Meet Marisa Stevens – Oncology Nurse Practitioner

Thanks for this opportunity Jackson to chat about my nursing role in the oncology team.

I have been nursing for >20 years now; my husband is a secondary school teacher (who has been doing it much tougher than me during COVID!) and we have 2 boys (9 and almost 11!).

I fell into oncology in my graduate year and haven’t looked back – I have worked in the public and private sectors, interstate and overseas, on the wards and in the outpatient setting. I dabbled with management and staff education but really found my niche in direct patient care.

My 2 biggest achievements would be instigating the oncology liaison nurse role back in 2009, which has continued to evolve into my current role; and completing my masters and becoming endorsed as a nurse practitioner (NP).

Can you tell us a little about what an oncology nurse practitioner does?

I guess my role is about ensuring patients are receiving individualised and timely care. I am based in outpatients and work closely with the oncologists.  While the oncologist provides the treatment pathway and manages the disease trajectory, I see my role as focusing on the patient’s quality of life (QOL) – whether side-effect management from treatments or symptom management from disease; providing education about treatment/diagnosis; co-ordinating and providing psychosocial support and coordinating care.

I look after patients whom we are treating for curative intent as well as patients with advanced cancer; their treatment may be oral therapy or IV.

I receive a referral from the oncologist and organise a 1:1 consultation with the patient and a support person prior to starting treatment. This initial meeting is primarily an opportunity to build rapport with the patient and be that familiar face; that central contact point. The consultation provides the patient with the time they need to clarify their understanding of their diagnosis/what the oncologist has explained, the goal of treatment; to discuss their fears; to explore treatment side effects – management and prevention strategies; to assess their IV access and whether or not CVAD (central venous access device) is warranted.  I also look at their social situation, what practical issues they may have, how to manage work/kids/financial issues etc. and ensure urgent allied health referrals are instigated.

There is so much information for patients that I never really expect them to remember everything, but having my role allows them to contact me to ask questions as needed. The initial discussion is aimed to help reduce anxiety and resolve any preconceived ideas/fears about cancer treatment they may have. I also work closely with the ward and the day oncology unit. We have a daily handover with the day oncology NUM and pharmacist about patients coming in the next day to help streamline our care. My role is also to co-ordinate allied health service, to work with the staff on the ward and day oncology to ensure the goal of care is clearly communicated.

I spend a lot of time on the phone; I call patients post-treatment and triaging incoming calls. This was a big part of instigating my role initially when I submitted my business case – I wanted to demonstrate that nurses could manage the majority of calls from patients and only escalate issues to the doctor as needed; this subsequently allowed for quick intervention for the patient and saved the doctor time.

As NPs are able to diagnose, prescribe and order tests, it also means that the patient/staff don’t have to wait all day for a doctor to get back to them about an issue that could be resolved quickly (remember in the private we often don’t have HMOs or registrars available). Intervening early also hopefully prevents unnecessary emergency admissions and allows for direct admission to the wards where possible.

Other parts of my role include staff education, liaising with family members, other specialists, community palliative care; I work with a lot of people so building relationships and good communication is crucial.

What are some of the clinical presentations you see and manage in your role as an oncology nurse?

Clinical presentations are most often side effect related (including febrile neutropenia, dehydration; with immunotherapy now seeing more colitis/pneumonitis) or it may be disease-related (poor pain control, nausea, abdominal ascites, pleural effusions, skin secondaries that need intense wound management): sometimes it may be completely unrelated to their cancer (which is always important to consider as we automatically jump to the fact that it is cancer-related, but often patients – particularly now as living longer – have other co-morbidities that can come into play).

Occasionally a patient presents quite unwell – last week, for example, a lady with metastatic breast cancer attended came in for review (who had previously been responding well to treatment) looking flat and a bit grey. She reported sudden onset gross bilateral leg oedema and right arm oedema; she was tachycardic, she had shortness of breath on exertion; she had no acute pain, no cough and her O2 sats and BP were NAD. We sent her off for echocardiogram, CT PA and ultrasound; she ended up having both a pericardial effusion and pulmonary embolus.

What cancer patients do you primarily work with?

