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JULY 2011 The official news magazine of The oncology nUrsing socieTy

Cancer Center Design

Enhancing the Patient Care Environment
Page 8

Outpatient Symptom Management

Page 14

Breast Cancer in Developing Countries

Page 20

Writing for Publication

Page 21

Kimberly Caudill, RN, BSN

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inside

8 Cancer Center Design

UP FRONT Nursing involves caring for the whole person, not just the physical body. An optimal patient care environment is holistic as wellencompassing the physical structure and amenities of the facility, the quality and breadth of services provided, and the culture of the people providing care. Learn how ONS members are using cancer center design to provide holistic patient care.

ALSO iN THiS iSSUE

EDiTORS NOTE Cancer center design must focus on patient needs.

6 JUST iN
The latest news from the oncology field YOU TELL US Does the patient care enviroment affect outcomes?

16

17 WHAT WOULD YOU DO?

The case of anticipated alopecia CAPiTOL CONNECTiON Partnership for Patients aims to reduce hospital mortality and readmission rates. CALENDAR OF EvENTS Events and deadlines for summer

14 Developing an Outpatient Symptom Management Clinic

FivE-miNUTE iN-SERviCE Because patients in an outpatient clinic are seen less frequently by the healthcare team, symptoms and side effects can be better managed and more efficiently addressed in a specialized symptom management clinic that works in tandem with the outpatient clinic.

18 18

20 Treating Breast Cancer in Developing Countries

NEW TREATmENTS, NEW HOPE As the most common cause of cancer death among women around the world, breast cancer outcomes need to be addressed proactively as a way of preventing the predicted global cancer epidemic.

22 WORKiNG FOR YOU

New conference model will better meet member needs.

22 ONS:EDGE
ONS:Edge helps to double your membership benefits. STAYiNG ON TOP Networking puts you in the know.

21 Almost Anyone Can Write for Publication

A CLOSER LOOK

23

In the animated picture Ratatouille, Remy was inspired by the slogan Anyone Can Cook. While not everyone can write manuscripts, in many ways, writing for publication is similar to cooking.

23 CAREER CENTER
Find your next oncology nursing job.

ONS Connect is indexed in CINAHL, MEDLINE, and the International Nursing Index. The Oncology Nursing Society and the ONS Connect Editorial Board do not assume responsibility for the opinions expressed by authors. Editorials represent the opinions of the authors and not necessarily those of the Oncology Nursing Society. Acceptance of advertising or corporate support does not indicate or imply endorsement by ONS Connect or the Oncology Nursing Society. Mention of specific products and opinions related to those products do not indicate or imply endorsement by ONS Connect or the Oncology Nursing Society. Websites published in ONS Connect are provided for information only; the hosts are responsible for their own content and availability. Postage Privileges: Periodical rates paid at Pittsburgh, PA, and at additional mailing offices. Postmaster: Send address changes to ONS Connect, Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA. Published monthly by the Oncology Nursing Society, P.O. Box 3510, Pittsburgh, PA 15230-3510 USA. Yearly subscription rates are $29.99 for individual nonmembers and $39.99 for institutions. As part of ONS membership dues, $4.53 are for a one-year subscription to ONS Connect. Vol. 26, No. 7. ISSN: 1935-1623. Copyright 2011 by the Oncology Nursing Society. Blanket permission for copying any material in ONS Connect is granted to ONS members.

Printed on 10% postconsumer recycled paper. Please recycle this publication.

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instant poll
Do You Have a Policy to Assess Patients Competency for Decision making?
In response to the May ONS Connect instant poll, Do you have a policy to assess patients competency for decision making? 93% of readers indicated no (N = 96). To respond to this months poll, Do you have influence on the patient care environment? visit www.ONSConnect.org. Results will be shared in an upcoming issue.

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ONS Connect is published monthly as a benefit for members of the Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA. mission The mission of ONS Connect is to Provide timely news and resources to oncology nurses that can be incorporated easily into daily practice. Communicate ONS updates and news. Reinforce ONS as an industry leader and an authority in the healthcare field. Editor Debra M. Wujcik, RN, PhD, AOCN, FAAN Email: ONSConnectEditor@ons.org Contributing Editors Tamara B. Dolan, RN, MSN, OCN Seth Eisenberg, RN, OCN Heather McCreery, RN, MBA, OCN, CCRC Christine Merenda, MPH, RN, OCN Jennifer K. Mitchell, MSN, ANP-BC, GNP-BC Paula M. Muehlbauer, RN, MSN, AOCNS Susan Pillet, RN, CPNP, CPON Contributor Deborah McBride, RN, MSN, CPON ONS Communications Staff Anne Snively, BS, CAE, Director of Communications Elisa Becze, BA, ELS, Managing Editor and Staff Writer Carrie Smith, BA, Communications Coordinator and Staff Writer Jason Mosley, Graphic Designer ONS President Carlton G. Brown, RN, PhD, AOCN ONS Chief Executive Officer Paula T. Rieger, RN, MSN, CAE, FAAN National Office information Phone: 866-257-4ONS, +1-412-859-6100 Fax: 877-369-5497, +1-412-859-6163 Email: pubONSConnect@ons.org ONS Connect website: www.ONSConnect.org ONS supports the principle of financial disclosure and has taken steps to ensure that all ONS editors, editorial board members, reviewers, and authors understand and comply with its policy. ONS also respects the privacy of its customers. Copies of the ONS Financial Disclosure Policy and ONS Privacy Policy are available upon request by contacting ONS at customer.service@ons.org or 125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA, Attn: Customer Service. All advertising is subject to the approval of the editor and publisher. ONS mission Statement The mission of the Oncology Nursing Society is to promote excellence in oncology nursing and quality cancer care. ONS Core values Integrity Innovation Stewardship Advocacy Excellence Inclusiveness

93%
said no

survey says
How Do members Like to Receive Educational Programming From ONS?

64% said printed materials. 62% use online programs with less than two hours of content. 47% like local chapter meetings. 40% said regional conferences. 33% said national conferences. 23% use online programs with more than two hours of content. 17% like CD-ROMs. 6% said podcasts. 4% use PDA or smart phone applications.
ONS conducted a survey of all ONS members in late 2010 to identify the trends and issues facing members in their work. Results represent 1,589 responses.

