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Memorial Sloan Kettering Cancer Center

When their caseload numbers jumped, this team took action.

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TAKING OWNERSHIP: The oncology nurses recognized that the privilege to participate in phase I clinical trials would require additional training and responsibility for the entire staff. photo courtesy Memorial Sloan Kettering

Memorial Sloan Kettering Cancer Center, New York
Team: Developmental Therapeutics Unit, Phase 1 Program
Category: Adaptability
Entry submitted by Elaine B. Llanos, MSN, RN, OCN
Judge's notes:
These team members recognized that they work in a unique area and that finding help during increased census would not be easy. They took matters into their own hands to adapt to the new volume of work and resolve their own problems.

As oncology nurses, we are a specialized group of professionals whose central goal is caring for patients whose lives have been affected by cancer. Efforts to find better treatments toward controlling or ultimately curing every type of this disease begin with clinical trials. Our Developmental Therapeutics Unit (DTU) team has the privilege to participate in the very latest research, that of phase I clinical trials. We find it exciting and extremely rewarding to implement the complexities of novel protocols while administering and monitoring side effects of drugs that carry alphanumeric names. However, this type of oncology nursing can be daunting to others, making recruitment into this specialty difficult. The year 2013 provided another challenge for our unit, as a result of an increase in both the number of trials and patient accruals the previous year, in the first three months of 2013, our treatment census grew from 1,581 in 2012 to 1,939 - an average monthly increase of 119 patients. How our team recognized, adapted to, and successfully conquered this defining moment is the basis of our submission as the ADVANCE 2014 Best Nursing Team.

Faced with a substantial increase in workload, our DTU team discussed the situation. Members included research clinic nurses, chemotherapy nurses, our nurse clinician and nurse leader, pharmacokinetic technicians (PK techs), administrative staff, and medical director.

We recognized four main areas to address immediately: volume, space, time and workload. While dialogue ensued among all of us concerning each issue, point people were established to coordinate scheduling for the increased patient volume, explore improved utilization for our allocated space and chair time, and, most importantly, how to correctly identify resources to meet the aforementioned needs. Nursing, administration and pharmacy worked collaboratively on the areas of volume, space and hours of operation. Nursing looked at justification of additional staff to meet the workload demand. Our nurse leader was instrumental as the entire unit's advocate, and acquired approval for two incremental full-time chemotherapy registered nurse positions and one newly created PK tech position. Recruitment ensued and although it would be several months before our three new slots were filled, we were grateful for the support and commitment shown by leadership.

When a new staff member joins our team, whether it is a professional nurse or nursing support staff, it is integral to make it the highest priority to provide support and education. Doing so promises benefits for each of us - such as building stronger teamwork, individually by supporting our professional development, institutionally with satisfied employees, and inter professionally toward successfully run trials - all of which translate into the very best patient care.

Both the clinic nurses who initiate patients onto trials and monitor their progress, along with the treating nurses, who administer the therapies, understood the responsibility to retain fresh, talented staff rested strongly on our shoulders. With the rapidly increasing and unique workflows we were experiencing in our phase I clinical trials unit, a unique orientation was essential. We took ownership of creating just that, incorporating all the facets of phase I clinical trial oncology nursing, in addition to incorporating it with the established Department of Nursing (DON) and basic new employee hospital orientation.

First, each new orientee was paired with a primary preceptor and schedules were established to maximize exposure and working days together. Alternate preceptors were chosen as well, not only as fill-ins for days when the primary was off, but to support protected time, cover meetings, projects and lunches. The nurse educator assigned to our unit provided the template for the required DON and hospital orientation for both the newly hired RNs and PK tech. From this point on, our own nursing staff really took the helm to craft individualized orientation pathways and integrate clinical experiences specific to the care of clinical trial patients.

To do so, the nursing staff shared experiences felt most valuable during our own orientations to this unit, as well as what improvements could be made. Interestingly, our answers pointed toward off-unit experiences and we incorporated these into new staff's schedules while their orientee status rendered them as "not counted" in our staffing numbers. Experiences built in were: spending time in pharmacy with the verification nurses and pharmacy staff to better understand the process leading up to drug delivery; shadowing treatment nurses from other chemotherapy units; orienting with the phase I clinic nurses to observe and attain a better understanding for the determination, eligibility , registering scheduling and educating patients beginning immunotherapy/biotherapy or chemotherapy trials; developing skill sets in cardiology with ECG technicians since so many of our trials involve multiple ECGs; learning blood-drawing techniques by training with phlebotomists; and observing how our PK techs prepare, obtain, document, process, store and ship protocol samples.

These collaborative and unique pathways created by all nursing staff was not only a way to create a more thorough orientation toward assuring new members attain the highest competency in their new role; it also held immeasurable collective benefits. By establishing a culture of reverence for other employees' expertise, our nursing unit fully recognized the power of inter-professional collaboration. This was the key to our successfully retaining our newly hired staff in our phase I clinical trial unit. Taking this approach, our orientees met and saw firsthand the many people involved in treating our patients. By offering these varied experiences, we provided the foundation of not only new skill sets, but also of relationship-based care, which begins with the welcoming of new staff.

Our enthusiasm and support of each other while several new staff were precepted has been rewarded by all three of them now being fully integrated members of our phase I clinical trial unit. For our efforts and positive outcomes in adapting to the challenge of increased workload in our unique setting, we proclaim our DTU team worthy of the ADVANCE 2014 Best Nursing Team award.


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