POSITION PAPERGuidelines for Integrated Activity Between Pediatric Hematology-Oncology

Nurses and Physicians

Doctor–Nurse Integrated Workgroup of the Italian Association of PediatricHematology and Oncology (AIEOP)*

Key words: guidelines; clinical practice; pediatric oncology

PREMISE

In the last half-century, the cure rate of children af-fected by malignant neoplasia has progressively in-creased. Whereas in the 1950s fewer than 30% of pedi-atric oncological patients could hope for a cure, today therate has surpassed 60%. Estimates for the year 2000 proj-ect that 1 young adult in 900 in developed countries willbe a patient cured of cancer [1,2].

Among the primary reasons for such success is theadvent and organization of multidisciplinary groups totreat children with malignant diseases. These groupshave facilitated the concentration of educational andtechnical resources that none of the disciplines involvedwould have been able to provide individually. The abilityto work in a ‘group’ does not come about spontaneouslyor as a result of fortunate combinations. It requires aneducational plan and clear operating decisions. This isparticularly true considering that such teams includemembers with diverse training experience, educationalbackgrounds, and professional competence and who havedifferent tasks and responsibilities. Two of the key play-ers in this team are the pediatric oncologist and the nurse.The desire to solidify a ‘way of thinking’ among doctorsand nurses in the AIEOP stimulated members of the phy-sician and the nursing groups to formulate recommenda-tions on how to facilitate professional and cultural inte-gration among doctors and nurses. These guidelines areput forward to generate discussion and/or to allow theirimplementation by other national pediatric hematologyand oncology groups that seek to advance in this way.

GUIDELINES FOR INTEGRATED ACTIVITY

1.0 CLINICAL ASSISTANCE ACTIVITY

1.1 Exchange of Clinical Information Between Doc-tors and Nurses. 1.1.1 Every day doctors and nurses onduty must share the problems of the children under treat-ment in the ward or day hospital. They must communi-cate concerning their respective objective observations

and justify their diagnostic and therapeutic decisions.Communication among doctors and nurses must not takethe form of directives from the doctor to the nurse. In-stead, the goal should be to make every member of theassistance team fully aware of the clinical situation. Stepscan then be taken expeditiously and efficiently on thebasis of a common understanding to coordinate and har-monize support activities for both the sick child and thefamily. Such communication also serves as a means forteam members to compare their own observations andconsiderations regarding the child’s clinical situation andthe nuclear family’s wellbeing. In this way, impressionsfrom different but complementary points of view areformed regarding the same problem. Such communica-tion must come at a predetermined time and place (sittingor walking ward rounds) and, therefore, must be consis-tent with the ward’s time needs and work shifts. It isessential that such communication occur on a daily basis.Also, at the day hospital, such meetings must take placeat a predetermined time and be both concise and fo-cussed. Furthermore, nurses should be expected to attendthe plenary meetings to update the medical staff andreview all of the patients presently under care. Theirpresence at multidisciplinary tumor boards also is impor-tant so that they can participate in management decisionsreached there. Communication between doctors andnurses becomes all the more vital when the issues con-cern clinically critical episodes, when there are psycho-logically and emotionally intense problems, or whenthere are ethical conflicts such as often arise in the careof children who are critically ill or in a terminal phase.

Adapted from an article (in Italian) that appeared in Ital J Pediatr1999;24:1176–1178

*Correspondence to: Giorgio Perilongo, MD, Pediatric Hematology-Oncology Division, Department of Pediatrics, University of Padova,Via Giustiniani 3, 35128 Padova, Italy.E-mail: perilong@child.pedi.unipd.it

Received 16 March 1999; Accepted 11 November 1999

Medical and Pediatric Oncology 34:259–262 (2000)

© 2000 Wiley-Liss, Inc.

1.1.2 It is likewise important that doctors and nursesare able to review in detail the requisite therapy and, inparticular, the daily orders for chemotherapy. This is par-ticularly important in clinical settings, where internalcontrol systems such as double-signed orders by physi-cians and/or a dedicated pharmacist in charge of prepar-ing and delivering the prescribed therapies do not exist.These reviews should establish that the therapies to beadopted are described with precision and clarity regard-ing timing, scheduling, dosages, and routes of adminis-tration. Also of great importance is the implementation ofsystems of reciprocal verification that check the actualtherapy administered against that recommended. Suchcontrols are aimed at minimizing the risk of human errorin the administration of drugs and/or the application oftherapeutic protocols.