ONS Wants Your Suggestions and Feedback

Got an idea? Have a concern? Want to make a suggestion? Take a minute to send your ideas and feedback to ONS at SuggestionBox@ ons.org. Thank you for supporting our ongoing improvement! 4
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editors note

Cancer Center Design Must Focus on Patient Needs

[By Debra M. Wujcik, RN, PhD, AOCN , FAAN, Editor]

Despite our best efforts, what works or is current in space design and decoration may not be congruent with what patients need.
t looks like a spa was the comment made by a woman as she entered the newly remodeled breast health center in the public hospital where I practice. Despite a very limited budget, the manager and staff had taken the opportunity to change the atmosphere when the clinic space had to be reconfigured to accommodate new equipment. Small changes in the colors of the walls, placement of the waiting room furniture, and decorations completely moved the atmosphere from a clinical to a comfort focus. Although this is common in large hospitals and cancer centers, a spa-like environment is novel in city-owned facilities. Often, nurses have little or no input into the design of the clinical space despite the fact that equipment placement, numbers and location of electrical outlets, and location of supplies and medications can greatly influence the efficiency of the workflow. However, years ago I was part of the construction planning team for an expanded bone marrow transplant unit in a major cancer center. The final design was state of the art and incorporated nurse serversclosets holding supplies, medications, and the food tray that open both in the hall and inside the patient room. The rooms were large with plenty of outlets on both sides of the bed. The other

Debra M. Wujcik, RN, PhD, AOCN , FAAN, Editor

nurses on the team and I felt we had successfully advocated for both patient and nursing needs. A decade later, the nurse servers are no longer used as designed and supplies and medications are stored in out-of-the-way spaces. Someone who knows me overheard one of the nurses commenting, Who designed this unit anyway? Despite our best efforts, what works or is current in space design and decoration may not be congruent with what patients need. Although large, spacious clinics may be visually appealing and soothing, the distance a weakened patient has to walk from the parking lot or front door to the treatment chair can be daunting. The ONS Connect Editorial Board selected cancer center environment as this months topic. Two centers are featured that incorporate physical design and a positive patient care environment to meet the physical and emotional needs of patients. In One Nurses Perspective, a staff nurse shares not only the frustrations of working in a physical space that was designed for another purpose but also tips on adapting the space to accommodate patient needs. As always, we invite you to share your comments on what works or does not work in your patient care environment along with any strategies used to make changes that worked.

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just in

[By Deborah McBride, RN, MSN, CPON , Contributor]

Pancreatic Cancer Survival improved With Combination Therapy

atients with metastatic pancreatic cancer who take a combination of four chemotherapy medications were found to have a 60% better average survival than with the current standard therapy, according to a new report. Pancreatic cancer has a high death rate. Fewer than 6% of patients survive for longer than five years after diagnosis, making it the fourth leading cause of cancer-related death in the United States. The new multicenter, randomized, phase II and III trial compared gemcitabine with FOLFIRINOX (oxaliplatin, irinotecan, leucovorin, and fluorouracil) in 342 patients with metastatic pancreatic cancer. All of the participants were younger than 76 years old and received

their medications for six months. The median survival time was 6.8 months in the gemcitabine group and 11.1 months in the FOLFIRINOX group. Those in the FOLFIRINOX group experienced significantly more side effects, including diarrhea, weight loss, numbness in the hands and feet, and pain. According the researchers, FOLFIRINOX therapy represents a new standard of care for metastatic pancreatic cancer against which other therapies will need to be compared. According to the researchers, given the toxicity of the therapy, care must be used in choosing patients for this more aggressive combination therapy.
Conroy, T., Desseigne, F., Ychou, M., Bouche, O., Guimbaud, R., Becouarn, Y., . . . Ducreux, M. (2011). FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. New England Journal of Medicine, 364, 18171825.

Fiber Optics may increase Colonoscopy Comfort

lthough colonoscopy is regarded as the best way to screen for colon cancer, the potentially life-saving procedure can be painful. Researchers have designed a device to reduce patient discomfort while also ensuring the accuracy of the examination. The device, an endoscopic fiber optic shape tracker, navigates the scope through bends and turns in the colon. Currently, when the tip of the scope hits the colon wall, the tip can become stationary and, as the healthcare worker applies more pressure, causing more patient pain, a loop can form in the length of the scope behind the tip. Because the traditional endoscopy provides only a frontal view during the procedure, the provider cannot see the loop. By outfitting the endoscope with fiber optic bend sensors and digital electronics that display its position and shape on a video monitor, the researchers have a way to see in real time how the scope is moving inside a patients body, and if the scope begins to loop, they can make the adjustments to straighten it out without applying pain-causing pressure. More comfortable colonoscopies may increase the number of individuals who are willing to seek the procedure.
Gavalis, R.M., Wong, P.Y., Eisenstein, J.A., Lilge, L., & Cao, C.G.L. (2010). Localized activecladding optical fiber bend sensor. Optical Engineering, 49, 064401. doi: 10.1117/1.3449110

Several Cancers Are Underrepresented in Clinical Trials

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everal cancers with a high burden of disease are not getting the clinical trials they require, according to a new study. The study compared cancer

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clinical trial activity, burden of disease, and sponsorship of clinical trials. Four out of five cancers (lung, colorectal, prostate, and pancreatic) with the greatest burden of disease had relatively few clinical trials in Australia. According to the authors, the number of trials for each cancer type did not always match the burden of disease caused by that cancer, resulting in gaps in cancer trials research. Of the 368 interventional cancer trials open to recruitment, breast cancer accounted for 62 trials. Yet only 24 trials were being conducted on lung cancer, despite it being responsible for the greatest burden of disease. The researchers found that industry sponsorship is more likely for randomized controlled trials that investigate systemic therapies (drugs or biological agents) for patients with advanced cancers. The researchers said their results also reflect the international situation.
Dear, R.F., Barratt, A.L., McGeechan, K., Askie, L., Simes, J., & Tattersall, M.H. (2011). Landscape of cancer clinical trials in Australia: Using trial registries to guide future research. Medical Journal of Australia, 194, 387391.

Nurses and other health professionals routinely underestimate the prevalence of limited health literacy and overestimate patients ability to understand medical information.
an individual can obtain, process, and understand health information needed to make appropriate health decisions and overestimate patients ability to understand medical information. The researcher compared several available health literacy screening tools, including Rapid Estimate of Adult Literacy in Medicine (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), the Wide Range Achievement Tests, and the Newest Vital Signs assessment. The study found that the TOFHLA and REALM were equally reliable and valid instruments and both were appropriate for older adults. The tests take nurses roughly three minutes to perform, according to the researcher, and should be used to assess patients literacy levels at the first appointment.
Mullen, E. (2011, April). Assessing health literacy of elderly cancer patients in clinical practice: What clinicians need to know [Poster 434]. Oncology Nursing Society 36th Annual Congress, Boston, MA.

