Bridging the Gap: Standardizing Inpatient/Outpatient, Adult/Pediatric Oncology Nursing Practices in a Rural Health Care Setting

The American Society of Clinical Oncology/Oncology Nursing Society (ASCO/ONS) Chemotherapy Administration Safety Standards and the Commission on Cancer (CoC) include requirements for annual competency evaluations and comprehensive, continued education for staff.¹ The changing world of oncology care and risks associated with cancer treatments underscores this rationale.

At a small health care organization located in rural northwestern Montana, nurses recognized the need for chemotherapy competency evaluations due to a dearth of standardization between inpatient and outpatient, adult and pediatric oncology nursing; the organization lacked chemotherapy competencies, an oncology nurse educator, and opportunities for oncology nurses across settings to discuss practices.

Oncology nurses identified variances in practice, as well as a disconnect between staff in the inpatient and outpatient settings. Many had little knowledge of each other’s respective work areas. Staff that worked in adult and pediatric oncology also noted numerous differences in care of patients receiving chemotherapy. To standardize the practice and network with other oncology nurses from the inpatient and outpatient setting, a team of nurses developed a hands-on Skills Day event for all evaluations of chemotherapy nurses using a scenario approach.

Inconsistencies in Practices

Led by the acute care educator, a team was assembled that included nursing staff and nurse managers from the oncology adult inpatient unit and outpatient infusion, the hospital infusion area staff, an educator from the pediatric inpatient unit, and staff from outpatient pediatric oncology infusion. The team met twice monthly and identified practice variances in chemotherapy administration, personal protective equipment, extravasation, hypersensitivity reaction, safe handling of body fluids, hazardous drug disposal, and spill management. Reasons for the variances included differences in policies and procedures; equipment; resources for inpatient and outpatient areas; difficulties locating updated and current standards, as well as guidelines; lack of staff knowledge; few opportunities for hand-on training; and limited continuing education on the subject areas.

The team gathered all policies regarding caring for oncology patients throughout the organization and found policies for inpatient and outpatient nursing were different, including variations in content for the same procedure. Some policies contained outdated references and were not easily accessible to staff. For example, the hazardous drug spill policy was located under the pharmacy department and not easily accessible to nursing.

Team members gathered current literature as evidence for updating practices. Policies and procedures regarding all aspects of chemotherapy administration were updated and merged to encompass inpatient as well as outpatient areas. Additional search terms were included to allow for staff to readily locate these policies.

Inconsistencies in Equipment

Next, the work group gathered equipment used during care of patients undergoing chemotherapy. Variations were found in gowns, gloves, spill kits, extravasation kits, hazardous drug trash bins, IV tubing set-up for administration, and bags for disposal of linens contaminated with body fluids. Current practice standards were then reviewed as a group, and decisions were made to update the equipment.

Staff worked with the organization’s materials management department to obtain equipment. All equipment was brought up-to-date and standardized across the adult and pediatric, and inpatient and outpatient areas. Job aids were created to assist staff with just-in-time information about the equipment (nursing staff had noted that infrequency of chemotherapy administration was a contributing factor to the variances).