“I would like to respectfully acknowledge the Traditional Owners of the land on which this event is taking place and pay my respect to their Elders both

past and present."

Moving Beyond Contemporary Nursing Practice to Bridge the Gap

Margaret Barton-Burke, PhD, RN, FAANDirector, Nursing Research (and Innovation)

Memorial Sloan Kettering Cancer CenterNew York

Professor Emeritus, University of Missouri St. Louis

Adjunct Professor, QUT, Brisbane, AU

Good Morning

G’DAY

Bonjour

Jambo / Karibo

Salam Alaikum

Sawasdee ka

Magandang hapon

Hola

Objectives

• Present a MEANINGFUL policy lecture after a night of partying

• Invite nurses to consider advocating for Policy change re: equity

• Suggest that cancer nurses take a leadership role in Health Care (not Sick Care)

HAPPY ONCOLOGY NURSES MONTH

HAPPY NURSES WEEK

Happy International Nurses Day 2016Florence Nightingale's birth

Did You Know?• Gallop Poll in the U.S.

• As the single largest group of health professionals, with a presence in all settings, nurses can make an enormous impact on the resilience of health systems.” “By promoting the nursing voice, we can help guide improvements in the quality of health service delivery and inform health systems strengthening.” ICN President, Dr. Judith Shamian

• “It is our duty to ensure that governments and policymakers understand that confident, well-informed nursing leaders who understand their role in developing a workforce to meet new challenges are essential to ensure the success of the Sustainable Development Goals and to meet the health challenges of the future.“

Dr. Frances Hughes, ICN’s Chief Executive Officer

Cancer/Oncology Nurses: A Force for Change

• Globalisation: a process of increasing global connections, interdependence & integration, especially in economic arena, …affecting cultural, social political, ecological and technological aspects of life.” (Tuschudin & Davis, 2008, p.4)

• Move from MDGs to Sustainable Development Goals

• SDGs relevant to all countries &cover economic, environmental social pillars of sustainable development with focus on equity addressing root causes of poverty

http://www.icn.ch/images/stories/documents/publications/ind/IND_kit_2016.pdf

17 Sustainable Development Goals

• SDG Goal 3: Ensure healthy lives & promote wellbeing for all at all ages

• Goal 3 most specific to health & well-being, has 13 targets (3.1-3.9) &enablers (3.a-3.d)

• WHO Framework Convention on Tobacco Control

• Support R & D vaccines & medicines for non-communicable diseases developing countries … provide access medicines for all

• Substantially increase health financing & recruitment, development, training & retention of health workforce in developing countries, especially in least-developed countries & small island developing States

Global Strategy on Human Resources for Health: Workforce 2030 (WHO 2015e)

Overall goal:

To improve health & socioeconomic development outcomes by ensuring universal availability, accessibility, acceptability & quality of health workforce through adequate investments & implementation of effective policies at national, regional & global levels

.

Commission on the Social Determinants of

Health Framework

So What Does This Have to Do with ME?

• Social justice means the fair distribution of resources and responsibilities among the members of a population with a focus on the relative position of one social group in relationship to others in society as well on the root causes of disparities and what can be done to eliminate them (CNA 2009)

• Every health professional has potential to act as advocate for individuals, communities, health workforce & general population, many factors affect health lie outside health sector, in early years’ experience, education, working life, income &living & environmental conditions - health professional may need to use positions as experts in health & as trusted respected professional to encourage or instigate change in other areas. Institute of Health Equity (2013), p.5

I’m Just The Nurse

• ICN Code of Ethics for Nurses states nurses’ responsibility for initiating & supporting action to meet health & social needs of public, in particular - vulnerable populations (ICN 2012a).

• Role of nurse as advocate for equity & social justice appears in guidance of many National Nursing Associations

• There are examples of health professionals working together to have greater influence on policy makers to improve opportunities in this area (Allen et al 2013).

• American Nursing Association Social Policy Statement (2015)

• ONS Position Statement on Quality Cancer Care

https://www.ons.org/advocacy-policy/positions/policy/access

1.In all settings in which nurses work, ethical challenges are embedded in everyday

practice

2.The need to strengthen the ethical foundation of nursing is urgent, particularly in

light of pressures that threaten the integrity of individual nurses, the profession, and

the people they serve

3.The ANA Code of Ethics is foundational to understanding the ethical landscape for

nurses, and serves as an invaluable resource and guide for how nurses carry out

their professional ethical obligations

4.Many ethical pressures arise more from disparities in the human resources,

social capital, and financial resources available across the system (many of

which result from resource allocation decisions and waste, rather than from

resource scarcity) and contribute to persistent problems in access to care

5.Moral distress is a pervasive reality for nurses when they are unable to

translate their moral choices into action because barriers prevent them from

practicing in accord with their values

6.Nurses must define the boundaries of their professional responsibility with inter-

professional colleagues in the environments where they practice

7.Nurses are ideally situated to lead and contribute to contemporary models of

care delivery, policy, research, and education [see The Future of Nursing:

Leading Change, Advancing Health]

8.Efforts to improve the ethical environment for nurses have a direct impact on the

quality of care provided to patients and families and the sustainability of the health

care system

IOM: Delivering High-Quality Cancer Care

“Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence.”

