Publications by authors named "Virginia LeBaron"

29 Publications

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Evaluating Acupuncture for the Treatment of Chemotherapy-induced Peripheral Neuropathy: An Integrative Review.

West J Nurs Res 2021 Feb 9:193945921992538. Epub 2021 Feb 9.

University of Virginia School of Nursing, Charlottesville, VA, USA.

The purpose of this integrative review of the literature is to synthesize the current evidence and identify gaps in knowledge regarding the effectiveness of acupuncture to treat chemotherapy-induced peripheral neuropathy (CIPN). PubMed, CINAHL, Web of Science, and Cochrane Review databases were searched using inclusion criteria: keywords acupuncture, cancer, and peripheral neuropathy, published in English, between 2009 and 2019. Sixteen articles met the inclusion criteria. The literature indicates that acupuncture is generally well tolerated by patients with cancer, and a majority of patients with CIPN reported decreased pain and increased quality of life after receiving acupuncture treatment. A comprehensive understanding of the ability of acupuncture to treat CIPN is limited by variability of acupuncture techniques and inconsistency in measures of evaluation.
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http://dx.doi.org/10.1177/0193945921992538DOI Listing
February 2021

Understanding the Experience of Cancer Pain From the Perspective of Patients and Family Caregivers to Inform Design of an In-Home Smart Health System: Multimethod Approach.

JMIR Form Res 2020 Aug 26;4(8):e20836. Epub 2020 Aug 26.

The George Washington University School of Engineering & Applied Science, Washington, DC, United States.

Background: Inadequately managed pain is a serious problem for patients with cancer and those who care for them. Smart health systems can help with remote symptom monitoring and management, but they must be designed with meaningful end-user input.

Objective: This study aims to understand the experience of managing cancer pain at home from the perspective of both patients and family caregivers to inform design of the Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C) smart health system.

Methods: This was a descriptive pilot study using a multimethod approach. Dyads of patients with cancer and difficult pain and their primary family caregivers were recruited from an outpatient oncology clinic. The participant interviews consisted of (1) open-ended questions to explore the overall experience of cancer pain at home, (2) ranking of variables on a Likert-type scale (0, no impact; 5, most impact) that may influence cancer pain at home, and (3) feedback regarding BESI-C system prototypes. Qualitative data were analyzed using a descriptive approach to identity patterns and key themes. Quantitative data were analyzed using SPSS; basic descriptive statistics and independent sample t tests were run.

Results: Our sample (n=22; 10 patient-caregiver dyads and 2 patients) uniformly described the experience of managing cancer pain at home as stressful and difficult. Key themes included (1) unpredictability of pain episodes; (2) impact of pain on daily life, especially the negative impact on sleep, activity, and social interactions; and (3) concerns regarding medications. Overall, taking pain medication was rated as the category with the highest impact on a patient's pain (=4.79), followed by the categories of wellness (=3.60; sleep quality and quantity, physical activity, mood and oral intake) and interaction (=2.69; busyness of home, social or interpersonal interactions, physical closeness or proximity to others, and emotional closeness and connection to others). The category related to environmental factors (temperature, humidity, noise, and light) was rated with the lowest overall impact (=2.51). Patients and family caregivers expressed receptivity to the concept of BESI-C and reported a preference for using a wearable sensor (smart watch) to capture data related to the abrupt onset of difficult cancer pain.

Conclusions: Smart health systems to support cancer pain management should (1) account for the experience of both the patient and the caregiver, (2) prioritize passive monitoring of physiological and environmental variables to reduce burden, and (3) include functionality that can monitor and track medication intake and efficacy; wellness variables, such as sleep quality and quantity, physical activity, mood, and oral intake; and levels of social interaction and engagement. Systems must consider privacy and data sharing concerns and incorporate feasible strategies to capture and characterize rapid-onset symptoms.
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http://dx.doi.org/10.2196/20836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481872PMC
August 2020

Reply to Baum.

Authors:
Virginia LeBaron

JCO Oncol Pract 2020 03 6;16(3):147. Epub 2020 Feb 6.

Virginia LeBaron, PhD, APRN, FAANP, University of Virginia School of Nursing, Charlottesville, VA.