1.1.3 Doctors and nurses on duty must be present atpsychosocial meetings. Such meetings aim to analyzehow the family as a whole is facing the illness and itsrelated problems. These sessions should be scheduled inadvance on a weekly or bimonthly basis and always heldduring work hours. They must include doctors and nursesand, if possible, a psychologist, a social worker, andvolunteers. By providing a complete support network,this multidisciplinary evaluation can help both the healthcare staff and the family to resolve issues other thanmedical problems and difficulties that need attention.

1.1.4 In the case of the death of the young patient,centers should make an attempt to set up a family meet-ing some time soon after the event. Such encounters seekto help the family overcome their pain and develop anappropriate sense of grief. For such meetings it is fun-damental that the medical and nursing teams be well-represented.

1.2 Information to the Patient and the Family

The doctor and nurse must be present when informingthe family and the patient of the diagnosis or at any othersignificant event (together with other persons deemedimportant to that event, such as a social worker and/or apsychologist). Doctors and nurses, in different and par-ticular ways, are called upon to address the same medicaland psychological problems. The presence of both pro-fessionals demonstrates to the family that all medicalpersonnel concerned are aware of both every aspect ofthe patient’s condition and of the therapy to be carriedout. ‘Team’ communication gives the patient and thefamily a great sense of security and confidence in theorganization.

Finally, a critical review should be periodically con-ducted to assess the quality of these meetings. Commu-nication is a process that improves with time.

2.0 CONTINUING EDUCATION AND RESEARCHACTIVITY

2.1 Exchange of Scientific Information BetweenDoctors and Nurses

2.1.1 A continual and systematic exchange of scien-tific information should take place between medical per-sonnel and nurses. This exchange of information is per-haps most successful when undertaken in regularlyscheduled semiformal workshops. The discussionsshould include presentation of new diagnostic and thera-peutic protocols as well as any progress or new knowl-edge in the field of hematology and oncology. Theseworkshops should be geared specifically and exclusivelyto nursing personnel to guarantee the highest possiblelevel of communication and understanding. In this way,for any given topic presented, attention can be focused onnursing-related problems. Ample time for group discus-sion also should always be scheduled. In addition to theward doctor and nursing staff, at least one other personshould be designated to help organize such meetings andto plan their content and organization. The meetingsshould take place during working hours, at a time con-venient for the ward. Written precis of the topics coveredshould be provided to all those who cannot attend. Forthe nurses in particular, this should be part of more ar-ticulated and self-organized continuing education pro-cesses. These could include seminars run by nurses, in-vited guest lectures, and attendance at intra- orextramural meetings.

2.1.2 To be included in this type of continuous edu-cation is a comparison among doctors and nurses of theirways of handling such common problems as emesis,pain, transfusion procedures, etc., with a view towardsreaching a consensus.

2.1.3 Doctors and nursing staff should periodicallyreview instructions for, and carry out practical simula-tions of, emergency procedures that might occur on theward. Such reviews should be designed to keep up to dateall mechanisms necessary for treating children in a stateof septic shock, convulsions, cardiac arrest, and similarurgent situations.

2.2 Participation of Nurses in Diagnostic andTherapeutic Protocol Design

There should be nursing representation on protocoldevelopment committees to assist in the design of diag-nostic and therapeutic protocols. This is essential in orderto add the nurses’ experience and points of view in pro-tocol generation. It would be the nurses’ responsibility toevaluate 1) the feasibility of the planned practices andprocedures, 2) their impact in the workload of the nurses,and 3) whether, for their implementation, specific newinstruction must be given to the personnel.

260 Doctor–Nurse Integrated Workgroup of AIEOP

2.3 Other Combined Research Activity

The continuous improvement of patient care should bereviewed in the context of research activity. The neces-sary procedures to control the quality of the medicalteam’s performance, necessary to ensure the maintenanceof excellent daily clinical practice, should focus not onlyon fundamental diagnostic and therapeutic strategies butalso on all facets of psychosocioeconomicic supportiveprocedures. The study of and research on these support-ive procedures in pediatric hematology-oncology impactboth doctors and nurses and must become part of theirbody of knowledge. Doctors and nurses should thereforecooperate in planning and conducting productive re-search in this field.

In summary every hematology-oncology center must:

• consider study and research in the field of supportivemedicine a fundamental part of its own daily activity;

• form a multidisciplinary medical and nurse group fordiscussing, studying, planning, and conducting re-search in the field of supportive medicine;

• treat these activities not as after-work-hour responsi-bilities, which depend on individual initiative and goodwill, but as a primary function of the pediatric-oncology division to be scheduled appropriately. Moreprecisely, a dedicated ad-hoc trained “research nurse”should be identified within nursing to facilitate andpromote this research activity.