IOM, (2013). Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.

Author: Washington, D.C.

An Adequately Staffed, Trained & Coordinated Workforce

IOM, (2013). Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Author: Washington, D.C.

High-Quality Cancer Care Delivery System

Current Status: Oncology Workforce

• Inadequate Physician workforce

• Inadequate Geriatrician workforce

• Insufficient Nursing workforce

– Little, if any, dedicated cancer content

– Few graduate programs with oncology content

– Only 1.2% of the 1 million with certification in clinical specialty are OCN or AOCN (HRSA, 2010)

• Insufficient Rehabilitation workforce

• Aging out of the Nursing workforce (tsunami)IOM, (2013). Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Author:

Washington, D.C.

ASCO Workforce Study

48%

Increase

In Demand

14%

Increase

In Supply

Australia

The Australian Medical Oncologist Workforce StudyMJA 196 (1) · 16 January 2012

Conclusion: The current shortage of MOs is expected to persist in the future. National strategies are needed to increase the capacity of the medical oncology workforce and the chemotherapy utilisation rate.

Workforce Recommendation

• An Adequately Staffed, Trained, and Coordinated Workforce

– Goal 3: Members of the cancer care team should coordinate with each other and with primary/geriatrics and specialist care teams to implement patients’ care plans and deliver comprehensive, efficient, and patient-centered care.

– GOAL 4: All individuals caring for cancer patients should have appropriate core competencies.

IOM, (2013). Delivering High-Quality Cancer Care:

Charting a New Course for a System in Crisis. Author: Washington, D.C.

The Future of Nursing Report• Nurses should practice to the full

extent of their education and training.

• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

• Effective workforce planning and policy making require better data collection and an improved information infrastructure.

IOM. (2010). The Future of Nursing: Leading Change, Advancing Health. Author: Washington, DC.

The Future of Nursing ReportUpdate 2014:

1. 60% increase – RN-to-BSN programs increased 2010 & 2014 (77,000 -> 130,300)

2. Enrollment increased –6.6% masters; 3.2% research-focused doctorate; 26.6% practice-focused doctorate

3. 9 states modernized APN laws

IOM. (2010). The Future of Nursing: Leading Change, Advancing Health. Author: Washington, DC.

Everyone in America can live a

healthier life, supported by a system

in which nurses are essential

partners in providing care and

promoting health.

Nursing Models of Care• Advanced practice

registered nurses practice to full extent of education & training

• Engage student nurses early

• Care Coordination

• Certification – measure outcomes

• Nursing Education Curriculum/Faculty Practice

• Cancer Nursing Education Curriculum

• Clinical Academic Partnerships

What Women Want (Dr. Rainey)

• Study of 218 breast cancer survivors (USA)

– Evaluation of self-perceived impact on survival, worrying & cancer-related stress of follow-up visits to different clinic types, or virtual visits

– Conclusions: BC survivors comfortable with GP or nurse practitioner follow-up care, although preferred medical oncologists

– Virtual visits perceived negative impact on cancer survival & cancer-related stress

• Study of 722 breast cancer survivors (AU)

– Evaluated what follow-up would be preferred if specialist care was no longer available

– Conclusions: Beyond 2 years, women prefer follow-up in routine breast cancer clinic i.e. face to face every 6 months with breast physician* or breast care nurse, in preference to GP

– Drop in clinics also highly valued

Inadequately Prepared Oncology Nursing Workforce

• Accrediting bodies for basic preparation focus on minimum for safe care but currently do not address basic information on health care economics, quality measures

• Lack of competency in health informatics, managing data sets, benchmarking to measure outcomes

• Little dedicated oncology content in basic programs, few graduate programs in oncology

• Not prepared to function in teams, much less high-performing teams

• Not prepared to be leaders/lead teams

The Time for Nursing

is

NOW

Where Will These Changes Take Place?

Who Will Lead These Change?

HOW WILL THESE CHANGES TAKE PLACE?

