Original Research: Nurses' Perspectives on Caring for Patients with Do-Not-Resuscitate Orders.

BACKGROUND: Confusion about what a do-not-resuscitate (DNR) order means, including its misinterpretation as "do not treat," has been extensively documented in the literature. Yet there is a paucity of research concerning nurses' perspectives on DNR orders. PURPOSE AND DESIGN: This mixed-methods study was designed to explore nurses' perspectives on the meaning and interpretation of DNR orders in relation to caring for hospitalized adults with such orders. METHODS: Direct care nurses on three units in a large urban hospital were asked to respond online to a case study by indicating how they would prioritize care based on the patient's DNR designation. These nurses were then invited to participate in open-ended interviews with a nurse researcher. Interviews were audiotaped, transcribed, and analyzed. FINDINGS: A total of 35 nurses responded to the case study survey. The majority chose to prioritize palliative care, despite no indication that any plan of care was in place. Thirteen nurses also completed a one-on-one interview. Analysis of interview data revealed this overarching theme: varying interpretations of DNR orders among nurses were common, resulting in unintended consequences. Participants also reported perceived variances among health care team members, patients, and family members. Such misinterpretations resulted in shifts in care, varying responses to deteriorating status, tension, and differences in role expectations for health care team members. CONCLUSIONS: Nurses have opportunities to address misconceptions about care for patients with DNR orders through practice, education, advocacy and policy, and research.

GOG 244 - The Lymphedema and Gynecologic cancer (LeG) study: The impact of lower-extremity lymphedema on quality of life, psychological adjustment, physical disability, and function.

OBJECTIVE: To assess quality of life (QOL) in patients who developed lower-extremity lymphedema (LLE) after radical gynecologic cancer surgery on prospective clinical trial GOG 244. METHODS: The prospective, national, cooperative group trial GOG-0244 determined the incidence of LLE and risk factors for LLE development, as well as associated impacts on QOL, in newly diagnosed patients undergoing surgery for endometrial, cervical, or vulvar cancer from 6/4/2012-11/17/2014. Patient-reported outcome (PRO) measures of QOL (by the Functional Assessment of Cancer Therapy [FACT]), body image, sexual and vaginal function, limb function, and cancer distress were recorded at baseline (within 14 days before surgery), and at 6, 12, 18, and 24 months after surgery. Assessments of LLE symptoms and disability were completed at the time of lower limb volume measurement. A linear mixed model was applied to examine the association of PROs/QOL with a Gynecologic Cancer Lymphedema Questionnaire (GCLQ) total score incremental change ≥4 (indicative of increased LLE symptoms) from baseline, a formal diagnosis of LLE (per the GCLQ), and limb volume change (LVC) ≥10%. RESULTS: In 768 evaluable patients, those with a GCLQ score change ≥4 from baseline had significantly worse QOL (p < 0.001), body image (p < 0.001), sexual and vaginal function (p < 0.001), limb function (p < 0.001), and cancer distress (p < 0.001). There were no significant differences in sexual activity rates between those with and without LLE symptoms. CONCLUSIONS: LLE is significantly detrimental to QOL, daily function, and body image. Clinical intervention trials to prevent and manage this chronic condition after gynecologic cancer surgery are needed.

ONS Guidelines™ for Cancer Treatment-Related Lymphedema.

PURPOSE: Lymphedema is a chronic condition that may result from cancer-related surgery. The incidence of lymphedema varies greatly; however, patients remain at risk for life and may experience decreased quality of life and functional capacity. Providing recommendations for an evidence-based guideline for care of cancer treatment-related lymphedema will help to improve outcomes for patients with this chronic condition. METHODOLOGIC APPROACH: A panel of healthcare professionals with patient representation convened to develop a national clinical practice guideline on prospective surveillance, risk reduction, and conservative treatment of lymphedema. Systematic reviews of the literature were conducted and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology approach was used to assess the evidence. FINDINGS: The panel made multiple recommendations for patients who are at risk for or experiencing lymphedema. IMPLICATIONS FOR NURSING: Early diagnosis and treatment of lymphedema may mitigate symptoms. This evidence-based guideline supports patients, clinicians, and other healthcare professionals in clinical decision making. SUPPLEMENTARY MATERIAL CAN BE FOUND AT&NBSP;HTTPS: //onf.ons.org/supplementary-material-ons-guidelines-cancer-treatment-related-lymphedema.