SUMMARY AND CONCLUSIONS

This document addresses exclusively the problem ofwork integration between pediatric hematology and on-cology doctors and nurses. It neither attempts nor pre-tends to be a complete or final treatment of integratedactivity between nurses and doctors. It outlines an ideal-ized, yet practical everyday working environment start-ing from the present level of cooperation and work inte-gration between doctors and nurses in Italy. It is beingproposed as a working base to be elaborated upon inorder to find the best solutions for day-to-day situationsin pediatric hematology and oncology centers, whereverthey are located. Only through actually putting theseguidelines into practice can they be shaped and madeconcrete. Thus, this is not a finished document. An in-novative and inventive spirit on the part of everyoneinvolved is necessary to meet this goal, starting withbasic changes in the traditional strictly hierarchical rap-port between doctors and nurses. A final challenge isfinding the time needed in busy clinics to implementthese recommendations.

SUMMARY OF THE INTEGRATED ACTIVITYBETWEEN DOCTORS AND NURSES OF PEDIATRICHEMATOLOGY AND ONCOLOGY

1. Daily meetings both in the ward and the day hos-pital for exchanging information on the clinical and psy-chosocial aspects of the child and the family, and cross-checks of drug prescriptions (time, method, dosage)

2. Multidisciplinary psychosocial meetings3. Presence of both nurses and doctors at least at the

communication of the diagnosis and at every other eventsignificant for the family and the child

4. Family meetings after the child’s death

Part II: Continuiing Education and Research Activity

1. Updating workshops (at least monthly) for pur-poses of training and education in recent advances intreatment and science

2. Comparative workshops on support therapy proce-dures (pain, nausea and vomiting, etc.)

3. Nurse consultation for diagnostic and therapeuticprotocol design

4. Combined research activity

ACKNOWLEDGMENTS

We thank Ms. Zehava Packer for her editorial assis-tance, in particular for the translation of this documentinto English.

REFERENCES

1. Simone JV, Lyons J. The evolution of cancer care for children andadults. J Clin Oncol 1998:16,2904–2905.

2. Meadows AT. Effetti tardivi della terapia dei tumori infantili: ilprezzo del successo. Prosp Pediatr 1996;26:53–58.

3. Batel-Copel LM, Kornblith AB, Batel PC, Holland JC. Do on-cologists have an increasing interest in the quality of life of theirpatients? A literature review of the last 15 years. Eur J Cancer1997;33:29–32.

4. Masera G, Jankovic M, Adamoli L, et al. The psycho-social pro-gram for childhood leukemia in Monza, Italy. Paediatric Oncol-ogy. Ann NY Acad Sci 1997;3-3007:324–340.

APPENDIX: LIST OF MEMBERS OF THE INTEGRATEDDOCTOR–NURSE GROUP OF THE ITALIANASSOCIATION OF PEDIATRIC HEMATOLOGY ANDONCOLOGY WHO HAVE CONTRIBUTED TO THEWRITING OF THIS DOCUMENTNurses

Celeste Ricciardi, I.P., and Matteo Steduto, I.P., Pae-diatric Haematology/Oncology Division, “Casa Sollievodella Sofferenza,” San Giovanni Rotondo

Guidelines for Doctors and Nurses 261

Sonia Bellin, I.P., and Piera Tobanelli, C.S., PaediatricHaematology/Oncology Division, Ospedali Riuniti,Parma

Margherita Borazio, I.P., and Ettore Mazzanti, I.P.,Paediatric Haematology/Oncology Division, OspedaleSant’Orsola, Bologna

Elena Rostagno, V.I., and Claudia Ferrero, V.I., Pae-diatric Haematology/Oncology Division, Ospedale In-fantile “Regina Margherita” Torino

Daniela Trucco, C.S., Paediatric Haematology/Oncology Division, Ospedale “Giannina Gaslini,”Genova

Chiara Zampieri, I.P., Paediatric Haematology/Oncology Division, Departments Of Paediatrics, Padova

Doctors

Dr. Alberto Garaventa, Paediatric Haematology/Oncology Division, Ospedale “Giannina Gaslini,”Genova

Dr. Momcilo Jankovic, Paediatric Haematology/Oncology Division, Ospedale San Gerardo, Monza

Dr. Giorgio Perilongo, Paediatrics Haematology/Oncology Division, Departments of Paediatrics, Padova

Prof. Alberto Donfrancesco, Paediatric Haematology/Oncology Division, Ospedale “Bambin Gesu`,” Roma

Dr. Saverio La Dogana, Paediatric Haematology/Oncology Division, “Casa Sollievo della Sofferenza,”San Giovanni Rotondo

262 Doctor–Nurse Integrated Workgroup of AIEOP