• Management Approach

• Professional Relationships

• Professional Values

• Compensation and Rewards

• Patient Care Delivery System

• Leadership

• Teamwork

• Developed into “We CARE”

• Resource-Driven Practice

• Professional Nursing Practice

• Care Delivery

• Outcomes34

A Professional Practice ModelProvides a framework for nursing practice

What’s important / prioritiesProvides an identity for nursing

What’s unique / approachMagnet requirement

Relationship-Based Care®

Our Professional Practice Model

• Patient/family-centered

• Evidence-based

• Primary nursing– Responsibility, authority, accountability for patient

care decisions

– Continuity of care

• Collaborative interdisciplinary relationships

• Shared decision-making

• Professional development

Memorializing RBCHeart• Compassion• Patient/family is at the heart of what we do

Ribbons• Iconic cancer awareness ribbons• The Meaning of “3”

• 3 relationships

• 3-fold mission (care, education, research)

WeCARE - Every Day, Every Way• Underscores our teamwork• Depicts our values• Refers to the journey / continuum of care

Color• Diversity of our patients and our staff• Different colors associated with different cancers• Different colors depict different dimensions

LeadershipLeaders know the vision, act with purpose, remove barriers,

and consistently hold patients, families and staff as their highest priority.

We believe in Shared Leadership

•Council Structure•N-CARE•L&OD

LEADERSHIP:

“The hospital, the administration and the institution recognize the importance of having us work to our potential...we have clinical ladders for registered nurses as well as nurse practitioners…”

TeamworkHealthy teams are characterized by trust, mutual respect,

consistent and visible support and open, honest, communication.

• Diverse but with a shared purpose

• Multidisciplinary Committees, Rounds

• Commitment to my Co-Workers©

TEAMWORK: “Everyone really just comes together to try and help do whatever is needed to help this patient survive.”

“I work with incredible nurses that are intelligent, compassionate…no one is working on their own…”

ResourcesAdministrators, managers and staff members partner to design

and continuously improve the infrastructure for optimal patient care delivery.

We use our generous resources wisely and with accountability

• Philanthropy

• Technology

• Clinical Support

RESOURCES:

“Having the equipment, having the supplies allows you to provide the care that you want to give to patients…”

Professional PracticeProfessional nursing exists to provide compassionate care to

patients and their loved ones. Nursing is a primary component in a complex and interdependent health care

delivery system.

• Compassionate, holistic patient and family-centered care

• Evidence-Based Practice

• Authority

• Responsibility and Accountability

PROFESSIONAL PRACTICE:

• “One thing I really treasure here at Memorial Sloan Kettering is that nurses are really respected and valued…”

Care DeliveryWe believe in the power of the therapeutic , healing

relationship which primary nursing provides.

• Primary nursing is core to safe quality care

• Primary nursing benefits the patient/family and the nurse

CARE DELIVERY: • “You have this rapport

with the family that they can really trust you and they really look to the nurses for help and for decisions, and you almost become like one of their family members…”

• “As a nurse, you really are at the frontlines with those patients and their families…”

OutcomesAchieving quality outcomes requires planning, precision

and perseverance. Goals must be specific, attainable, measurable and meaningful.

Outcomes are reflective of our nursing practice. Our major outcomes are measurements of:•Patient safety (nursing-sensitive indicat0rs)•Patient satisfaction•Practice environment

CARING, HEALING and INNOVATIVE ENVIRONMENT:

“To be able to advocate for people, to be able to care –it is so fulfilling to know that I did what I’m called to do.”

“You have patients that are extremely, extremely giving and so brave and to witness that really helps you grow as an individual, as a nurse…”

“I think it’s an honor to have even a small part in a patient’s course of their treatment here.”

http://www.bioethicsinstitute.org/nursing-ethics-summit-report

“There is a river flowing now very fast. It is so great

and swift, that there are those who will be afraid. They

will try to hold on to the shore. They will feel they are

being torn apart and will suffer greatly.

Know the river has its destination. The elders say we must

let go of the shore, push off into the middle of the river, keep

our eyes open, and our heads above the water. And I say,

see who is in there with you and celebrate. At this time in

history, we are to take nothing personally. Least of all,

ourselves. For the moment that we do, our spiritual growth

and journey comes to a halt.

The time of the lone wolf is over. Gather yourselves! Banish

the word struggle from your attitude and your vocabulary. All

that we do now must be done in a sacred manner and in

celebration.

We are the ones we’ve been waiting for.”-Oraibi, Arizona, Hopi Nation

"Be the change that you wish to see in the world.“ Mahatma Gandhi

Thank you

Merci

Asante Sana

Salamat