients who’re getting infused with chemo and better ways to identify troubling symptoms and side effects among cancer patients. She also discovered surprising patterns among the thousands of telephone calls that come into Wilmot from worried patients and families. The phone patterns revealed, for example, that lung and gastrointestinal cancer service lines received the most calls proportionately, and that pain complaints and test results were the chief reasons for the calls. Wilmot became more proactive as a result of her study and hired two additional nurses to manage the intake, Flannery says. The data was published in the Journal of Oncology Practice.
Lately, her work is focusing on Wilmot’s Geriatric Oncology Program and finding ways to use electronics and the MyChart system to better connect patients with their caregivers.
For example, in a National Cancer Institute-approved study, Flannery’s team is studying whether electronic reporting is a reasonable way for cancer patients to tell of pain, depression, and other symptoms. Patients seen by four cancer center oncologists are being asked if they are willing to complete symptom surveys on MyChart and are being given iPads to take the surveys in clinic waiting rooms.
Past research has established that patient reporting of symptoms results in improved outcomes. However, it is not clear how to make the process go smoothly, and thus the goal of the study is to establish whether the tool is feasible in a busy clinic.
Mary Jo Paciorek completes a symptom survey on a tablet as part of a study led by Marie Flannery, Ph.D., R.N., AOCN.
“We want to involve patients as much as possible, and by providing data in real time the health care team can intervene earlier,” she says. “It’s pretty powerful.”
Oliva is also using modern technology to develop a separate study that would allow patients who’ve received treatment from Wilmot’s Samuel E. Durand Blood and Marrow Transplant (BMT) program to monitor their health at home and call in with concerns between scheduled oncology visits. Based on her specialized clinical practice in BMT, Oliva completed a doctoral thesis in 2016 that investigated graft-versus-host disease, a transplant complication.
Patients with leukemia or lymphoma who receive stem cells from an outside donor are more prone to graft-versus-host, where the donor’s immune cells attack the patient’s tissues and organs. Medications can control the disease but scientists do not fully understand the pathophysiology.
Oliva investigated whether the number of T cells, a type of immune cell, in a patient’s blood sample was associated with graft-versus-host disease. In the next phase of her research, she’s exploring the use of a software program that would allow patients to keep track of their graft-versus-host symptoms on their own.
As more nurses like Oliva seek advanced degrees, enrollment in research-focused doctoral programs has also climbed, according to the American Association of Colleges of Nursing. Teaching students to dig for evidence is a critical piece for translating science to clinical care.
“Once the evidence is in,” Oliva says, “we can make things happen in the clinic.”
Karen Abbas, M.S., R.N. AOCN, and Tammy Clarke, M.S., R.N., OCN, BMTCN, focus their research on reducing patients’ risk of falling.
Nurses as troubleshooters
Knowing how to use data appropriately to benefit patients is the essence of an academic institution.
Nurses play a crucial role in this effort because they’re tuned into clinical problems, big and small. A primary example is the nearly one million patients who fall and injure themselves each year in U.S. hospitals, making it one of the most common complications of patient care, according to The Joint Commission, the accrediting body for hospitals. Although it’s a widespread problem, Karen Abbas, M.S., R.N., AOCN, and Tammy Clarke, M.S., R.N., OCN, BMTCN, are determined to reduce the risk of falling at Wilmot with an evidence-based approach.
They astutely recognize, however, that falling is not just a physical issue.
“People with cancer can come into the hospital otherwise healthy, but treatment will weaken them and they don’t always realize it. And they want to maintain their independence,” Clarke says.
Abbas agrees, adding: “Cancer patients express a loss of control. Their body has betrayed them and now they’ve lost the ability to simply walk around the room when they want to, and it’s very distressing.”
This is why we do research... to find something better for our patients and to make the practice of nursing more evidence-based.
Wilmot nurses had been using a tool provided by Strong Memorial Hospital, the main hospital on the University of Rochester Medical Center campus, to assess the fall risk of cancer patients as they arrived for admission to the cancer center. Classifying risk accurately can go a long way toward preventing falls, and they had concerns about the special needs and classifications for people with cancer, who are often older adults.
Abbas and Clarke discovered that the Cleveland Clinic developed a validated, fall-risk tool particularly for oncology, and launched a study to compare the standard tool to Cleveland’s tool. They’ve retrospectively reviewed 50 cases of people who fell and examined their initial risk assessment. It’s early in the investigation, but Abbas believes the eventual result will allow Wilmot’s team to design their own cancer-specific tool that suits the needs of this region’s unique population. “A more accurate assessment will help nurses do their jobs and patients better understand their limitations,” Abbas says.
Two years ago, they took on a similar research project—this one involving small blood clots related to a certain type of central-line catheter for chemotherapy—and the results showed, to their surprise, that an older catheter produced fewer blood clots than a newer model among 75-100 leukemia patients.
Like patient falls, peripheral-line blood clots are an issue that nurses, patients, and hospital systems grapple with across the country. Abbas was invited to share her study at a podium presentation at the Oncology Nursing Society 2016 annual meeting.
“This is why we do research,” Abbas says: “To find something better for our patients and to make the practice of nursing more evidence-based.”