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http://dx.doi.org/10.1200/JOP.19.00791DOI Listing
March 2020

Leveraging Smart Health Technology to Empower Patients and Family Caregivers in Managing Cancer Pain: Protocol for a Feasibility Study.

JMIR Res Protoc 2019 Dec 9;8(12):e16178. Epub 2019 Dec 9.

The George Washington University School of Engineering & Applied Science, Washington, DC, United States.

Background: An estimated 60%-90% of patients with cancer experience moderate to severe pain. Poorly managed cancer pain negatively affects the quality of life for both patients and their family caregivers and can be a particularly challenging symptom to manage at home. Mobile and wireless technology ("Smart Health") has significant potential to support patients with cancer and their family caregivers and empower them to safely and effectively manage cancer pain.

Objective: This study will deploy a package of sensing technologies, known as Behavioral and Environmental Sensing and Intervention for Cancer (BESI-C), and evaluate its feasibility and acceptability among patients with cancer-family caregiver dyads. Our primary aims are to explore the ability of BESI-C to reliably measure and describe variables relevant to cancer pain in the home setting and to better understand the dyadic effect of pain between patients and family caregivers. A secondary objective is to explore how to best share collected data among key stakeholders (patients, caregivers, and health care providers).

Methods: This descriptive two-year pilot study will include dyads of patients with advanced cancer and their primary family caregivers recruited from an academic medical center outpatient palliative care clinic. Physiological (eg, heart rate, activity) and room-level environmental variables (ambient temperature, humidity, barometric pressure, light, and noise) will be continuously monitored and collected. Behavioral and experiential variables will be actively collected when the caregiver or patient interacts with the custom BESI-C app on their respective smart watch to mark and describe pain events and answer brief, daily ecological momentary assessment surveys. Preliminary analysis will explore the ability of the sensing modalities to infer and detect pain events. Feasibility will be assessed by logistic barriers related to in-home deployment, technical failures related to data capture and fidelity, smart watch wearability issues, and patient recruitment and attrition rates. Acceptability will be measured by dyad perceptions and receptivity to BESI-C through a brief, structured interview and surveys conducted at deployment completion. We will also review summaries of dyad data with participants and health care providers to seek their input regarding data display and content.

Results: Recruitment began in July 2019 and is in progress. We anticipate the preliminary results to be available by summer 2021.

Conclusions: BESI-C has significant potential to monitor and predict pain while concurrently enhancing communication, self-efficacy, safety, and quality of life for patients and family caregivers coping with serious illness such as cancer. This exploratory research offers a novel approach to deliver personalized symptom management strategies, improve patient and caregiver outcomes, and reduce disparities in access to pain management and palliative care services.

International Registered Report Identifier (irrid): DERR1-10.2196/16178.
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http://dx.doi.org/10.2196/16178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928698PMC
December 2019

Opioid Epidemic or Pain Crisis? Using the Virginia All Payer Claims Database to Describe Opioid Medication Prescribing Patterns and Potential Harms for Patients With Cancer.

J Oncol Pract 2019 12 4;15(12):e997-e1009. Epub 2019 Nov 4.

University of Wisconsin School of Pharmacy, Madison, WI.

Purpose: A key challenge regarding the current opioid epidemic is understanding how concerns regarding opioid-related harms affect access to pain management, an essential element of cancer care. In certain regions of the United States where disproportionately high cancer mortality and opioid fatality rates coexist (such as southwest Virginia in central Appalachia), this dilemma is particularly pronounced.

Methods: This longitudinal, exploratory, secondary analysis used the Commonwealth of Virginia All Payer Claims Database to describe prescription opioid medication (POM) prescribing patterns and potential harms for adult patients with cancer living in rural southwest Virginia between 2011 and 2015. Descriptive and inferential statistical analyses were conducted at the patient, prescriber, and prescription levels to identify patterns and predictors of POM prescribing and potential harms. To explore geographic patterns, choropleth and heat maps were created.

Results: Of the total sample of patients with cancer (n = 4,324), less than 25% were prescribed a Controlled Substance Schedule II POM at least three times in any study year. More than 60% of patients never received a Controlled Substance Schedule II POM prescription. Six hundred fifty-two patients (15.1%) experienced 1,599 hospitalizations for any reason; 10 or fewer patients were admitted for 11 opioid use disorder-related hospitalizations. The main findings suggest potential undertreatment of cancer-related pain; no difference in risk for opioid-related hospitalization on the basis of frequency of POM prescriptions; and geographic disparities where opioid overdoses are occurring versus where POM prescription use is highest.