Health Literacy Tests may improve Patient Care

ow health literacy is a significant barrier to quality care, especially among older adults, but increased use of simple and effective health literacy assessment tests by nurses and clinicians can help improve communication and health outcomes. Several tools are available to assess health literacy, but they are underutilized, according to a presentation at the ONS 36th Annual Congress. According to the researcher, nurses and other health professionals routinely underestimate the prevalence of limited health literacythe degree to which

and other healthcare providers are unprepared and uncomfortable when initiating discussion about sexuality with their patients, according to an abstract presented at the ONS 36th Annual Congress. The researchers surveyed nurses and found multiple barriers to addressing sexuality issues with their patients, including lack of necessary knowledge, confidence, and comfort initiating the discussion. According to the researchers, the nurses surveyed understood the need to address sexual problems in their patient assessments but were afraid they wouldnt have the answers to patients questions. The researchers created a patient education brochure on sexuality and cancer for nurses to give to patients in their initial assessment and recommended education sessions for nurses on the physical and psychological side effects associated with cancer and cancer treatment.
Mathew, L. (2011, April). Nurses knowledge, attitude, and practice related to sexuality in patients with cancer: What is the evidence? [Poster 217]. Oncology Nursing Society 36th Annual Congress, Boston, MA.

most Nurses Are Uncomfortable Discussing Sexuality With Patients

exual problems often result from the physical and psychological side effects associated with cancer and cancer treatment. Many patients, male and female, experience significant issues related to sexual function, body image, and intimacy. However, nurses

Contributor Deborah McBride, RN, MSN, CPON, is a staff nurse III at the Kaiser Permanente Oakland Medical Center and an assistant professor at Samuel Merritt University in Oakland, CA.
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Cancer Center Design

Enhancing the Patient Care Environment
[By Jennifer K. Mitchell, MSN, ANP-BC, GNP-BC, Contributing Editor]

ronment is holistic as wellencompassing the physical structure and amenities of the facility, the quality and breadth of services provided, and the culture of the people providing care.

ursing involves caring for the whole person (body, mind, and spirit), not just the physical body. In the same way, an optimal patient care envi-

Kimberly Caudill, RN, BSN, says that by ensuring patients are educated about support services, nurses are caring for patients on the mental and spiritual level.

The Physical Environment One way that cancer care centers can enhance the patient care environment is through space planning and physical amenities. North Star Lodge (NSL), in Yakima, WA, is a cancer center designed exclusively with patients in mind. ONS members Charlotte Montgomery, RN, MSN, a psychosocial nurse at NSL, and Kimberly Caudill, RN, BSN, nurse manager at NSL, describe the facility as a free-standing, comprehensive cancer center that is designed to look like an outdoor lodge. Serving a rich agricultural area with natural beauty, it was very important to the designers of NSL to build a tranquil, peaceful cancer center with an emphasis on nature. To enter the building, you cross over a log bridge with a stream running beneath, Montgomery explains. Once inside, the

comfortable lodge treatment setting offers a warm, healing atmosphere with waterfalls, peaceful spaces, and other natural surroundings. In the main waiting area, a glass wall overlooks the man-made waterfall located at the center of the building. There are large stone fireplaces in the waiting area and the infusion room. To reduce noise that can cause stress, we ask patients to have a caregiver or visitor at their clinic visits but to limit guests to one to two people out of respect for other patients, Montgomery says. Large groups of visitors are encouraged to use the main lobby and other common areas or meeting rooms. Although NSL was designed solely with patients with cancer in mind, many patient cancer care centers reside in structures that were designed for other purposes. ONS member Nancy

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Lehde, RN works as a clinic nurse in the Jane C. Nelson, MD, Breast Surgery Clinic in Austin, TX. Lehde explains that the facility is part of a medical office condominium where the layout was designed specifically for the breast clinic. The design team needed to add specific, functional elements, such as lead shielding for staff and patient protection, darkening screens for the positron-emission mammography (PEM) room, and chart racks and preparation areas for the exam and diagnostic rooms. The exam rooms and PEM scanner are located at the front of the office, while the file rooms, treatment supplies, and administrative offices are in the back, Lehde says. This optimizes patient flow and helps minimize patient travel in the office, which is important for patients who may have trouble moving or may become easily tired. As at NSL, nature and natural light are very soothing, positive distracters to patients and family members in the breast clinic. Although the facility does not have direct access to nature, Lehde says they simulate a natural environment with large windows that let in natural light, live plants in the waiting room, and artwork featuring natural landscapes with cool colors such as purples and greens. To minimize noise, the office has soft background music and mostly carpet flooring. One of the exam/ procedural rooms has bamboo flooring, which is beautiful and practical because it is easy to clean and durable. A variety of Services Looking beyond the physical environment, Montgomery says, nurses and other members of the clinical team can improve the patient care environment by connecting patients to appropriate support services. Montgomery is a psychosocial nurse who works closely with a clinical social worker to help nurture the mind and spirits of patients by building relationships with patients and families. 10
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Charlotte Montgomery, RN, BSN, says that nurses can build relationships with patients and families to better meet their needs during times of stress.

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I identify patients early on who are at risk for difficulty coping and build relationships with patients and families before they begin treatment so that if a stressful event occurs, I can quickly direct the patient for support or assistance, Montgomery explains. Some of the patient services offered at NSL include exercise and yoga classes, journaling clubs, and learning opportunities such as the American Cancer Societys Look Good, Feel Better classes or NSLs own Learn at Lunch series, which offers the community and patients information on dietary and complementary therapies in a living room setting. As nurse manager, Caudill helps to improve the patient care experience by encouraging nurses to become more

involved in educating about ancillary services and to participate in developing and providing enhanced patient support services. It is the role of a nurse to make sure patients are aware of various support resources, and efforts should be made to shore up education surrounding support services, she says. Increased awareness of available services and educational opportunities can lead to better patient education, increased participation in group classes, and improved adherence for patients who are on oral chemotherapy. Thorough patient and family education can go a long way in alleviating stress and improving the patient care environment because it can reduce the patients fear of the unknown. At the