I primarily work with breast cancer patients and the young women with breast cancer do have a multitude of physical effects that affect self-image/self-esteem – surgery, early menopause, weight gain from chemotherapy, social issues, fertility issues etc. Although, I do enjoy working with other tumour streams as you learn little tips from other specialities – for example, shortness of breath management with lung cancer can be translated to a breast cancer patient with lung metastasis.

There are a lot of similarities across tumour streams, ie: the goal of care, if they are metastatic, is still about their QOL or those that are adjuvant still share the same fear of recurrence. There are a lot of myths/fears regarding chemotherapy and it is essential that staff have had training that the correct equipment is provided and policies are in place. 

What drives your interest in oncology?

I think I like the fact that no two patients are the same, even if on paper they have the same diagnosis and are having the same treatment: everyone will respond differently. I enjoy the relationships with patients (as often we know them for years) and the oncology team. It’s always exciting to see new treatments coming out, particularly for those with metastatic disease.

It’s also fun attending conferences and networking. I guess ultimately I like making a difference (which sounds a bit naff, but it is true).

Challenges as an oncology nurse?

• Because I do a lot of patient education, I know that there are a lot of misconceptions about cancer treatments (horror stories from 20 years ago, what they see on TV, everyone knows someone and has a story to tell), and patients often come in with information from the internet – blogs particularly – that often we have to unpack and work through.
• I think that providing consistent information, even within oncology, is difficult. Unfortunately, it doesn’t take much to confuse and unsettle patients.
• The concept of what “palliative” means – patients/society still interpret it as meaning end of life care,  but it really means that a person’s cancer or disease is not curative and therefore our goal is to control a patients disease and ensure they have good QOL.  So referring a patient to community palliative care does not necessarily mean end of life care.
• Trying to get patients to trust our treatments – despite being evidenced-based, a significant number of patients do alternate therapies or take supplements (which is often fine, but often they don’t feel comfortable disclosing it). Unfortunately, patients can get conflicting information from other “specialists” which then can confuse patients even more.
• Media:  advertising “breakthroughs” that haven’t even been tested in humans yet.
• Molecular testing: whilst providing more information and potentially individualising treatments, it also adds complexity.
• For patients with metastatic disease, while they are often living for a lot longer as we have a lot more treatments available, when there are no more treatments for the patient that is likely to be effective (ie looking at risk: benefit for the patient) it is often difficult for them to comprehend.

Misconceptions about oncology nursing?

• I think the biggest misconception is that oncology is depressing; it sure can be heartbreaking at times, but the majority of the time it is far from that.
• The other is that chemotherapy is such horrible treatment and that all chemotherapy is the same. There are a lot of different drugs, regimens, doses and thus a lot of varying degrees of intensity and types of side effects.  There are also a lot of treatments that are not chemotherapy based – immunotherapy, targeted therapies, and endocrine therapies.
• That metastatic patients are all in one group and they are all going to die tomorrow – often very far from the truth. All cancers have different behaviours and thus different targets for treatment. There are a significant number of women with metastatic breast cancer living/working in the community that you would not even know that they have cancer.
• Patients receiving chemotherapy that are heading towards terminal phase is cruel – often this decision is made by the patient, not the treating team; our job is to give the education but still support them in whatever decision they make.

Oncology Nurse Practitioner Scope of Practice (SOP)?

In relation to SOP, there are different elements to consider: it isn’t just about legal qualifications/endorsement. You also need an agreement with the hospital and the doctors you are working with. Most importantly, it is knowing your own limits.  So you may find an NP at one hospital may be able to work differently to another NP at a different hospital.

Although there are no formularies anymore for NPs in relation to prescribing, I have gone through all the medications that we utilise regularly with the oncologist and pharmacist and agreed upon ones that I can initiate and others that I can do continuing scripts for during my first year.  As an NP I can order some scans and pathology, but not all; so it can be a bit messy for staff, so again clear guidelines/policies need to be in place.   I have no doubt my role will continue to evolve as the years pass – and hopefully lobbying the government will increase our scope!

