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We are excited to collaborate with GenesisCare to interview Anna Crawford, one of their Clinical Nurse Specialists with over 20 years of oncology nursing experience! GenesisCare is a leading healthcare provider in Australia that specialises in the treatment of cancer, heart disease, sleep & respiratory conditions. They have 5000 highly trained healthcare professionals and support staff across Australia, the U.K., Spain and the United States, designing innovative treatments and care for people with cancer and heart disease.
Introduction
My name is Anna Crawford and I am a Registered Nurse managing adult patients who have been diagnosed with cancer. I live in Sydney with my husband and my 14-year-old daughter. I have 2 grown sons and am a proud Nanny to 3 amazing grandchildren. I am originally from New Zealand and have over 20 years of nursing experience.
I spent the first 5 years of my nursing career in Coronary Care and Intensive Care before I accepted a Registered Nurse position in the Oncology Outpatient Unit. After a few months, I knew I had found my niche, as a high level of clinical skill was required, plus I had the autonomy to make clinical decisions while delivering patient care. I began my Master’s in Nursing with an oncology focus and made the move to the Medical Assessment and Planning Unit and the Oncology Inpatient Ward so I could fulfil the requirements of my clinical assessment paper.
Over the next 8 years I had the opportunity to work across a range of cancer services – including clinical haematology, radiation oncology and medical oncology as a Clinical Nurse Specialist and an Oncology Nurse Educator. I completed my master’s degree and found I had a passion for supporting patients throughout their cancer diagnosis and treatment. Seven years ago, I made the move from the Public Hospital system in New Zealand to a Private Hospital setting in Bundaberg Queensland.
I worked in an Oncology Outpatient Unit as an Oncology Clinical Nurse which further added to my career and life experience. Four years ago, I made the move to Sydney and commenced a role as a Cancer Nurse Consultant for GenesisCare. The CNC role was one I truly enjoyed. I got to work alongside doctors, make clinical decisions with the patients and have my own patient load. Last year I accepted a position in a new GenesisCare facility as my husband and I decided to relocate to Western Sydney.
What is your current role?
I am currently employed as a Clinical Nurse Specialist in Medical Oncology. I work in a Stand-alone, Private Outpatient Cancer Care Service, caring for patients who need treating with a variety of cancer treatments.
What are some common conditions you and your team care for?
Common conditions our patients are diagnosed with are bowel, breast, pancreatic, melanoma, bladder, lung, endometrium, ovarian, testicular, head and neck and prostate cancers.
What does a typical day look like for me?
I work Monday to Friday 8.30 to 4.30pm and each day brings its own challenges and people to assist. At the start of my week, I ensure all treatments are ordered and available (for the coming week), and patient appointments are scheduled – both to see the doctor and for treatment in the unit. Each day I ensure all patient bloods and pre-treatment tests are completed prior to the patient attending for treatment.
I administer the treatments alongside my team members and am highly skilled at cannulation, accessing portacath’s, taking urgent pathology, triaging unwell patients, managing a wide variety of daily phone calls, and managing deteriorating patients. In a small unit nurses must be able to manage anything that may happen and be astute at assessing and triaging patients to achieve best outcomes. The patients I care for have been referred to see a Medical Oncologist for their cancer and will require either chemotherapy, immunotherapy, or targeted therapies to systemically treat their disease.
When the patient sees the Medical Oncologist and a treatment regime is confirmed, I am introduced to the patient. It is my job to educate each patient on the regime they will be having, ensure the patient has a full understanding of the treatment and that they know how to manage any side effects that may present. I also check all the necessary baseline tests are completed prior to the patient commencing treatment.
As we are an outpatient service there is no co-located hospital, or after-hours staff. Patients must be taught all the knowledge required to manage any potential symptoms and side effects when they go home and know when to go to the local Emergency Department for any unmanageable adverse effects.
Therapies you deliver and their side effects?
Chemotherapy kills all fast-dividing cells – the bad cancer cells but also some of the good cells – which accounts for the side effects of chemotherapy. Most commonly diarrhoea, constipation, nausea, vomiting, a sore mouth, possible hair loss, a lowered immunity (higher infection risk), tiredness, loss of appetite and skin and nail changes are experienced.
Patients can do very well on chemotherapy with all the take home medications that are available. Immunotherapy is a fairly new treatment option available for many types of cancer that boosts a patient’s immune system to attack the cancer cells. It creates an immune response which can cause side effects in any body system based on the individual. Patients with a history of asthma may develop shortness of breath, or those with a history of colitis may develop severe diarrhoea. Severe side effects require a dose of steroids to dampen down the immune response.
Patients on oral targeted therapies and hormone therapies may experience tiredness, hot flushes, mood changes, weight gain, skin rashes, and muscle and joint aches. It is important for nurses to understand the mechanism of action of each drug to provide accurate advice when patients experience side effects.
How does outpatient oncology differ from inpatient oncology nursing?
