When I left pediatric intensive care to work in a hospital-based oncology infusion clinic, I needed to acquire oncology skills and national certification. More importantly, I had to revise my approach to patient care. Ambulatory care is no less challenging than hospital nursing. Both require knowledge, expertise, critical thinking, and communication skills.
In the outpatient setting, an understanding of insurance carriers, ICD codes, pre-authorization, and billing is helpful. Patient care is coordinated with home infusion, hospice, or medical offices, sometimes located outside of our hospital system. Exchanging information to insure continuity of care creates extra work.
Besides chemotherapy, we also infuse blood products and other medications that require monitoring such as Rituxan, infliximab injection, and IVIG (intravenous immunoglobulin). Although most medication reactions are controlled by premedication and slowing infusion rates, it is not unusual to hear a nurse shout and find a patient in the beginning phase of anaphylaxis. I have acquired ninja-like skill with subcutaneous Epipens.
We have advanced IV and central venous access device (CVAD) skills, because we are responsible for the care of our patients' PICC and midlines, ports, Broviacs, and, with permission from their doctors, dialysis catheters. If any of these devices clot, patients come to us for first-line treatment.
We do a lot of teaching about cancer, including stem cell transplant mobilization and tri-lumen catheter care. Encompassed in teaching oncology patients is compassionate presence, the ability to sit quietly listening to the patient and his or her caregivers. In my opinion, this is the most rewarding part of our work: the juncture where science, humanity, and art converge.
Our clinic is nurse-run. Most days, my only contact with a physician occurs over the telephone through his or her medical assistant. Physicians send patients with orders for treatments, and most of the time they are discharged home afterwards. Occasionally, patients confuse ambulatory care with emergency care and arrive too sick for our services. We then must deliver them to the ER for the care they need.
Our clinic is open 365 days a year. On weekends, patients frequently ask if I like my job. And, since nursing sort of makes one day equal to another, "weekends" aren't special per se. What they want to know is if I mind giving up my weekend or holiday caring for them.
What I enjoy most about ambulatory care nursing is that, at the end of the day, everyone gets to go home. When I worked inpatient, it felt like a continuing onslaught of never-ending tasks; only the person in the bed changed. It felt like a relay race: The baton is passed from runner to runner, but the finish line is never in sight.
Ambulatory care is like a 10K: You go as fast as you can, as hard as you can, but sooner or later the race is finished. The sun rises the next day. We come back and start over, anticipating the challenges of a new day.
Have you experienced a major transition in your oncology career? What was helpful, funny, or unexpected?