Ergonomics for Oncology Practice Settings

The goal of ergonomics is to reduce or eliminate musculoskeletal disorders (MSDs), which are the result of incompatibilities between the work conditions, work demands, and worker capabilities (Occupational Safety and Health Administration [OSHA], 2007). Even when workspaces are designed by nurses, the focus is on work flow and space needs, not on making them ergonomically correct. A trained ergonomics specialist can assess a work area and make recommendations to alleviate incompatibilities. If an ergonomic assessment isnt possible, here are some common ergonomic problems and tips for alleviating them. Prolonged standing on hard flooring can contribute to MSDs of the feet, legs, and lower back. OSHA (2000) recommends using anti-fatigue mats as a simple and inexpensive solution. Bending the wrists up or down or resting them on hard or sharp objects can contribute to MSDs of the wrists and hands. OSHA (n.d.) recommends using an ergonomic keyboard, because it maintains a neutral wrist posture. A wrist rest, preferably gel, is also recommended to minimize contact pressure on the wrists and forearm. Awkward postures or unsupported positions can compress nerves and irritate tendons, leading to MSDs of the arms, legs, neck, and back. OSHA (n.d., 2000) recommends using adjustable ergonomic chairs and stools as a simple and relatively inexpensive solution.
Occupational Safety and Health Administration. (n.d.). OSHA ergonomic solutions: Computer Workstations eTool. Retrieved from http://www.osha.gov/SLTC/etools/computerworkstations/ index.html Occupational Safety and Health Administration. (2000). Ergonomics: The study of work. Retrieved from http://www.osha.gov/Publications/osha3125.pdf Occupational Safety and Health Administration. (2007). Ergonomics. Retrieved from http://www .osha.gov/SLTC/ergonomics/index.html

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Nancy Ledhe, RN, explains that even facilities without direct access to nature can bring the outdoors to their patients with windows and plants.

pretreatment education session with the nurse, patients receive a notebook of tailored information about their illness and an itinerary for treatment so they can track their treatment and experience. This one-on-one session with the nurse prior to beginning therapy builds patients trust with the care team and helps them feel more comfortable because they understand their treatment plan. Nursing Staff Support and Workflow Caudill believes that a major reason patients report a positive care environment at NSL is because of the caliber of staff and overall culture. Because oncology nurses play a major role in helping provide an optimal healing envi12
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ronment for patients, it is important for nursing leadership to support nurses well-being. I help ensure my nursing teams well-being by ensuring smooth workflow, adequate staffing levels, and offering emotional support to the nurses, Caudill says. Nursing leaders at NSL focus on retaining existing staff and recruiting nurses who are skilled, compassionate, and patient-centered. These qualities are reflected in the pool of nurses at NSL, where over 50% of the RNs on staff are OCN certified and have extensive nursing experience. For nurses who work directly with an oncologist, Caudill has helped to alleviate work place stress and balance nurses workload by scheduling one administrative day per week that

coincides with the physicians administrative day. Nurses use this time to schedule patient education sessions, review diagnostic results with providers, follow-up on patient phone calls, and review upcoming clinic patients, Caudill explains. Other strategies to improve workflow and the patient-care experience are initiatives like Shared Leadership (Shared Governance), which allow nursing and administrative staff to work collaboratively and autonomously to resolve issues. Oncology nurses do their best to promote a positive patient care environment, but because of the stressful nature of oncology nursing, it sometimes becomes difficult to remain positive and supportive to patients and other team members day after day. The psychological well-being of the nursing team is vital in enhancing the patient care environment and minimizing nurse burnout, Montgomery says. Participation in programs like NSLs remembrance sessions to assist staff in dealing with grief and loss, candlepassing ceremonies to promote staff coping, and roundtable discussions about issues that are meaningful to staff members all help strengthen the interpersonal relationships and wellbeing of the members of the healthcare team. The patient care environment encompasses the physical space, culture, and nature of the services provided within the facility. Oncology nurses, regardless of their role, have the opportunity to impact one or more of these components, which can positively influence the environment of patient care.

Contributing Editor Jennifer K. Mitchell, MSN, ANP-BC, GNP-BC, is a cancer access center leader for Vanderbilt Ingram Cancer Center in Nashville, TN.

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one nurses perspective

How Do You Overcome Obstacles in Your Oncology Practices Design?

ONS member Laurie Rosenthal, RN, is a staff nurse in outpatient oncology in North Carolina.

work in a building that was constructed in the early 1980s and was originally used by a law firm. When the large health system I work for in North Carolina took over the space, nurses had minimal input in the redesign of the suite. We had outgrown our space on the medical campus, so our focus had been on the need for more space. By the time nurses were brought into the process, the blueprints were already drawn up and the walls were in place. I and the other oncology nurses were asked about the number of nurses stations we needed, but we werent asked how the nurses

stations should be designed or laid out. Im always concerned about making things easier for my patients, and I think thats true for most oncology nurses. For example, electrical outlets are located low on the walls, so patients have to bend down to unplug their pumps to go to the bathroom. This happens often because of the drugs we give them that cause diarrhea or all the hydration we give. I would love to have one private infusion room to care for patients who are neutropenic, but we dont. Currently we use an exam room for this purpose, but the exam table isnt as comfortable as an infusion chair. Its not as easy for the nurse to see the patient, either, and it means the physicians in the practice have one less exam room for seeing patients. We also

need more bathrooms (we only have two now), and ideally they would be located on each end of the infusion suite. Patients have commented on the lack of bathrooms; they watch to see when they are free or ask other patients to tell them when its free. I have learned to overcome these structural obstacles in providing care to my patients. Our solution has been to institute a policy where only the infusion nurses can plug and unplug the pumps, so that patients dont have to bend down. We have now equipped two exam rooms with infusion chairs, and they are covered by an RN who is not working the infusion room, usually a nurse whose assigned physician is out that day. Although we are not currently considering redesigning our office, when other satellite offices were added or opened, they did ask for nursing input. Even nurses had some hits (e.g., a patient and family common area equipped with tables in the infusion room) and misses (e.g., infusion and practice nurses stations side-by-side) in designing the new offices. Although we continue to learn from our past mistakes, we havent arrived at the perfect design. I guess you could say designing the ideal environment for oncology nurses and patients is a work in progress.
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five-minute in-service
As seen in the CliniCal Journal of onCology nursing

Developing an Outpatient Symptom Management Clinic

[By elisa Becze, BA, ELS, ONS Staff Writer]

atients with cancer have identified a key need for symptom relief in the outpatient setting. In inpatient units, patients are constantly monitored by the healthcare team, so symptoms and side effects can be addressed as they appear. In the outpatient setting, however, patients are seen less frequently by the healthcare team. Symptoms and side effects can be better

managed and more efficiently addressed in a specialized symptom management clinic (SMC) that works in tandem with the outpatient oncology clinic. In their article in the February 2011 issue of the Clinical Journal of Oncology Nursing, Whitmer, Pruemer, Wilhelm, McCaig, and Hester discussed their development of a business plan for an SMC at their outpatient cancer center.

