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June 2014, Volume 18, Number 3
Deborah K. Mayer, PhD, RN, AOCN®, FAAN—Editor
Regulatory Requirements: A Necessary Evil or a Way to Highlight the Essence of Good Nursing Care?
Marcia Grant, RN, PhD, FAAN
The essence of good clinical nursing care often moves into the spotlight when new regulatory requirements are created. Years ago, the Joint Commission initiated a new standard that addressed the need for patient and family education (Wakefield, 1994). “Why?” I thought, “We have been doing that for years!” I remember in graduate school in the 1960s how one of my required clinical experiences was to take care of a newly diagnosed patient with diabetes who was about to be discharged. Guess who taught her about insulin injections, diet, exercise, and follow-up care? Nevertheless, I don’t remember charting all that—the Joint Commission helped to reveal what good nursing care was all about by requiring us to chart what we have taught patients.
Another accrediting agency for cancer centers is the American College of Surgeons (ACS) Commission on Cancer (COC) (www.facs.org/cancer). This organization was established in 1913 and is a consortium of 52 professional organizations, one of which is the Oncology Nursing Society (ONS). The mission of the ACS COC is “to improve survival and quality of life for cancer patients through standard-setting, prevention, research, education and the monitoring of comprehensive quality care” (ACS COS, 2014a, p. 1). More than 1,500 hospitals have COC accreditation, and these institutions provide care for almost 70% of patients with cancer (ACS COC, 2014b). This accreditation of hospitals occurs every three years (ACS COS, 2014c).
Two new standards to be required for ACS COC accreditation in 2015 fascinate me the same way the Joint Commission patient education standard did. Standard 3 on navigation requires a patient navigation process to address healthcare disparities and barriers to care (ACS, 2011). Navigation, as a component of good cancer care, was started in 1990 by Harold P. Freeman, PhD, in Harlem, NY, to eliminate barriers to timely cancer screening, diagnosis, treatment, and supportive care for African American women. Freeman hired lay people from neighborhoods to teach the public about cancer screening, assist them in signing up for screening programs, and follow through on cancer treatment when positive results occurred (Freeman, 2004). Since that time, the concept of navigation has swept through cancer care and is now being applied to other diseases, such as diabetes. There are lay navigators and professional navigators (nurses, social workers); two national nursing organizations, The National Coalition of Oncology Nurses Navigators and the Academy of Oncology Nurse and Patient Navigators; as well as an ONS special interest group. A navigation-specific publication, the Journal of Navigation and Survivorship, also is available.
Why did nursing connect so quickly with the navigation concept? Again, it fits so well with what nurses have been doing for years. Staff nurses, office nurses, ambulatory nurses, discharge planning nurses, chemotherapy nurses—just about every nursing position—means that a nurse will be talking with the patients about their disease, what treatment they will receive, what side effects will occur and how to manage them, and what follow-up care is needed. Is this navigation? Don’t nurses do this already?
I think nurses have been navigating the public through the complexities of health care for a long time. Now the ACS COC is requiring all cancer settings to provide navigation in an organized way. Implementation may require healthcare settings to increase resources for navigation. Put a nurse in this position and implementation can be a breeze.
The second standard that the ACS COC is requiring in 2015 addresses cancer survivorship (ACS, 2011). Standard 3.3 requires a survivorship care plan (SCP) that documents the care each patient received and seeks to improve cancer survivors’ quality of life. This standard is a little more complex than Standard 3. The two components of the SCP, recommended by the Institute of Medicine report on survivorship (Hewitt, Greenfield, & Stovall, 2006), are the treatment summary and the survivorship care plan. Hmmm, care planning . . . isn’t that a phrase we use in nursing?
Collaboration across disciplines is an important component in the implementation of survivorship care. The treatment summary will require being able to retrieve information from the medical treatment record; therefore, collaboration with medical records and working with the electronic medical record, if present, is needed. The care plan will require coordination with the physicians involved in care (i.e., medical oncology, surgeons, and radiation oncologists) to determine follow-up care and the potential for late and long-term effects. Management of the late and long-term effects requires complex assessments and will likely be done by nurses (Institute of Medicine, 2011). Referral will be needed for services that address physical, psychological, social, and spiritual challenges. Healthy living education is an important component of survivorship care and can be accomplished by including dietitians, psychologists, psychiatrists, and spiritual counselors, as well as incorporating access to a smoking cessation clinic. The multidisciplinary nature of an SCP can be coordinated by nurses responsible for organizing the treatment summary and creating the care plan. The preparation for this expanded nursing role will include education and training on the nature of survivorship care and ways to expand the nursing care plan to one that addresses the late and long-term effects of survivorship care, as well as the resources needed to address them.
