Structure Amid Uncertainty

“Guidelines represent the best evidence currently available for how to keep patients safe and deliver the highest quality care,” ONS member Jessie Holland, MSN, RN, OCN^®, nurse leader of ambulatory care services at Memorial Sloan Kettering (MSK) Cancer Center in New York, NY, and member of the Hudson Valley ONS Chapter, said. “How we practice should change as new evidence comes to light, and guidelines represent what we understand to be best practice right now.”

“This past year has brought about many changes to oncology care, from using personal protective equipment (PPE) to infection prevention to staffing ratios,” ONS member Michele Abbitt, BSN, RN, OCN^®, clinical nurse manager of hematology oncology and the bone marrow transplant unit at the University of Oklahoma Medical Center in Oklahoma City, said. “Guidelines have and continue to evolve rapidly and serve as a way to provide timely information and structure in the midst of uncertainty.”

For example, Abbitt’s institution was affected by the PPE shortages in early 2020, and she turned to ONS recommendations for guidance on usage and best practices for keeping her staff and neutropenic patients safe.

“As our institution has navigated these changes, I have used the ONS interim guidelines to evaluate hospital-wide practices especially in regard to infection prevention,” Abbitt, who is a member of the Central Oklahoma ONS Chapter, said. “These guidelines have allowed me to better advocate for our patients and staff.”

Rapid Response to New Needs

Some days, Holland feels like implementing guidelines is her entire job description. “We have introduced a lot of new guidelines in the last year,” she said.

Many of them were in response to needs from the COVID-19 coronavirus pandemic. One critical guideline issued internal recommendations regarding testing and treating ambulatory patients with cancer:

• Test patients for COVID-19 before surgeries or procedures.
• Test patients with hematologic malignancies before initiating antineoplastic therapy.
• Routine pretreatment testing is not required for patients with no symptoms.
• Defer antineoplastic therapy for two weeks in patients who test positive for COVID-19.

“It balanced the risks posed by the virus against the risks of interrupting or delaying essential cancer treatment,” Holland said.

MSK also has a guideline to distinguish the visits appropriate for telehealth from those that require an in-person assessment. The guideline informed a new policy that clearly defines the role and scope of nurses in telehealth visits.

Holland said that her institution also accelerated its expansion of remote monitoring programs.

“For several years, MSK has been using electronic patient-reported outcomes (ePROs) to stay in touch with our patients at home,” she said. “Patient responses can be tied to thresholds that alert nurses when patients need to be contacted for concerning symptoms.”

However, Holland said, the potential of ePROs to bridge the isolation brought about by the pandemic made their value evident, and MSK is integrating ePROs into practice across the care continuum.

“Between telehealth and remote monitoring, what I really see is a shift toward bringing cancer care to the patient rather than always bringing the patient to us,” Holland said. “Recent guidelines, like our proposed telehealth guideline, reflect this shift and help us navigate these changes while maintaining safe, quality care.”

Choose and Introduce Guidelines the Right Way

When evaluating and deciding on which guidelines to use, Abbitt’s process begins with research. Guidelines must have a clear purpose, evidence-based recommendations, and feasible application to practice.

“I consider the outcomes as well as any risks that could be involved by implementing or changing current practice guidelines,” she said. “I look at available evidence to support recommendations for implementation and seek out subject matter experts that can offer insight about processes that might be unclear to me.”

Communication, education, and competencies are critical for successful guideline implementation, Abbitt said. “I work closely with our unit educator and our clinical nurse specialist to ensure we’re sharing a clear purpose for the guidelines and that practice changes are streamlined to promote buy-in and decrease confusion.”

Positive clinician attitudes and adherence to guidelines center around four themes:

• Accessibility and ease of use
• Endorsement and dissemination of guidelines and adequate access to treatment facilities and resources
• Awareness of guidelines and belief in their relevance
• Belief that guidelines support decision making, improve patient care, reduce clinical variation, and reduce costs

Take an Interprofessional Approach

Both Abbitt and Holland recognized the critical role of the entire cancer care team. “I am fortunate to work with a wonderful interprofessional team that collaborates when identifying guidelines that we want to adopt into practice,” Abbitt said. “The team often works together to decide what guidelines are adopted. Collaboration and teamwork encourage buy-in during the implementation process.”

MSK has an interprofessional clinical council that develops their internal practice guidelines, which are then evaluated by the clinicians who will ultimately be using them, Holland said. After clinicians provide comments on a guideline, the department of nursing’s evidence-based practice division ensures that MSK’s practice council writes and approves any new or modified policies or procedures to support the new guideline. Then the professional development division develops and delivers staff education.

Identify Challenges Before They Become a Barrier

“I think hardwiring a new process and time are my two biggest challenges when implementing new guidelines,” Abbitt said. “Bedside nurses are pulled in numerous directions throughout their shift, and it can be challenging to find uninterrupted time to complete educational in-services related to changes in process. In addition, depending on the kind of change taking place, it might not always be well received. So, it’s important to explain the ‘why’ up front.”

She said that she begins by introducing a new process to supervisors, charge nurses, and preceptors. They discuss the changes and rationale, identify any potential barriers, and outline educational needs to ensure a smooth delivery. Once the guidelines are implemented at the staff level, the team monitors for and corrects any unforeseen challenges and then continues to assess staff throughout the next few months to ensure everyone is implementing the new process into their daily routines.

“I really like to brainstorm with my team the best options to implement process changes," Abbitt explained. "I try to identify any challenges up front and have our team ready to work through them. Once we go live with the changes, I then follow-up with staff to assess how the process is being received.”

Holland said that in her experience, it’s often a matter of simply overcoming human nature. “The greatest obstacle to any new guideline is resistance to change. Even changes that seem like a slam dunk—adjustments that save time, reduce risk, save money—often are initially met with skepticism,” she said. “Implementation plans should always reflect an understanding of change management. You have to prepare the staff that change is coming, explain why, get everyone the training and tools they need to succeed, and, after implementation, continue to reinforce the new practices.”

Educate, Communicate, and Involve

Education is the key to a smooth transition for practice changes, Abbitt said. “Staff need to understand the changes before things are put in motion. In my experience, this keeps advocacy in the forefront and reduces the anxiety associated with change.”

MSK communicates practice changes through evidence-based practice updates, which are sent to nursing leadership in every unit. The nurse leader, clinical nurse specialist, and nursing professional development specialist work together to communicate changes to the staff, ensure the necessary training is complete, and monitor for adherence to the new process.

“We often lean on invested nurses to be the champions for new guidelines amongst the staff,” Holland said. “These champions serve as the resident experts, advocates, and, sometimes, auditors of new practices.”

At an institutional level, MSK’s clinical council evaluates new evidence and makes recommendations to ensure quality of care. At a departmental level, new nursing guidelines are often introduced through a shared governance structure, that offers a forum for staff nurses to provide feedback about how new guidelines might affect their clinical area. The process empowers nurses to refine how the guidelines are implemented and facilitates staff buy-in about the practice changes.

Nurse leaders should engage clinical nurses as early as possible in the guideline implementation process, Holland said. “The perspective of the bedside or chairside nurse is invaluable in determining what the clinical staff needs to be successful with a practice change. This also provides nurses with ownership over changes affecting their practice.”

Implementing guidelines requires time, patience, and persistence, Abbitt reminded. “Remember that the process is about advocacy and ensuring the best possible care for patients. Take time to develop a culture that promotes evidence-based practice and interprofessional care. That is the foundation for success.”