Development of the Clinic The idea for the SMC began with an oncology nurse, a clinical pharmacist, and an oncologist. The clinic first focused on managing pain and fatigue, then additional symptoms were added as needed. Oncologists in the outpatient oncology clinic refer patients to the SMC, where the symptom is managed solely by the SMC. Patients cannot self-refer. Whitmer et al. explained that because of the uniqueness and complexity of the symptoms experienced by patients with cancer, oncologists welcomed the aid of a referral service as they faced increasing numbers of patients (p. 176). To the authors knowledge, their clinic is the only multidisciplinary, collaborative SMC in the Ohio, Indiana, and Kentucky area. Communication: The SMC communicates with referring oncologists by email, reporting plans of care, progress in symptom control, and updates of services rendered. The communication becomes part of a patients medical record. Management and staffing: The SMC is overseen by an administrative board that is led by the medical director. All SMC staff members (see Figure 1) also serve on the board, as well as invited interdisciplinary members who have a needed expertise. The board meets monthly to address administrative issues, discuss challenging plans of care, and evaluate outcomes of care.

Five-Minute In-Service is a monthly feature that offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes Development of an Outpatient Oncology Symptom Management Clinic, by Kyra Whitmer, PhD, RN, Jane Pruemer, PharmD, BCOP, Cheryl Wilhelm, RN, OCN, Linda McCaig, RN, ACRN, and Jennifer D.B. Hester, DNP, AOCNS, ACHPN, which was featured in the February 2011 issue of CJON. Questions regarding the information presented in this Five-Minute In-Service should be directed to the CJON editor at CJONEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.

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Developing guidelines: SMC staff reviewed, assessed, and adapted nationally recognized guidelines for the needs of the patients being seen. Evidencebased protocols or algorithms for each symptom were developed to ensure consistency of patient care. Assessing clinical and financial success: The SMC regularly surveys oncologists and patients to measure satisfaction. In addition to the surveys, patients are asked at each visit about their satisfaction of the management of the symptom being treated. Financially, the SMC was able to compensate staff for percent of effort by year two, planned to financially break even by year three, and was able to hire an advanced oncology clinical nurse specialist (AOCNS) by year four. Patients are charged for services only when the physician examines them, although reimbursement for services provided by the clinical pharmacist, AOCNS, and oncology nurses has been explored. Any operating loss is absorbed by the affiliated hospital as a community service. Clinic Procedures Patient visits: On a patients first visit, after contact and insurance information is taken and vital signs and weight are obtained, patients are asked to complete a self-assessment form and pain management agreement. Because opioids are frequently prescribed for pain, the agreement outlines behavior expected from patients and providers, risks of treatment, methods of monitoring for abuse, and consequences of inappropriate behavior. The nurse assesses the patient, followed by the clinical pharmacist and social worker, if needed. The team reviews the findings and makes a recommendation to the medical director, who

Figure 1. Symptom management Clinic Staff

Administrator: Hires SMC staff; addresses administrative issues; consults with referring oncologists; receives patient calls Advanced oncology clinical nurse specialist (AOCNS): Performs physical examinations; assesses patients functional status, pain, and symptoms; works with medical director and pharmacist to develop and document plan of care; sees patients for follow-up Clinical pharmacist: Reviews patient records to verify medications and allergies; works with AOCNS and medical director to develop and document plan of care; provides patient education and answers patient and family questions; writes prescriptions; makes referrals and schedules follow-up appointments; receives patient calls; sees patients for follow-up Consultant: Monitors patient services for outcomes and satisfaction; continually develops and advocates for the SMC; applies for external funding Medical assistant: Reviews patient history and verifies medications and allergies listed in medical record Medical director: Provides consultations; orders additional diagnostics as needed; prescribes medications; reports on overall patient findings and plans of care Receptionist: Schedules and reminds patients of appointments; obtains referrals Oncology certified nurse: Reviews patient history and verifies medications and allergies listed in medical record; reviews and documents patients self-reports; provides and documents patient education and patient and family questions; contacts patients to assess for outcomes; sees patients for follow-up Social worker: Reviews medical record; reviews patients self-reports; documents plan of care; counsels patients as needed; contacts patients to assess for outcomes; sees patients for follw-up

provides consultation. The team reviews the plan with the patient, providing education and answering questions. Written medical instructions are given to the patient and placed in the medical record. Follow-up visits are scheduled as needed, and an oncology nurse or clinical pharmacist is on call during nonbusiness hours for urgent patient questions. Medication reconciliation: The staff reviews and reconciles all patient medications at each visit. The SMC has found that this improves patient safety by decreasing drug interactions and helps patients to better understand their medication regimens. At the beginning of

each visit, the provider reviews all medications, prescription as well as over the counter, with patients, explaining when and how each drug is taken. As part of their treatment plan, patients receive a written list of all medications that includes route, dose, amount, times, and specific instructions. For more information on Whitmer et al.s SMC, refer to the full Clinical Journal of Oncology Nursing article.
Whitmer, K., Pruemer, J., Wilhel, C., McCaig, L., & Hester, J.D.B. (2011). Development of an outpatient oncology symptom management clinic. Clinical Journal of Oncology Nursing, 15, 175179. doi: 10.1188/11.CJON.175-179

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you tell us

How Do You Think the Patient Care Environment Affects Outcomes?

