This month’s Nursing Notes newsletter delves into the world of the clinical nurse specialist. Recently, we got the chance to talk with Featured “Get to Know Nurse” Susan Bruce, a clinical nurse specialist in oncology at Duke Raleigh Cancer Center in North Carolina. I asked Susan about her career as a nurse and what inspired her to continue to advance her practice level as a Clinical Nurse Specialist.
MP3 Audio Podcast
Jamie Davis: Susan, welcome to Nursing Notes Live.
Susan Bruce: Thank you, Jamie. I’m happy to be here.
Jamie: Susan, one of the things I like to always ask is what led you to become a nurse and enter this career, this calling which I think any of us nurses really believe it is a calling, to be part of this healing team that brings people such comfort and nurses certainly are very good at doing that. Tell us a little bit about how you became a nurse, how you made that decision.
Susan: Yes. Once upon a time – now, seriously though, my grandmother was nurse. I think I never had any questions about what I wanted to be. I don’t recall ever wanting to be anything else but a nurse. I think I was very much taken in with some of her stories about what it was to be a nurse. Back in those days, because I’ve been a nurse now for 33 years, so back in those days they prepared the meals, they scrubbed the floors, they did the nursing care and all of that. There was just like something very touching about the way she would tell stories about being a nurse. Her background was mother-baby. She worked nights and spent a lot of times with the new mothers after they had delivered babies so I think a lot of teaching occurred. Then I thought, “That really sounds like what I wanted to do.” I get to meet people at a happy time in their life – or she did anyway – I would have that opportunity as well. I think that’s what initially got me drawn into nursing. Also of note, her sister was a nurse. I don’t know that much background, what kind of nursing she did, but just the thought that a couple of members in my family were nurses, I think, just kind of guided me in that direction. How I got to where I am today in oncology: I started out in a Children’s Hospital after I graduated from school and worked on a teenage Psych unit and Medicine unit. I think I took care of my very first oncology patient there. She was a 16-year-old leukemia patient. I just really got involved with her care and the fact that she was in and out and the ability to get to know her better. I really liked that more than just hands-on a patient that maybe came in to surgery, have their surgery, and went home. You really didn’t get to know the people that well. After that, I did a brief period of medical-surgical nursing and have the opportunity to relocate to Boston and decided to pursue my career in oncology nursing. I’ve been doing that now for 30 years and can’t think of anything else that I would rather do. There is something about being able to reach out and touch the lives of people and their families when they are at a very vulnerable time in their life and certainly people diagnosed with cancer they are in a very vulnerable state of time. Just getting to know them being there and being their guide through this journey is how I like to think of it. I have worked very many years at the bedside. In fact, for the majority of my career, I’ve been at the bedside. Within the last 15 months or so, I have taken on a clinical nurse specialist role which is certainly a little bit different than being at the bedside. There is some ambiguity in that role. I’m in a hospital-based cancer center. I cover only the cancer center. I don’t have any inpatient responsibilities. It was a good point in my career. There was a new director. This was a new position actually for the cancer center. Coming into that position, I’ve been able to kind of take it on and mold it and develop it as our needs have grown and based on what our needs and things are, so it’s been a good fit.
Jamie: Many nurses decide at a later point in their careers that it’s time to go back to school and reach for this next academic level of knowledge. I am always fascinated to hear about just the different decisions that have gone into that process. As a clinical nurse specialist, as that advanced practice nurse in this facility, what is your role when it comes to working with the other nurses there? Really you have this leadership role and you’re setting clinical standards, I would assume, for the nursing care provided at the bedside?
