Oncology nurses

To describe oncology nurses in words is impossible. They could be called endangered – like some of our animal species, or fynbos. They could be defined as dedicated – like nuns to the Pope. They could even be described as extra special – like an expensive whiskey. But one thing is for sure, oncology nurses are like oxygen – absolutely essential; without them an oncology practice won’t function.

Oncology nurses are an unique species, displaying qualities of endurance, patience, empathy, compassion, tact, diplomacy and wit. I’ve been fortunate enough to work among the finest. But, they’re also certainly not a species to mess with; it must be noted to work with them can either be: heaven or hell. And in the treatment room, they reign with an iron fist.

The professional responsibilities of a registered nurse are embodied in the   South African Nursing Council (SANC) regulation. Their scope of practice is defined under the Nursing Act (2005/1978). The registered nurse is responsible for evidence-based physical, chemical, psychological, social, educational and technological nursing care. Therefore, specialised knowledge is required by the nursing staff in an oncology unit. There was no specialised oncology nurses training or course available, until recently.

There are a few matriarchs left; they started in the 70s-80s, next to the oncologist, mixing and administering chemotherapy to patients in, sometimes, inhospitable places. They can multitask like an octopus on adrenalin, their knowledge is astounding – ranging from poop colour and horse shampoo choices to explaining an intricate pathway of a new drug – and their stories  are fascinating.

With no training available then, they learned from scratch and gained experience through practice (trial and error). Today, further oncology nursing courses and postgraduate diplomas are available.

Meeting the basic health needs of the oncology patient is intricate and is a specialised area. In order to retain control of their lives, many cancer patients need to change their habits. They modify their prescribed social roles, and are forced to redefine and reinterpret basic concepts such as health, illness and death. With a lack of social services, the oncology nurse’s role include assisting patients to adjust to different ways of meeting their daily requirements; establishing new techniques of self-care, often modifying self-image; and revising the routine of daily living.

If you’re receiving chemotherapy, many of you will be familiar with the drill. The oncology nurse will reinforce your oncologist’s explanation of disease, treatment and prognosis, and will also clarify the aims of chemotherapy, the types of drugs administered, their frequency and possible side effects, as well as the procedures and the special-care required – all of this and more.

And, while you sit and ask for advice on how to respond to what your boss said last week, your oncology nurse will listen, answer, make you laugh, and take measures to preserve your veins, access your blood pressure, heart rate, breathing, etc. without you even noticing.

Chemotherapy drugs have a narrow therapeutic index and require checking and rechecking, from dispensing to administration, in order to eliminate mistakes. You might not notice, but when your nurse is fetching the drug from the mixing room/hatch, she probably has ten thousand thoughts running through her mind. People have little knowledge of what goes through the oncology nurse’s head: right drug to right patient. Right dose. Right volume. Right vein. Right drip rate – over the right length of time.

They can multitask like an octopus on adrenalin, their knowledge is astounding – ranging from poop colour and horse shampoo choices to explaining an intricate pathway of a new drug – and their stories are fascinating.

Multiple factors can influence the sequence of administration of chemotherapy drugs. Based on their mechanism of action, some drug combinations are more effective when given in a specific sequence and at a specific rate.

In other cases, this may also influence the toxicities of the chemotherapy regimen. Other considerations may be more practical, as in cases, where it may be best to follow a certain order, due to the risk of infusion reactions with the drugs being administered. So, don’t be fooled and think she doesn’t see you messing with that drip rate. If you hear the clang of a dustbin being kicked in the corner – it is because you fiddled with the drip rate!

The species of oncology nurses in Frankfurt, Vancouver, Los Angeles, London and Melbourne are no different to the species of oncology nurses in Johannesburg – they’re cut from the same cloth.

The only difference is there are international guidelines for oncology nurses, whereas, to my knowledge, currently there are no legislated guidelines, in place at present, for oncology nurses in South Africa. The international guidelines include the Oncology Nursing Society (ONS) in America, with alliances with the European Oncology Nursing Society (EONS) and United Kingdom’s Oncology Nursing Society (UKONS). There is also the Cancer Nurses Society of Australia (CNSA). They all adhere to strict guidelines that have been legislated and are law.

Reading all these guidelines, it is encouraging to see that our oncology nursing practices are on par with international regimes and treatment, and that we’re not even falling behind. In some countries, they have the privilege of one nurse per patient. Ideally, there should be a maximum of four patients per oncology nurse, which is not always feasible in our African setting.

The American Society of Clinical Oncology (ASCO) and ONS’s chemotherapy safety standards are intended not only to reduce the risk of errors with chemotherapy, however, also to provide a framework for best practices in cancer care. Recommendations for what personal protective equipment (PPE) to wear, when handling chemotherapy, are consistent across several groups. These recommendations don’t differentiate between high- and low-risk situations, due to the fact that there is no known minimum safe exposure, and there is always the potential for contamination.

Minimum requirement, mentioned in these international guidelines, while administrating chemotherapy are to wear PPE, such as a chemotherapy gown, mask and gloves. New administration lines are now available and affordable in South Africa, which enables the oncology nurse to administer chemotherapy with a lesser chance of spilling. The use of these administration lines will also eliminate spiking and priming the filled chemotherapy bags.

What is spiking?
Spiking is when the nurse connects the iv line to the chemotherapy bag. The iv line has a sharp spike that gets inserted into the outflow valve of the bag. This can cause spillage. The new line is then still full of air – thus the oncology nurse must run the chemotherapy down the line to expel the air. The problem is that the end of the line is open, and, often, it is very difficult to stop the chemotherapy in time, before it drops out the bottom – spilling again. There is, usually, no dedicated space to prime the line, therefore, oncology nurses are often seen holding the chemotherapy bag pinched between their necks and chins, or under their arms. Or the worst – clenched between their teeth! 

However, the use of these new administering lines will require change, and changing old habits is hard. Many of the oncology nurses’ habits stem from being taught that way by peers, and never questioning the science. It is also hard to work as fast – which oncology nurses take pride in – when changing habits. Change is hard at the beginning, messy in the middle, but utterly magnificent in the end.

New devices are also available to safeguard the oncology nurses/pharmacists’ health while mixing the drugs. However, the safety devices do   add to the cost of the treatment. It was 11 years ago, that a representative first showed me safety devices to mix oncology products in South Africa. To date, no private practise, medical aid or state hospital is prepared to pay for these safety devices. It is in this area, that we (South Africa) are lagging far behind in standards.

First world countries, now have guidelines as to which device they prefer, out of all available devices, while we, in South Africa, still mix and even administer (push) chemotherapy with needle and syringe, creating spillage and health hazards to staff. New safety devices are also available, at affordable prices, to safeguard the sterility of a vial once used, and then stored for a period of time. But it seems money is still the enemy here.

I am not an oncology nurse, however, I do have the utmost respect for them and salute them. It is for this reason, that I wish to see the new administration lines and safety devices being used here – to make their job that more easier and to protect them. They might be difficult and stubborn at times, but it is all for good reason – fighting for their patients and always wanting the best for them.

P.S. – Be nice to them; catheters and needles come in sizes they choose!

MEET THE EXPERT

Carien van der Merwe is an oncology pharmacist and has 12 years of experience in oncology pharmacy, paediatric and adult. She has been involved with chemotherapy training to ensure higher standards within the work flow of the oncology pharmacy units, and has travelled extensively in Africa evaluating and tutoring oncology pharmacy for trial sites in Uganda, Malawi, Zimbabwe, Nigeria, Tanzania and Kenya.

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