Environment Puts the Therapy in Chemotherapy believe the physical patient care environment plays a pivotal role in outcomes. I work at a new state-of-theart chemotherapy infusion site complete with serene indoor gardens, a water wall, and an art gallery space. Every time patients visit the site for the first time, they are in awe of the environment and comment that it is very spa-like and serene. Each patient has a private treatment room with a chemotherapy recliner chair that is equipped with a touch-screen interactive system. The system allows patients to call a staff member for assistance, watch television, surf the Internet, review patient education online, log in to the Patient Portal, and Skype with friends and family. The ability for patients to have all of this at their fingertips gives them a great sense of empowerment, which increases patient satisfaction and quality of life. Recently as a patient was leaving the site after treatment, she stopped at the front desk and said this place puts the therapy in chemotherapy. Its moments like that when we know we created the physical environment just right.

lot, and floor-to-ceiling windows that look out on two water fountains, beautiful Japanese maple trees, and flowers. Recently, one of our nurses placed a hummingbird feeder in front of the window so our patients could enjoy it while they are getting their treatments. We hear all the time how beautiful it is outside, and the patients look calm and relaxed when they look outside. It has made a huge difference for our patients, and its easier for them to relax. Jennifer Gougas, RN, BSN, OCN Facey Medical Group Mission Hills, CA The Environment Affects Everyone in it t has synergistic effects with the holistic well-being and functioning of patient/family and staff. Much has been done to safeguard the standard of patient care, less for families, and perhaps even less for nurses and other care staff

Jeanine Gordon, RN, MSN, OCN Nurse Leader Memorial Sloan-Kettering Cancer Center Brooklyn Infusion Center New York, NY A Calming Environment Helps Patients Relax lmost two years ago we remodeled our infusion center with an amazing patio area, well-thought-out with a beautiful cedar fence that blocks the parking

in general, from where we are. On the whole, the physical environment for patients has improved. Some provisions are made for families also. As to nurses and other care staff, it does appear that better patient care outcomes could come about, when they have the space to work in comfort. And even more so, when there is dedicated space for them to relax and constantly renew themselves, thereby feeling understood and valued for what is demanded and expected of them daily at the worksite. Even the most attractive physical environment could be soulless and heartless. To have optimal outcomes for quality care and quality of life, a supportive environment has to be integrated for everyone in it as policy in action. Happy patients and families, happy staff! Camila Suk Li Yi Hong Kong Anti-Cancer Society Pok Fu Lam, Hong Kong

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what would you do?

The Case of Anticipated Alopecia

[By seth eisenberg, RN, OCN , Contributing Editor]

fter being diagnosed with cancer, Fran was told that the treatment would result in losing her hair. The news was as almost as devastating as the diagnosis, and she briefly considered alternative therapies that would not have this side effect. Fran arrives for her first chemotherapy appointment emotionally distraught and asks the nurse if there is any way to prevent losing her hair. She then tells you about a product she saw on the Internet which provides cooling to the scalp. What Would You Do? Although the precise pathophysiology is not fully understood, alopecia is caused by damage to rapidly dividing hair follicles. Mitotic cessation of kera-

tinocytes in the follicle bulb causes constriction of the hair shaft, with resultant shaft breakage (Trueb, 2009). Hair loss has been described as one of the worst aspects of chemotherapy and can have a profound impact on a patients well-being and ability to cope with treatment (Johnson, 2010). Despite the impact, it has largely been ignored in scientific studies. Scalp cryotherapy (ice or cold caps) dates back to the 1970s and theoretically works by reducing chemotherapy to the hair follicles through vasoconstriction and by reducing the biochemical activity of the follicle itself (Trueb, 2009). Because decreased blood flow can prevent chemotherapy from entering tissues, concerns have been raised regard-

ing inadvertent sequestering of scalp metastases (Johnson, 2009). However, there is no evidence to validate or nullify this concern. Similarly, only a handful of small studies have been conducted to demonstrate efficacy, with varying results. The nurse should explain the lack of evidence to support the use of scalp cryotherapy and should also ask the patients physician to discuss it further. If cryotherapy is not used, the nurse should provide the patient with resources for obtaining wigs or head coverings.
Johnson, W.J. (2010). Alopecia. In J. Eggert (Ed.), Cancer Basics (pp. 345351). Pittsburgh, PA: Oncology Nursing Society. Trueb, R.M. (2009). Chemotherapy-induced alopecia. Seminars in Cutaneous Medicine and Surgery, 28, 1114. doi: 10.1016/j.sder.2008.12.001

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capitol connection

Partnership for Patients Aims to Reduce Hospital Mortality and Readmission Rates
[By Alec stone, MA, MPA, ONS Health Policy Director]

atient-centered care continues to be a focus for healthcare providers, and its now drawing the attention of the U.S. Department of Health and Human Services (HHS). In April, HHS unveiled a new initiative called Partnership for Patients, designed to provide better care and lower costs to the healthcare system. Using as much as $1 billion from the Affordable Care Act, along with existing programs, HHS aims to reduce preventable hospital-acquired infections by 40% and lower readmissions by 20% by 2012.

The current data highlights the urgency to train providers in infection control practices, said Assistant Secretary for Health Howard K. Koh, MD, MPH. In a unique teaching format, HHS created the interactive Partnering to Heal video (www.hhs.gov/ash/ initiatives/hai/training), which allows providers to follow decision-makers who impact health risks and then learn from those choices. Over the next three years, HHS estimates that the two changes could result in as many as 1.8 million fewer

injuries to patients, with more than 60,000 lives saved. Furthermore, this may mean that about 1.6 million patients would not develop preventable complications requiring readmission to hospitals within 30 days of discharge. Ultimately, in addition to decreasing mortality rates and increasing patients quality of life, an estimated $11 billion will be saved by the healthcare system annually. For more information, visit www .healthcare.gov/center/programs/part nership/index.html.

calendar of events

Mark Your Calendar for These Upcoming Oncology Nursing Events and Deadlines
Survivorship issues in Cancer Care Regional Conference Conference dates: August 19 20, Baltimore, MD; October 78, Detroit, MI; coming soon, San Francisco, CA For more information: Visit www .ons.org/CNECentral/Conferences/ Survivorship. ONS Foundation APN Conference and iOL Scholarships Application deadline: September 1 For more information: Visit www .onsfoundation.org/apply/ed/APN or www.onsfoundation.org/apply/ed/ MaryScherbring. 18
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ONS Radiation eConference: Radiation Then & Now Conference date: September 910 Description: This virtual conference gives you quality radiation education without the high costs of travel. For more information: Visit www .ons.org/CNECentral/Conferences/ radiation2011.

Primary Care issues in Cancer Care Regional Conference Conference dates: September 2324, Charlotte, NC; September 30October 1, Nashville, TN; November 1819, Hartford, CT For more information: Visit www .ons.org/CNECentral/Conferences/ PrimaryCare.