I think if you want to work towards becoming an NP– experience is definitely essential. When I visited hospitals in the US, they said when NPs first came out there wasn’t a requirement to have a certain number of hours of clinical experience, which meant a lot of young graduate nurses were suddenly becoming NPs with limited knowledge, which wasn’t ideal!

To be accepted to masters in Australia (certainly, with the course I did – see below) you need a specific amount of hours working in CNC role in addition to other qualifications. Having the right support/mentoring is key: from doctors, nursing colleagues, pharmacist and hospital management.

I am finding also in my first year as NP, that support is key not only from the doctor/s you are working with but by an NP mentor.  I am the first NP at my work, and there aren’t many NPs in the private hospital setting, so I am finding my own way a bit. Thankfully I do know some other NPs from my course and also those who have been NPs for a while to tap into their experience!

You play a large role in the Triage of oncology patients

Phone triage is probably what dominates my practice; patients can call in anytime during the day (irrespective to what plans I may have had!). I always need to ask myself – what is their diagnosis, what treatment are they on, do they have any co-morbidities; are the symptoms they are describing expected or not. I need to ensure I ask the right questions, for example, a classic one is: “Do you have a temperature? No. What was it when you took it? I haven’t taken it….!”

Knowing what to do with the patient is the next step; can they manage the symptoms at home? Or can they try to intervene one way but if not resolving what they should do next; do they need urgent assessment, do they need bloods etc.

Triage is also helping manage drug reactions in day oncology or patients who come in unwell who attend day oncology who wasn’t due to see the Dr on that day. When I’m consulting with the oncologist, some patients present to the clinic (as in the case above) who I may see in the waiting room who isn’t looking so flash, so again I can start assessing them and getting the ball rolling and a working hypothesis of what is happening before the Dr sees them.

As a nurse it is really empowering being able to independently meet with patients and help guide their cancer journey. I love being able to help fix a problem and put the patient at ease; I enjoy having the time to ensure all aspects of their care are discussed, not just cancer. There is always that level of trust with nurses where often patients divulge more than with the Dr, and I think that’s why the nurse/Dr collaborative care works well as we can put all the information from the patient together to help manage their treatment and care.

Emotional toll as an oncology nurse? And any advice on the topic of death and dying?

Oh look there is still the occasional patient that gets to you (& I have always vowed if I stop feeling completely, then I’m probably burnt out!), but to be honest, I have never really taken it home with me. I think catching the train and walking home has always given me that time to unwind/reflect.

I think I often grieve before a patient dies; when recommending that treatment will no longer be a benefit – ie patients heading to the terminal care phase. Occasionally if there is a run of deaths, I have hit a wall, but it’s about acknowledging it, acknowledging that what we do is emotionally taxing (whether in oncology or other areas) and that often our friends/family won’t understand it. It is incredibly important to take some time out if needed – and I don’t think oncology nurses do always get enough debriefing or emotional support at work. Often a patient passes away and we are expected just to move on to the next patient.

If you are thinking about working in oncology you need to be professional – compassionate and have a great rapport with patients, but understand that it isn’t necessarily a friendship – we are their health care team.

I think you really have to understand and accept that some of the patients we look after are going to die and they and their family will look to you to help them through that. Really need to put ourselves to the side and focus on doing best for family and patient.  I would say, however, it is incredibly important to have an outlet – watching trashy television, exercise or reading or whatever.

Building rapport and trust in oncology

Patients are only going to listen to your recommendations and information if they feel they can trust you; it does take a lot of work and patience. The key is really trying to understanding the patient’s perspective/ personality/background and then trying to target the same information but specifically for them

Because I work across adjuvant and metastatic patients, if a patient, unfortunately, relapse, it is incredibly reassuring for a patient to be that familiar face for them.

What are your research interests?

I really got thrown into having “Quality” as my portfolio when I was an ANUM and thought it was going to be dull – but actually, it helped me have the tools to be able to implement change in day oncology.  Although I have done a tiny bit of research, I really focus on our unit and reading others research and try to look at ways to improve services in a practical way.