Susan: Exactly. When I was hired, my primary responsibility that was laid out for me was that of a staff nurse education and development. Looking at what are our clinical practice issues, how do we get around – or not get around them – but how do we develop the right kind of practice. Are we practicing based on standards of care and evidence-based practice? Where are the gaps in the current way that we practice? That’s been a big challenge but a big focus of my job. Some of the other things have kind of evolved over time such as doing some patient education which I very much enjoy and then looking at some program development because that’s a very strong interest of mine as program development. I do a lot with the nursing in terms of education. I actually have a monthly nursing education forum for the entire year that I plan at the end of the year. For the upcoming year where I bring in different speakers on topics that they have identified by doing a needs assessment and schedule those folks and then provide contact hours. I have to say I’m very protective of those education forums. I’ve had a lot of reps from pharmaceutical companies who want to come in and do in-services. I don’t put them in any of those slots for the very reason that I am wanting to be able to offer them contact hours that they may need to keep up their oncology certification or to meet our education requirement in the state of North Carolina. We have to have 30 contact-hours a year for license renewal. I’m very protective of that. I’ve just taken the stand that I can’t let other people that can offer contact hours come in and take up that time because I feel that’s too valuable.
Jamie: When you read about some of the advances that are going on right now as a clinical nurse specialist, are you excited about some of the things on the horizon that are going to really affect your patients?
Susan: Oh, definitely. I’m very excited. Just in the past ten years, when you look at chemotherapy and the big switch to oral chemotherapy or targeted therapies where patients can actually stay at home and take their chemotherapy or these targeted agents. I think it enhances their quality of life because they’re not coming in here one week to see the doctor, another week to have blood counts checked, and later in that week to get their chemotherapy treatments. I think it affords them the ability to have a more normal life so that’s very exciting. Part of my oncology career I spend in radiation oncology. There have been a lot of changes in the last ten or fifteen years in radiation oncology that are bringing new options to patients that weren’t available before that. It’s a very exciting time. I think as we move forward in oncology, they’re actually hoping at some point, maybe in the next twenty years, to be able to deliver chemotherapy that is specific not only to your cancer but your genetic make-up, so really having very targeted plan for you and your particular cancer. I think it’s a great time. It’s an exciting time with what we look at for trends coming and things that have happened up in the last ten to fifteen years. It’s very exciting. Sometimes it’s really hard to keep up with all the changes that are coming. It’s very exciting time for us on oncology.
Jamie: I’ve just was recently speaking with an oncology nurse and speaking about this very topic and the idea that just in recent years, the survival rates for patients long-term, she made the comment now you’re talking with families and patients about, “Hey, you’re going to live with this.” This has become a chronic illness not necessarily a terminal illness.
Susan: Yes. You hit on that, Jamie, when you said it’s becoming more of a chronic illness. That’s exactly what we’re seeing. We have more survivors now than we ever have in any point in time. The issue of survivorship is really coming to the forefront and many institutions are developing survivorship clinics where these folks that have survived their cancer come back and we see them and we recommend and do their screening, their regular screening as any normal person would do, continue to do the mammogram, the colonoscopies, those things, to make sure that they stay healthy and stay on track in their survivorship journey. That’s very exciting and that’s something that we’re hoping to bring maybe in the next couple of years as to offer maybe a nurse-run survivorship clinic for our patients. For the patients, I think it’s very difficult for them, especially in an outpatient setting, such that we are is they come in they see us sometimes weekly. They really get to know us and we’re a second family to them. We get to know them in return. Then we say, “Okay, great! We’re celebrating. You’re cancer-free! Now go out and live your life.” They have to take on a new meaning of what that new normal is for them. That can be of a challenge for them is, they spend all this time coming here, getting to know us, and then finally it’s done and “What do I do next?” It’s easy to say, “Go out and live your life” but we’ve been a part of that for so long that we have to help them I think reframe what that new life looks like and moving forward. It’s very exciting that we’re seeing this kind of a problem to have. It’s a good problem to have in oncology that more people were surviving and it’s an opportunity I think to really reach to a different continuum that we haven’t had to deal with in the past.