Patients can have their treatment in an outpatient facility when they are otherwise fit and well and not likely to need the added supports of a 24-hour hospital admission. Inpatient care is usually for patients who have acute illness, require critical care input, or are scheduled for long treatments that require an overnight stay.
Outpatient patient care must be completed each day as there is no overnight shift or back up from external wards. If patients have a sudden deterioration, there is no acute care team to come and assist with the emergency care. Unwell patients must be admitted to the local hospital via ambulance if they require urgent inpatient care.
Working in oncology, particularly in the outpatient setting, is a very autonomous role that requires a high level of knowledge around types of cancer, treatment drugs, adverse effects, treatment protocol and procedure and management of potentially very unwell patients.
Biggest learning curve you’ve had since starting in oncology?
The biggest learning curve I have had since starting in oncology are – that cancer treatment is not all about death and dying. With the modern treatments available people are often cured or can live for many years with a cancer diagnosis. With the introduction of immunotherapies and more refined drugs, patients do not have the stereotypical look of a cancer patient and often still go to work and lead active lives. People from all ages can be successfully treated and cured from their cancers.
Diagnostic equipment and genetic testing are more accurate, so people are diagnosed earlier and treated more effectively. Clinical Trials offer the latest drugs as an option if regular treatments fail. Equipment is much more efficient and regimes that used to require a hospital admission now can be done in the outpatient setting and patients can even go home with portable infuser’s that will continue to deliver the treatments through a portacath while the patient is in their own home.
Advice would you give to a nurse about oncology?
Three pieces of advice: firstly, oncology work is challenging and very fulfilling. Nurses can really make a difference in the lives of others and oncology patients are so grateful. Secondly, you need sound emotional intelligence to not become too affected by some patients’ experiences, or when patients don’t do well. Nurses need to look after themselves too.
Thirdly, there are many opportunities in cancer nursing to further your nursing career. Oncology nurses need to be highly skilled at physical assessments, triaging, delivering care, identifying patient deterioration, and managing drug reactions. Oncology nurses need to think holistically about the patient and consider their physical state, their mental ability, their social needs, and family issues. Oncology nursing challenges nurses to think beyond the treatment chair.
What does family centred care look like in oncology?
Our unit welcomes one support person to attend with each patient receiving treatment. We get to know our patients’ significant others, friends, and family members well, as treatment can go on for many weeks, months and even years. We support consumer engagement and actively seek ways that we can improve our service.
Family are the key supports for patients undergoing treatments and should always be part of the education so that when side effects arise, they can support their loved one the best way possible. In our unit we like family members to feel confident to contact us if they have any concerns for their significant others as it is much better to find out that patients has problems earlier rather than later.
When patients live alone, I always ensure I have the contact details of a support person who can phone me, or I can phone them to check on the patient if the need arises.
Health literacy in oncology?
There are many challenges with educating patients and their families and ensuring they know how to apply that knowledge. Education must be adaptable based on who is being educated. I use a checklist to ensure I have covered all the necessary education, and the patient signs it at the end to acknowledge that they have understood and are happy with the level of education. I use written handouts with pictures to show patients the key take home messages.
For example, if patients on chemotherapy get a temperature of greater than 38 degrees, it is a medical emergency, and the patient must present to the emergency department within the hour. They can’t take a Panadol and see how they feel in the morning. When patients are on chemotherapy, they have a decreased immunity and with low infection fighting cells people can die if they do get an infection. Often the only symptom they will present with is a temperature.
Patients need to seek medical advice and get some antibiotics quickly. I developed laminated photos of the take home medications so that I can show the patients and teach them what they must take if they develop certain side effects such as nausea or diarrhoea. Uncontrolled diarrhoea will dehydrate a patient, alter their electrolytes, and make them very sick.
It is much better if a patient knows they must keep well hydrated and to seek medical advice if they do get diarrhoea. Patients and their families can phone us during business hours however after hours they need to seek help from their local Medical Centre or Emergency Department.
They may need to call an ambulance if the patient deteriorates or has unexpected side effects such as chest pain or shortness of breath. It is important that patients with English as a second language can understand me and feel confident with managing their own health care at home. I use a translator if needed to ensure the patient has a good understanding.
What do you do to prevent or reduce emotional burnout in your own role?
Throughout my nursing career I have worked in high acuity areas such as Intensive Care, and Coronary Care. My personal belief is that it is a privilege to look after people while they are unwell, and it is my job to try and make the patient’s experience better in any small way I can. I am aware that some people will deteriorate and not get better. I try to remember the people I am caring for are my patients and it is important to keep a professional element to my work and remember these people have family members and friends to love them.
Of course, as humans we connect with some patients much more than others and we become very fond of some people. I always try to maintain a professional boundary and don’t bring my work into my personal space. I care about my patients a lot and always put my heart into the care I deliver, however when patients want to connect on social media or catch up outside of work, I believe this is not part of my role. It is naturally very upsetting when I have worked with a patient for a long period of time, and they don’t do well.