GOG 244-The lymphedema and gynecologic cancer (LEG) study: Incidence and risk factors in newly diagnosed patients.

OBJECTIVES: To evaluate the incidence and risk factors for lymphedema associated with surgery for gynecologic malignancies on GOG study 244. METHODS: Women undergoing a lymph node dissection for endometrial, cervical, or vulvar cancer were eligible for enrollment. Leg volume was calculated from measurements at 10-cm intervals starting 10 cm above the bottom of the heel to the inguinal crease. Measurements were obtained preoperatively and postoperatively at 4-6 weeks, and at 3-, 6-, 9-, 12-, 18-, and 24- months. Lymphedema was defined as a limb volume change (LVC) ≥10% from baseline and categorized as mild: 10-19% LVC; moderate: 20-40% LVC; or severe: >40% LVC. Risk factors associated with lymphedema were also analyzed. RESULTS: Of 1054 women enrolled on study, 140 were inevaluable due to inadequate measurements or eligibility criteria. This left 734 endometrial, 138 cervical, and 42 vulvar patients evaluable for LVC assessment. Median age was 61 years (range, 28-91) in the endometrial, 44 years (range, 25-83) in the cervical, and 58 years (range, 35-88) in the vulvar group. The incidence of LVC ≥10% was 34% (n = 247), 35% (n = 48), and 43% (n = 18), respectively. The peak incidence of lymphedema was at the 4-6 week assessment. Logistic regression analysis showed a decreased risk with advanced age (p = 0.0467). An exploratory analysis in the endometrial cohort showed an increased risk with a node count >8 (p = 0.033). CONCLUSIONS: For a gynecologic cancer, LVC decreased with age greater than 65, but increased with a lymph node count greater than 8 in the endometrial cohort. There was no association with radiation or other risk factors.

GOG 244 - The LymphEdema and Gynecologic cancer (LEG) study: The association between the gynecologic cancer lymphedema questionnaire (GCLQ) and lymphedema of the lower extremity (LLE).

OBJECTIVE: To explore whether patient-reported lymphedema-related symptoms, as measured by the Gynecologic Cancer Lymphedema Questionnaire (GCLQ), are associated with a patient-reported diagnosis of lymphedema of the lower extremity (LLE) and limb volume change (LVC) in patients who have undergone radical surgery, including lymphadenectomy, for endometrial, cervical, or vulvar cancer on Gynecologic Oncology Group (GOG) study 244. METHODS: Patients completed the baseline and at least one post-surgery GCLQ and LVC assessment. The 20-item GCLQ measures seven symptom clusters-aching, heaviness, infection-related, numbness, physical functioning, general swelling, and limb swelling. LLE was defined as a patient self-reported LLE diagnosis on the GCLQ. LVC was measured by volume calculations based on circumferential measurements. A linear mixed model was fitted for change in symptom cluster scores and GCLQ total score and adjusted for disease sites and assessment time. RESULTS: Of 987 eligible patients, 894 were evaluable (endometrial, 719; cervical, 136; vulvar, 39). Of these, 14% reported an LLE diagnosis (endometrial, 11%; cervical, 18%; vulvar, 38%). Significantly more patients diagnosed versus not diagnosed with LLE reported ≥4-point increase from baseline on the GCLQ total score (p < 0.001). Changes from baseline were significantly larger on all GCLQ symptom cluster scores in patients with LLE compared to those without LLE. An LVC increment of >10% was significantly associated with reported general swelling (p < 0.001), heaviness (p = 0.005), infection-related symptoms (p = 0.002), and physical function (p = 0.006). CONCLUSIONS: Patient-reported symptoms, as measured by the GCLQ, discerned those with and without a patient-reported LLE diagnosis and demonstrated predictive value. The GCLQ combined with LVC may enhance our ability to identify LLE.