Jamie: It really speaks to, I think, nursing care because of the holistic approach that nurses take to their patients. That gives us an opportunity to really help them find that healthy place and develop that new life that is leading forward from the point of “You’re now cancer-free.” There’s a whole lot more to a patient than just curing their cancer and it’s great to hear you talking about taking them beyond that cure because so often the medical focuses on just curing the problem and not necessarily dealing with the patient’s issues that go along with that cure.
Susan: Exactly. The Oncology Nursing Society has declared this year 2011 as “The Year of the Psychosocial Care.” It’s really important and we’ve learned this along the way. It’s important to address the psychosocial needs of people because that’s going to help them with their treatment. For example, if they don’t have transportation to get here to the clinic, they can’t get here for their treatment or they’ll miss a treatment, it will be sporadic at best, and that’s going to decrease their chances of having a favorable outcome. By knowing what their needs are or their barriers to get them here, that’s very important. We just rolled out – the National Comprehensive Cancer Network has a distress management tool that actually asks the patient to rate the amount of distress. They are very similar to the Pain score – the pain scale, from zero to ten. On one side of your sheet, you have that zero to ten, mark where you are. The other side of the sheet, you have broken out into categories and then different situations, what are the factors contributing to your distress and how do we get you the right resources. We just rolled that out in February and are looking at screening people, identifying what their needs are. With this distress management tool, anybody with scores of five or above gets an automatic referral to our social worker be it whether it’s transportation needs, financial – “I can’t afford the drugs that you want to give me” – is it that they truly need some counseling because they have their normal lives going on before they come in here and then we say you have cancer and that really upsets the apple cart. Not only are they trying to deal what’s been normally going on in their life, now we said to them, “You’ll be coming in every three to four weeks for treatment. By the way, I need you to come in and get your blood counts checked in between.” That just intensifies the stress and distress that they have in their own personal life. I tell them when I teach our general chemo class, “Please, let us know. This is important part of your treatment that we know what these issues are so we can find you the right resources to help you. We want to make this as positive an experience as we possibly can and we can’t do that if you don’t share with us some of the things that are impacting your ability to get here or to afford treatment or whatever the issue is.” I’m looking down the line and hoping to see that we’ve really made this impact in being able to help people with the stress and distress that they’re feeling when they’re first diagnosed and as they go for treatment because it’s a very important part of their lives that we need to take into consideration.
Jamie: What would you say to nurses that are listening to this, both oncology nurses and nurses in other specialties, who might be thinking about moving on into that clinical nurse specialist role in their career path? Do you have any advice you might offer to them as they’re considering moving on in their careers?
Susan: I’ll try. I say that because there’s a lot of ambiguity with the clinical nurse specialist’s role in whatever setting you are in. In periods of time, they’ve done away with the clinical nurse specialist only to find out, five or ten years later, it’s that long, “Boy, we really need those people back.” We do offer a value, I think, to the institution. We are a change agent. We help to make change occur. With nurse practitioners, the world’s pretty clearly defined, the nurse practitioners of these patients in the clinic setting every day or whatever. The clinical nurse specialist, I think, just really adds so much more. Who is going to bring the evidence to the bedside if it’s not the clinical nurse specialist? Clinical nurse specialists look at systems as a whole. How do we implement this in the system? Whether I have an idea that I think would work good in the outpatient setting, is it something that could be incorporated in to the inpatient setting to help those people as well both nurses of those patients. It’s about the collaboration, I think – extending that information. But I really think we do have a very strong emphasis on keeping up with the evidence and ensuring that that gets into practice. I find that I’m doing that a lot in our setting, reviewing what standard of care is and how does that impact the way we practice. I see clinical nurse specialist is very essential in an organization be it large or small. I think other healthcare providers have a hard time seeing what we do because they don’t know what we do. They can’t articulate what we do and sometimes we can’t articulate totally what we do. But we’re good when you look at quality improvement processes. That’s one of our strengths, I think, is the ability to look at a process, see how it needs to be tweaked to being more effective. We know by taking care of population-based patients that we make a difference in health cost savings for the organization. Even though we can’t be like a nurse practitioner does in most cases, we do make an impact in cost-savings through those quality improvement processes and things of that nature. Who’s going to educate the nurses at the bedside, is the other thing. It won’t be the nurse practitioner that’s seeing patients in clinic because they don’t have time to do that. I think the CNS role is a great role to be in and I’ve embraced it and just looked at ways that I can make a difference within my own setting whether it’s through staff education or patient education and how that looks. I think we bring a lot to the role that other people don’t necessarily understand.