So how does nursing step up to the plate to embrace survivorship care? Two articles appearing in a supplement to the February 2014 issue of the Clinical Journal of Oncology Nursing provide great resources for integrating survivorship care into healthcare settings. Stricker and O’Brien (2014) describe how to implement SCPs, identify the barriers that may occur, and provide information on how to access SCP templates. O’Brien et al. (2014) describes the development and evaluation of a survivorship program that serves 10 clinics and several outreach areas in Minnesota. This program addresses urban, suburban, and rural populations. The article provides examples via case studies and reports on successful ways to implement survivorship care.
The cancer committee in each cancer healthcare setting is responsible for identification, implementation, and maintenance of the processes within the organization that address the COC standards. Who in nursing is on your cancer committee? Does the committee know what you already do in relation to navigation and survivorship care? Initiate a connection with this committee and with your quality assurance committee to help them capitalize on what is already excellent nursing care and request the resources you will need to expand and meet these new requirements. Repackage and extend the nursing care you already provide. These new standards address what I believe builds on the essence of excellent nursing care.
To provide credibility to my belief that these regulations from accrediting bodies are much more than a necessary evil, and that they really illustrate the care nurses can do, I reviewed the Scope and Standards of Oncology Nursing Practice from ONS (Brant & Wickham, 2013). “The primary goals of oncology nursing are to promote cancer prevention and early detection and to facilitate optimal individual and family functioning through the disease continuum” (Brant & Wickham, 2013, p. 9). “The oncology nurse functions as a patient care coordinator and collaborates with other healthcare team members. . . . The nurse acts as a patient navigator. . . . The oncology nurse provides care within a framework . . . focusing on 14 high-incidence problem areas: . . . health promotion, education . . . and survivorship” (Brant & Wickham, 2013, p. 10). Wow! It’s all there: patient teaching, navigation, and survivorship care. These are not new areas to oncology nursing care, but may not be recognized in your institution as care that oncology nursing embraces.
To prepare yourself to participate in today’s oncology nursing care, you will need to stay current by attending workshops, participating in ONS activities, reading oncology nursing journals, and networking with your oncology nursing colleagues. By doing these things, you can help make excellent nursing care for patients and survivors visible.
American College of Surgeons. (2011). New Commission on Cancer accreditation standards gain strong support from four national cancer advocacy organizations. Retrieved from http://www.facs.org/news/2011/coc-standards0811.html
American College of Surgeons Commission on Cancer. (2014a). About accreditation. Retrieved from http://www.facs.org/cancer/whatis.html
American College of Surgeons Commission on Cancer. (2014b). About the COC. Retrieved from http://www.facs.org/cancer/cocar.html
American College of Surgeons Commission on Cancer. (2014c). How are cancer programs accredited? Retrieved from http://www.facs.org/cancer/coc/howacc.html
Brant, J.M., & Wickham, R. (Eds.). (2013). Statement on the scope and standards of oncology nursing practice: Generalist and advanced practice (3rd ed.). Pittsburgh, PA: Oncology Nursing Society.
Freeman, H. (2004). A model patient navigation program. Oncology Issues, 19(5), 44–46.
Hewitt, M., Greenfield, S., & Stovall, E. (2006). From cancer patient to cancer survivor: Lost in transition. Washington, DC: National Academies Press.
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
O’Brien, M., Stricker, C.T., Foster, J.D., Ness, K., Ginsburg, A., & Schwartz, R.N. (2014). Navigating the seasons of survivorship in community oncology. Clinical Journal of Oncology Nursing, 18(Suppl. 1), 9–14. http://dx.doi.org/10.1188/14.CJON.S1.9-14
Stricker, C.T., & O’Brien, M. (2014). Implementing the Commission on Cancer standards for survivorship care plans. Clinical Journal of Oncology Nursing, 18(Suppl. 1), 15–22. http://dx.doi.org/10.1188/14.CJON .S1.15-22
Wakefield, B. (1994). The evolution of the Joint Commission’s nursing standards. Journal of Healthcare Quality, 16(3), 15–21.
Marcia Grant, RN, PhD, FAAN, is a distinguished professor of nursing research at the City of Hope National Medical Center in Duarte, CA. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Grant can be reached at email@example.com, with copy to editor at CJONEditor@ons.org.