Are genetics/genomics competencies essential for all clinical nurses?

In 2006, the American Nurses Association created a set of essential genetics and genomics (G/G) competencies for all RNs, regardless of academic preparation, practice setting, or specialty. However, more than half of the RNs practicing today received no prelicensure education on these G/G competencies. This study describes the current use of G/G nursing competencies in acute care hospitals and how nurses perceive them.

Ovarian Cancer: An Integrated Review.

OBJECTIVE: To provide an overview of the risk factors, modifiable and non-modifiable, for ovarian cancer as well as prevention, diagnostic, treatment, and long-term survivorship concerns. This article will also examine current and future clinical trials surrounding ovarian cancer. DATA SOURCES: A review of articles dated 2006-2018 from CINAHL, UpToDate, and National Comprehensive Cancer Network guidelines. CONCLUSION: There is no screening test for ovarian cancer and with diagnosis often in the late stages, recurrence is high in this population. Early identification can range from knowing the vague symptoms associated with the cancer to prophylactic surgical removal of at-risk tissue. Standard treatment for ovarian cancer is surgery followed by combination chemotherapy. Although advances are being made, ovarian cancer remains the most fatal female gynecologic cancer. IMPLICATIONS FOR NURSING PRACTICE: Becoming familiar with and educating women about risk factors and the elusive symptoms of ovarian cancer can increase patient autonomy and advocacy, as well as potentially improve patient outcomes for those affected by ovarian cancer.

Scope and Epidemiology of Gynecologic Cancers: An Overview.

OBJECTIVE: To provide a current overview of the scope and epidemiology of gynecologic cancers. DATA SOURCES: A review of articles dated 2005-2018 from PubMed, as well as data from The Centers for Disease Control and Prevention, National Cervical Cancer Coalition, and the American Cancer Society. CONCLUSION: Gynecologic cancers include any cancer that originates in a woman's reproductive system; cervical, ovarian, uterine, vaginal, vulvar, and fallopian tube (which is very rare), each named for the body part in which the cancer commences. The overall incidence of these cancers has decreased with time, except for vulvar and endometrial cancers, but racial disparities still exist. IMPLICATIONS FOR NURSING PRACTICE: Nurses play a significant role in educating patients on the importance of preventative measures and modifiable lifestyles and behaviors. Likewise, nurses are in a unique position to help coordinate patients' care, thereby improving patient satisfaction. Nurses can participate and contribute to gynecologic research and influence political change to benefit those affected by gynecologic cancers.

Awareness of symptoms and risk factors of ovarian cancer in a population of women and healthcare providers.

BACKGROUND: Awareness of ovarian cancer among women and healthcare providers is understudied. An early awareness of ovarian cancer may lead to early detection and treatment of ovarian cancer. OBJECTIVES: The purpose of this study was to determine the level of that awareness among a sample of women and providers. METHODS: Written surveys were developed by the authors based on available literature and were administered to women (n = 857) and healthcare providers (n = 188) attending or volunteering at a community health fair. Chi-square tests for independence and z tests were used for analysis. FINDINGS: Healthcare providers were significantly more likely to identify the symptoms and risk factors for ovarian cancer. Forty percent of women reported being at least slightly familiar with the symptoms of ovarian cancer. Women who were familiar with symptoms were significantly more likely to identify symptoms and risk factors correctly and to report symptoms immediately to a provider. Identification of symptoms among healthcare providers ranged from 59%-93%. Identification of ovarian cancer symptoms and risk factors is poor among women, and knowledge deficits are present in providers. Increasing familiarity and awareness could lead to improvements in early diagnosis.

Postpartum safety: a patient-centered approach to fall prevention.