Jamie: How closely do you work with other clinical nurse specialists and other specialties within your system?
Susan: In my area, Duke Raleigh Hospital, we have a handful of clinical nurse specialists. There is an inpatient clinical nurse specialist that I work closely with and I encourage the inpatient oncology staff to – they’re invited to my monthly nursing education forums that I do. We work collaboratively on policies and procedures to make sure that what works inpatient, works outpatient. If it doesn’t work outpatient, how do we tweak that to make it work in our setting. We collaborate a lot on issues of competency: what things do we want to do for our annual competency training to make sure that we’re looking at the needs of the oncology nurses. Duke Raleigh Hospital is part of the bigger Duke University Health System. Just this morning, I was at a meeting there and it’s a clinical nurse specialist meeting so that any clinical nurse specialists across the setting, and there are three hospitals in our health system, attend that meeting. We’re trying to make practice consistent across the hospitals so that if I’m a nurse that kind of floats and I like to float in oncology. One day I might work at the main campus, another day I work at the community hospital in Durham that’s in the health system where I work in Raleigh doing oncology there. What does practice look like across the continuum? We’re trying to make it as consistent as possible within what the unique needs of that hospital are. We’re doing a lot of our patient education, standardizing that so it can be used across the setting. We have a very active oncology clinical practice counsel where we bring issues forward and address it looking at what that looks like within our health system. I do collaborate within our health system a lot with CNS as well as I’m very active in the oncology nursing society. I belong to the clinical nurse special interests group. I participate in that. Through my years of attending the different ONS conferences, I have met clinical nurse specialist friends they are now. They’ve been very good at mentoring me since this is my first CNS role. I’m one of those nurses that went back later in life to get their Master’s and decided what they wanted to do with the rest of their career. I’ve been very fortunate to have the advantage of hooking up with people all over the country and seeing what it is that maybe different regionally in their practice from what ours is or ideas looking at what they do that works for them and is that something that might work for us. I really think that helped me to grow professionally by having that networking and collaboration with other CNS.
Jamie: Well, Susan, I want to thank you for taking the time to share your nursing experience with the listeners here at Nursing Notes Live. I know I always enjoy doing these segments and it’s just been a pleasure talking with you and learning about some of the things you’re doing that are making the outcomes for your patients better both in the near-term and in the long-term which is just great to hear.
Susan: Yes. I’m very excited to be in this position. I really think I have the best job in the world because I get to do all the things I like and I tell my director that almost every other week. I get to staff occasionally. I get that actual hands-on patient care that I love. I get to do patient education. I get to do nursing education. Even a little geeky, I like to write policies and procedures. I really have a great job that affords me a lot of opportunity to do the things that I really enjoy doing. I’m very thankful for those members in my family especially my grandmother who was a nurse and kind of started this whole impetus to become a nurse for me. I’m very thankful to her for that.
Don’t forget to check out the entire March, 2011 issue of Nursing Notes, shining a light on the advanced practice pathway of the clinical nurse specialist. You’ll find articles highlighting the return to school for an advanced practice degree, a look at the new ways clinical nurse leaders are changing patient care forever, and links to important survey results and additional nursing resources. You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month where we brought together a group of clinical nurse leaders, managers, and educators to discuss the unique challenges associated with their jobs. You’ll find this and our other podcast episodes at www.NursingNotesLive.com, the Nursing Notes by Johnson & Johnson Facebook page, and in the podcast area in iTunes.