Contact ONS
125 Enterprise Drive, Pittsburgh, PA 15275-1214 USA Phone: 866-257-4ONS (toll free) or +1-412-859-6100 Fax: 877-369-5497 (toll free) or +1-412-859-6165 Email: customer.service@ons.org Website: www.ons.org

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new treatments, new hope

Treating Breast Cancer in Developing Countries

[By Deborah McBride, RN, MSN, CPON , Contributor]

orldwide, cancer incidence and mortality are expected to increase by 50% between 2002 and 2020, according to a new report by cancer experts. These global cancer rates will be rising the most in developing countries. By 2020, 70% of the 16 million cancer cases that year are expected to be in low- and middleincome countries (LMCs). As the most common cause of cancer death among women around the world, breast cancer outcomes need to be addressed proactively as a way of preventing the predicted global cancer epidemic, according to the authors. The review was from the Breast Health Global Initiative 2010 summit, which brought together 150 experts from 43 countries who analyzed breast cancer control issues and implementation strategies for LMCs, where advanced stages at presentation and poor diagnostic and treatment capacities contribute to lower breast cancer survival rates than in high-income countries. The authors found that people living in low-income countries have little awareness that breast cancer is treatable, inadequate pathology services for diagnosis and staging, and poor treatment availability, especially for radiotherapy and drug treatments. In middle-income countries, the main challenges are latestage presentation of disease; limited data collection; poor community access to early detection, diagnosis, and treatment; and low prioritization of breast cancer control programs within the healthcare system. In LMCs, a lack of awareness about cancer or an inability to seek basic health care means that patients com20
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In low- and middle-income countries, a lack of awareness about cancer care and an inability to seek basic health care means that patients commonly present with late-stage disease.
monly present with late-stage disease. In India, for instance, 50%70% of patients have locally advanced or metastatic disease at diagnosis. Although four out of five breast cancers are cured in the United States and Western Europe, the disease is likely a death sentence in most Sub-Saharan African countries, according to the authors. In addition, healthcare providers in developing countries are often not well trained in cancer diagnosis, and treatment may either be nonexistent or too costly for patients (out-of-pocket expenses are highest in the poorest countries in the world). Healthcare professionals in LMCs may not have sufficient training in surgical techniques such as mastectomy, which means that malignant tissue may be left in the body. After surgery, patients may fail to receive the critical drug therapies that can prevent metastatic disease from becoming established. Public awareness about breast cancer is very low in most LMCs. Women are often not educated regarding selfexamination techniques. In the poorest settings, physicians themselves may have never seen an early breast cancer case and therefore may not recognize the need to initiate diagnosis and treatment at these early, potentially curable stages. The authors concluded that LMCs healthcare systems face several challenges, including national or regional data collection, program infrastructure and capacity (including appropriate equipment and drug acquisitions and professional training and accreditation), the need for qualitative and quantitative research to support decision making, and strategies to improve patient access and compliance. Increased awareness is needed among the public, healthcare professionals, and policymakers that breast cancer is a cost-effective, treatable disease.
Anderson, B.O., Cazap, E., El Saghir, N.S., Yip, C., Khaled, H.M., Otero, I.V., . . . Harford, J.B. (2011). Optimisation of breast cancer management in low-resource and middle-resource countries: Executive summary of the Breast Health Global Initiative consensus, 2010. Lancet Oncology, 12, 387-398. doi: 10.1016/S14702045(11)70031-6

Contributor Deborah McBride, RN, MSN, CPON, is a staff nurse III at the Kaiser Permanente Oakland Medical Center and an assistant professor at Samuel Merritt University in Oakland, CA.

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a closer look

Almost Anyone Can Write for Publication

[By seth eisenberg, RN, OCN , Contributing Editor]

n the animated picture Ratatouille, Remy was inspired by the slogan Anyone Can Cook. While not everyone can write manuscripts, in many ways, writing for publication is similar to cooking. Its wise practice to read through a recipe before you start cooking to ensure you understand the preparation process. Likewise, before launching into your writing masterpiece, you may want to send a letter of inquiry to the editor of your target journal to determine if your topic is a good fit (Oermann & Hays, 2010). Your letter, by the way, gives the editor a preview of your writing style, so draft it with care. Once youve settled on a topic, a preliminary outline will help limit the scope of your literature search and prevent tangential forays into areas you cannot cover within the confines of the article (Oermann & Hays, 2010). Thats important because articles have word limits. Book chapters generally do not have such constraints, but first-time authors may want to start with an article, similar to how new cooks may begin with a dessert dish instead of embarking upon a 12-course meal. Just as recipes require ingredients, manuscripts need published references to support the topic. ONS has done extensive research on hierarchy of evidence, which will be useful as you evaluate the strength of your references (Mitchell & Friese, n.d.) Electronic databases such as MEDLINE and CINAHL allow reading of abstracts, which is a good way to decide whether an article will be a useful reference. Using abstracts alone should be avoided as important details will not be

included, so obtaining original article PDFs is necessary. Just like recipes, there are a number of different ways to organize your downloaded references, and you may elect to separate them into key folders. You will often need the original work that has been cited in a newer article. Why? Because the newer article may have misinterpreted the original work or took some information out of context. Computer programs are available to help with long reference lists, although shorter lists can be done manually. Regardless, references must be accurate and formatted correctly (Oermann & Hays, 2010). Although the editor may add a dash of salt or pepper, the epic meal you serve must be properly cooked or it may be returned to your literary kitchen. Copy editors (those who are skilled in corralling commas and deleting dangling participles) will fix a few problems; major surgery, however, always belongs with the author. Once youve finished your draft, let it cool down for a while. Just as its difficult to slice freshly baked bread, its hard to proof something youve been working on without a break. Then give

your draft to someone you trust, preferably not a family member who will love anything you write (or consume whatever you cook). Most journals send manuscripts to other expert nurses for peer review. Such scrutiny takes time, so be patient. Hopefully you will get that email confirming your submission was accepted. But be forewarned: it will still require some revisions or clarifications. If your draft was not accepted, remember, writing tends to improve with more writing (Oermann & Hays, 2010). In the end, you will have prepared an intellectual feast that will feed many hungry nurses. Perhaps cooking is easier than writing. But your contribution to the nursing profession will live on long after the dishes have been cleared.
Mitchell, S.A., & Friese, C.R. (n.d.). ONS PEP weight-of-evidence classification schema: Decision rules for summative evaluation of a body of evidence. Retrieved from http://www.ons.org/ Research/media/ons/docs/research/outcomes/ weight-of-evidence-table.pdf Oermann, M.H., & Hays, J.C. (2010). Writing for publication in nursing. New York, NY: Springer Publishing.