I have cared for many special people who will always remain as part of my memories and that is the beauty of working with people. Connection is a priceless emotion and something that makes humans feel valued. The demand and pressure of nursing can also become stressful and tiring at times. I enjoy the endorphins of going to the gym and getting outside in the fresh air when needed. I use mindfulness to reflect on my day and what I did well and how I could have done things better.
Emotional Intelligence is important to prevent nurses from getting burnout and knowing when it is time to take on a different role. I am at work for more hours of my day than I am at home with my own family, so it is very important for me to enjoy my work and feel like I am adding value to my patients and my workplace.
How have you seen nursing evolve as a profession over the last 20 years?
As a student nurse I had to learn how to make a bed properly and I was examined on how well I did my hospital bed corners. It was an expectation that I would keep the patient’s bed space clean and tidy by washing down the bedside cabinet and ensuring there was no added clutter at the bedside. This was taught so if needed in an emergency you could get to the patient quickly and efficiently. I think now due to the increased workload for nurses, ward tidy and bed making would no longer be viewed as a task for nurses.
There are care assistants and nurse aids or ward staff who would likely do the tasks that do not involve direct patient care. My first nurses’ uniform, that I proudly wore, was a white dress. Modern uniforms are much more practical, with most hospitals adopting the use of scrubs for nurses or business attire. The acuity of patients has significantly increased. Patients no longer stay in a ward, taking up a hospital bed if they can go home. Family and carers in the community now play a key role in supporting patients with health problems.
Documentation and clinical orders have now become all electronic. I used to have to wait until the doctors had done their rounds and the other allied health had finished with the notes before I could access them to carry out the changes from the ward rounds. Today I have a computer on wheels that I can take to the patient bedside and have access to all craft group notes as they are entered. We have cell phones to text and call the doctors to clarify orders and can email the doctors directly if we have any concerns about the patient. Communication is so much more efficient without having to wait for a doctor to answer a pager when they were often very busy with another patient.
Equipment such as pumps, and administration lines have improved and become very easy to use. When I was working as a nurse on the ward there was only a certain number of pumps and often, I had to gravity feed fluids and work out the drip rate for hydration. This of course produced many problems when the fluids didn’t go through as planned for example if the patient was sleeping and had bent their arm and kinked off the line or if the entire bag went through too quickly. Modern pumps will beep and alert you quickly to any problems. Pumps will not allow air to run down the line, pumps are programmed to put a hard stop to drugs being given quicker than they should be.
This prevents drug errors and incidents arising that can be very serious and harmful for the patient. Oral medications have improved greatly for patients to self-manage their treatment related side effects. When I educate my patients, I explain to them I do not want them to experience side effects like nausea, constipation, and diarrhoea. The medications to manage chemotherapy induced nausea and vomiting have been much improved over the last 20 years. It is now unusual for a patient to experience vomiting after treatment in the outpatient setting.
Can you tell us about a memorable experience you will never forget?
One day I went down to the radiation treatment area to meet a new patient who was having radiation at the centre I worked at and chemotherapy at another hospital. I introduced myself to her husband and on seeing her I knew she was not at all well. She was scheduled to commence radiation and had felt unwell ever since her chemotherapy the day prior. I took her observations and there was nothing too far out of the ordinary except for a low blood pressure.
Her husband explained she had not had anything significant to eat or drink which could explain a low blood pressure. The lady was small and thin without any prior history, she was slumped in a wheelchair, appeared to be very weak and did not look well. I phoned her Medical Oncologist at the other facility, who asked if I could just give some fluids and monitor her. I worked at a stand-alone centre with no acute care support and no back up if the patients deteriorate.
I listened to my gut instinct and said, “I think its best if I refer her to the local Emergency Department”. I advised the patient’s husband that his wife had a low blood pressure, looked very dehydrated, and weak and needed to be assessed properly by a doctor. Her husband said he would be happy to drive her as it would be faster than calling an ambulance. I phoned the Emergency Department to let them know the patient was coming. About 3 hours later her husband called me and informed me that the patient had been taken to Intensive Care and had been put on blood pressure medications as her blood pressure had continued to drop and despite fluids, they could not get the blood pressure up.
I was completely shocked and so grateful I had not decided to keep her in the unit to give her fluids and monitor her. The family were very grateful for the decision I had made but I was so grateful she was alive! The family sent me photos a few months later of the patient at her daughter’s wedding. It was the best feeling ever. Everyone looked amazing and were all full of smiles. I believe as nurses we are given that little voice inside us that sometimes doesn’t make much medical sense, however it guides us to make the right decisions.
If you weren’t a nurse…what would you be?
In all honesty, I remember wanting to be a nurse as a very young child. It sounds cliché however I think it’s an innate calling that makes me who I am. I’m not sure what I would be if I wasn’t a nurse. I have thought about that often; however, I truly enjoy caring for others and making a difference in their daily lives.
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