Falls in the perinatal setting have received minimal attention and have not been well documented. Women are at risk for falling following vaginal or cesarean birth, especially during initial attempts at ambulation. Recently, a women's hospital that averages over 500 births per month recorded a postpartum fall rate that exceeded the national mean for adult surgical patient falls. A fall prevention team (FPT) of five nurses was formed with a goal to decrease the incidence of postpartum patient falls to zero within the following 7 months. A patient-centered fall prevention strategy was developed. The results of this project have laid the foundation for additional research of a program that will consider not only prevention of falls in a healthy population but also the development of a risk assessment tool specific to women in the immediate postpartum period.

Adults surviving lung cancer two or more years: A systematic review.

BACKGROUND: Lung cancer has had a low survival rate throughout the years. Some studies have shown that psychological variables such as hardiness and resiliency may play a role in the meaningfulness of survival among lung cancer patients. OBJECTIVE: The objective of this systematic review was to synthesize the best available evidence on the experiences of surviving lung cancer (including psychological/affective well-being dimensions such as resiliency, optimism, quality of life, and coping strategies) in adults over the age of 18, two or more years after diagnosis. INCLUSION CRITERIA: The review considered adults (18 years and older) who have survived lung cancer two or more years post diagnosis.The review included studies that examined the experiences (including psychological/affective well-being dimensions such as resiliency, optimism, quality of life, and coping strategies) of surviving lung cancer two or more years post diagnosis.The review considered patients' experiences of surviving lung cancer post two years diagnosis, including the examination of specific psychological/affective well-being aspects such as resiliency, optimism, quality of life and coping strategies.The review included quantitative descriptive studies and qualitative studies. SEARCH STRATEGY: A search for published and unpublished studies in English language from January 1999 through December 2010 was undertaken in multiple databases including MEDLINE, CINAHL, ProQuest and Psyc INFO. METHODOLOGICAL QUALITY: Assessment of methodological quality of studies was undertaken using critical appraisal tools from the Joanna Briggs Institute. DATA COLLECTION: Data was extracted using the Joanna Briggs Institute Data Extraction forms. DATA SYNTHESIS: Results were presented in a narrative format as the synthesis of qualitative or quantitative data was not appropriate. RESULTS: 13 studies were included in the review: one mixed methods study (including a qualitative research component) and 12 quantitative studies.The qualitative component of the included mixed methods study identified five findings related to the meaningfulness of surviving lung cancer post two years. The central themes that emerged were existential issues, health and self-care, physical ability, adjustment, and support.Quantitative studies identified that distressed groups had less meaningful experiences related to lung cancer survival than not distressed groups. The studies also found that emotional states and style of coping were related to the meaningfulness of lung cancer survival. CONCLUSIONS: With less emotional distress, seeing the good in everything, adjusting life to fit the changes from lung cancer, and adding physical activity to the daily routine, the life of a lung cancer survivor can be more meaningful. IMPLICATION FOR PRACTICE: Healthcare providers must assess lung cancer survivors for potential symptom clusters affecting key patient outcomes such as quality of life. Consider introducing interventions to promote light to moderate physical activity in older patients and moderate to vigorous physical activity in younger patients, and ceasing smoking. Teach active coping strategies. IMPLICATIONS FOR RESEARCH: There is a need for qualitative research studies exploring the experiences of lung cancer survivors. Further research is recommended on symptom clusters that might impact outcomes such as quality of life.

Faculty perceptions of an accelerated baccalaureate nursing program.

In response to one of the most severe staff and faculty shortages in the history of the nursing profession, second-degree accelerated nursing programs are springing up throughout the United States. Struggles, solutions, and learning experienced by faculty teaching in an accelerated baccalaureate program in its inaugural year are described in this article. Focus groups were conducted and themes were identified. Themes included adapting to a new clinical teaching model, effectively teaching a different type of student, combining accelerated and traditional students, and learning as you go. Recommendations were made based on the data and the extant literature.