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working for you

New Conference Model Will Better Meet Member Needs

[By Carlton Brown, RN, PhD, AOCN , ONS President]

n direct response to customer feedback and the changing landscape of healthcare meetings and education, the ONS Board of Directors recently approved some exciting new changes to ONSs national conference offerings. Instead of holding four national conferences as we have done for many years, in 2012 ONS will move to a new model of two national conferences per year. Regional conferences will also be offered to deliver additional general content. The 2012 ONS Congress will remain the same as usual and will include content of interest to all nurses, along with special interest group (SIG) and Annual Business/Town Hall meetings.

The second national conference will be held in fall 2012 and will encompass the combined audience of researchers and advanced practice nurses (APNs). For APNs, this meeting will offer intermediate- to advanced-level clinical content with preconference skills workshops. It also will target nononcology APNs with an increased interdisciplinary focus, as well as novice and expert researchers. The Advanced Nursing Research, Nurse Practitioner, and Clinical Nurse Specialist SIG meetings will be held in the fall along with a second Town Hall Meeting. We believe this new conference will more successfully assist with the translation of research to the clinical site and to patients.

The changes are in response to member feedback and changes in todays professional education environment. ONS Carlton Brown, RN, PhD, AOCN also has a strategic interest in meeting the oncologyrelated learning needs of nurses who care for patients with cancer but are not oncology specialists. Our challenge as the ONS Board is to move our society strategically forward into the future, ever focusing on what our members will need, not today or tomorrow, but in coming years. Note. I thank Anne Snively for her assistance with this column.

ONS:Edge Helps Double Your Membership Benefits

[By Laura M. Benson, RN, MS, ANP, AOCN , ONS:Edge President]

ave you noticed that your ONS dues have not increased in the past three years? One of the reasons that ONS has been able to maintain membership services without raising dues is because of ONS:Edge, one of the least understood ONS corporations. ONS:Edge was established as an ONS subsidiary in 2006, when changes in industry guidelines required the separation of continuing education programs and promotional activities. Unlike the other corporations (ONS, Oncology Nursing Certification Corporation, and ONS Foundation), ONS:Edge is a for-profit entity. As an ONS subsidiary, the dividends earned by ONS:Edge are returned to ONS to fund programs and activities. That
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helps to keep ONS dues low and provides an alternative revenue source for ONS. The mission of ONS:Edge is shaping cancer care through the power of knowledge. ONS:Edge is a healthcare intelligence company formed with the explicit purpose of bringing nursing knowledge and research deeper into the business of health care. It specializes in a core group of services: healthcare advisory boards, ancillary events at oncology nursing conferences, speakers bureau programs, strategic planning and marketing support, market research, and communications and awareness campaign development and support. ONS:Edge programming comes to you in many forms. You might receive a sur-

vey, attend an ancillary event, or participate in an advisory board or a speakers bureau. If you are an ONS chapter president or program chair, contact ONS:Edge to inquire about programming for a local meeting. You can support ONS:Edge by attending the activities that it produces. Keep in mind that ONS:Edge dividends go to help ONSs bottom line, supporting programs and augmenting member dues. By supporting ONS:Edge, ONS members benefit twice: first by receiving topnotch programs and events, and then a second time when ONS:Edge returns the profits to ONS! To learn more about ONS:Edge, visit www.onsedge.com.

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staying on top
Selling Yourself in Todays Job Market
[By Carrie smith, BA, ONS Staff Writer]

Networking Puts You in the Know

icture yourself at a conference. You are in a session, and the person sitting to your left is someone you do not know. You have a couple of minutes before the speaker begins. What are you doing? Many of you are probably checking your email or text messages, burying your head in the conference materials, or chatting with the person you do know on your right. Keeping to yourself when you might be able to make a professional contact may seem harmless enough, but it could mean missing a great opportunity or losing out on a helpful resource. Networking can make a difference in your career at any time, even if you dont have an immediate need. Who knows the next time you will need a mentor, a contact for a new job, or input from someone with expertise? Once you have convinced yourself the value of networking, the following tips

can help you get you and keep you connected. Have business cards, and take them with you to conferences. Exchange your card with people you meet, and send an email after the conference so they remember you. Join conversations on discussion boards and in comments on blog posts. Invite people you meet to become part of your network on LinkedIn, friend them on Facebook, or follow

them on Twitter. Make sure you do not take anyone in your network for granted. If someone offers their time or expertise, give them the credit and appreciation they deserve.
Gokenbach, V. (n.d.). Surviving modern healthcare: Nurses9 tips to keep your network strong. Retrieved from http://bit.ly/kEZVWu Marshall, L.S. (2010). Take charge of your nursing career: Open the door to your dreams. Indianapolis, IN: Sigma Theta Tau International.

career center
Ambulatory Care Nurses NY/NJ Metro Area Practice nursing in an environment that supports your professional growth and development. Memorial Sloan-Kettering Cancer Center (MSKCC), headquartered in New York City, is a world leader in cancer prevention, patient care, research, and education. MSKCC ambulatory care nurses are an integral part of a unique practice model that contributes to our reputation for excellence in patient care. New and expanded programs have created additional nursing positions in New York City, Long Island, Westchester, and New Jersey for office practices and treatment suites. Office practices: In collaboration with designated attending physicians specializing in a specific disease, office practice nurses provide comprehensive professional nursing care to this defined patient population. A significant component of the role is care coordination across the continuum through office visits, telephone triage and electronic communication. Treatment suites: Work collaboratively with designated physicians and in partnership with office practice nurses to provide patient education, assessment and symptom management to a defined patient population. Treatment unit nurses administer standard chemotherapy regimens as well as cutting-edge treatment to patients on clinical trials. Both areas require a New York or New Jersey RN license and a minimum of one to two years of current related clinical experience. Chemotherapy certification is preferred for chemotherapy positions. We offer modified work schedules and an excellent compensation package, including tuition reimbursement. For consideration, please apply online at www.mskcc.org/jobs. MSKCC is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply.

To place a classified ad, contact Sharon Hampton at Anthony J. Jannetti, Inc. East Holly Ave., Box 56 Pitman, NJ 08071 USA +1-856-256-2300, hamptons@ajj.com, http://careers.ons.org

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