My biggest research project was actually on the need to implement CNC roles in the private system for about 10 years or so ago. I spent more than a year gathering data and putting in a business case to the hospital demonstrating the benefits of a CNC role. I then received sponsorship to trial the role, evaluate it and then it became permanent.

I have presented research on the Vitamin D levels and supplementation in early breast cancer patients; I also have looked at weight gain for EBC patients. I recently have researched the complexity of difficult venous access in oncology and put together a pathway for patients/staff. I have also been involved with oncology rehab program and increasing allied health involvement for our cancer patients.

Collaboration and teamwork in your role

There is so much information for patients and so much complexity to a diagnosis, and it impacts every part of their life (physical, financial, social, practical, spiritual, emotional etc) that they need support and information from a specialized team of people.

The breast care nurse for surgical care, the radiotherapy nurse, psychologist, social worker, exercise physiologist, day oncology and ward nurses, physiotherapy, radiologist, lymphoedema specialist, surgeon, dietician, pain specialist, pall care team, oncologist, radiotherapist – I guess part of my role is ensuring all members are involved in a timely manner and know the right information about the patient.

I often do joint consultations with an oncologist for those patients on active treatment (IV or oral) – this is important as patients often present differently to Drs or forget things they wanted to ask; because I spend more time with patients ‘behind the scene’, I often can help give a truer picture and thus help ensure best decisions for a patient is made.

The breast care nurse and I also run an exercise/social group for early breast cancer patients – so it also allows patients to collaborate and support each other.

Brooke (Breast care nurse) and myself about to go walking with our BC patients.

What advice would you give to your younger self?

I think knowing that there are specialised roles and different pathways in nursing. Getting involved and finding a good mentor also really important. I think also on ward rounds, if you are a ward nurse, make sure you stay in the room when the medical team come around and listen –it’s a great way to learn. Ask the medical team why they make the decisions they do etc…

What advances do you want to see the role of nurse practitioners to take.

I think the main thing is the recognition of Nurse Practitioner’s, not just within the health community, of what NPs offer/the role they play. To have the role recognised, understood and valued in the community. I am still explaining my role to friends, patients and fellow nurses.

I would love to see nurses involved more as an essential member/leadership roles in the wider medical community and in government or as board members in relation to making decisions with health care policies for the community.

I would love the perception of what nurses do in society to change – to not hear nurses say “I’m just a nurse”.

Advice for nurses wanting to work in oncology:

Oncology is a diverse area and constantly evolving: there are practicals skills to be learnt (cannulating, administering chemotherapy and blood products, phlebotomy, accessing CVADs), communication skills (patient education/working with a team), networking (attending conferences): there are specialist roles, research, and end of life care; there is the surgical/medical/radiotherapy specialties; pain management etc. Getting a broad range of experience and then work out which area want to focus on. Definitely worth joining oncology groups such as CNSA to keep up to date and network, and get a good mentor

Any resources you suggest for those interested in oncology nursing?

Probably best resource is EVIQ

If I was in charge of nursing in Australia….

I think the change needs to come from education/promotion of our profession ie starting at schools exposing students to all the opportunities nursing brings: the skill required, the different roles with in nursing – ie research, clinical, management, education etc. I think as a profession we still need to break the social idea of the handmaiden/just there to wipe buts etc.

The second step would be to amend the undergrad program/graduate year: when I studied my undergrad at university, I spent more time learning how to make a bed than in pharmacology and yet we hand out meds every day and I didn’t do placement until my final year. I think there needs to be a bigger focus on patient assessment with a higher expectation of increased skill set at the end of the graduate year – cannulating, taking blood, inserting catheters etc. Grads are keen so we need to jump on that so they stay interested and don’t leave the profession.

I like the US model where every year need to do in-services/etc in order to get to next grade.

I’d like to see nurses not being passive, but using their initiative and being an essential part of the team – not just those in specialist roles.

---

Read other nurse practitioner content here

Read other oncology related content here

Looking for our next guest! Are you / do you know of a healthcare worker or student working in Australia, who would like to write about your/thier career, area of speciality, unique experiences or other nursing/midwifery/allied health related content? Please email us at hello@thenursebreak.org to discuss further or check out the Write for TNB Info Page on the website.