Conclusion: These findings have significant opioid policy and practice implications related to the need for cancer-specific prescribing guidelines, how to optimally allocate health delivery services, and the urgent need to improve data interoperability and access related to POMs.
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http://dx.doi.org/10.1200/JOP.19.00149DOI Listing
December 2019

Ethical issues in patients referred for palliative radiation therapy.

Ann Palliat Med 2019 07;8(3):231-239

Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.

Background: As patients with advanced cancer approach end of life, ethical issues may arise. We describe ethical issues encountered by radiation oncologists in this setting.

Methods: A prospective, survey-based study assessed 162 consecutive consults for palliative radiation therapy (PRT) over 4 months at 3 hospitals. Consulting radiation clinicians completed a survey assessing palliative care issues encountered, based on national guidelines. Ethical issues included 5 subthemes (conflict between clinicians, caregiver-clinician conflict, internal conflict, feeling unable to do what was best for the patient, and violation of personal morals), an option for unclassified issues, and open-ended responses. Multivariate analyses (MVA) assessed potential patient-related predictors of ethical issues: gender, performance status (PS), PRT indication, physical symptoms, and presence of psychosocial, goals of care, care coordination, cultural, or spiritual issues.

Results: Of 162 surveys, 140 were completed (response rate =86%). Overall, 14 (10%) surveys identified ethical issues relevant to care; 11 of 14 (78%) identified more than 1 ethical issue. Half (7; 50%) involved conflict between clinicians and clinician-caregiver conflict; 6 (43%) involved clinician distress or internal conflict; and 2 (14%) felt impeded from doing what they felt was best for the patient. Open-ended responses revealed differences in opinion between medical specialties (n=6, 43%), and conflict related to coordination of care among clinicians (n=3, 21%). On UVA, ethical issues were associated with PRT referrals for bleeding, dyspnea, or dysphagia due to visceral metastases (30%) versus CNS indications such as brain metastases or cord compression (7%) or for bony metastases (4%) P<0.001. On MVA, ethical issues were associated with PRT for visceral metastases (OR 13.0; 95% CI, 2.3-74.6; P<0.001) and presence of spiritual issues (OR 4.0; 95% CI, 1.1-14.5; P=0.04).

Conclusions: At least 1 in 10 referrals for PRT involve ethical issues. Further studies are warranted to assess the ability of radiation oncologists to manage ethical issues.
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http://dx.doi.org/10.21037/apm.2019.06.02DOI Listing
July 2019

Mental Health Comorbidities and Elevated Risk of Opioid Use in Elderly Breast Cancer Survivors Using Adjuvant Endocrine Treatments.

J Oncol Pract 2019 09 19;15(9):e777-e786. Epub 2019 Jul 19.

University of Virginia, Charlottesville, VA.

Purpose: Prolonged opioid use is common and associated with lower survival rates in breast cancer survivors. We explored whether opioid use in elderly breast cancer survivors using adjuvant endocrine therapy (AET) regimens was affected by the prevalence of mental health comorbidity and, in turn, how this affected survival in this population.

Methods: This retrospective study analyzed 2006 to 2012 SEER-Medicare data sets and followed patients for at least 2 years from the index date, defined as the first date they filled an AET prescription. The study included adult women with incident, primary, hormone receptor-positive, stage I to III breast cancer. They were also first-time AET users and fee-for-service Medicare enrollees continuously enrolled in Medicare Parts A, B, and D. We measured whether patients with a clinical diagnosis of a mental health comorbid condition used opioids after the initiation of AET and their survival at the end of the study period.

Results: A total of 10,452 breast cancer survivors who began AET treatments were identified, among whom the most commonly diagnosed mental health comorbidities were depression (n = 554) and anxiety (n = 246). Using a propensity score risk adjustment model, we found that opioid use was significantly higher in women with a mental health comorbidity (odds ratio,1.33; 95% CI, 1.06 to 1.68). In addition, mental health comorbidity was associated with a significantly increased hazard of mortality in this population (hazard ratio, 1.49; 95% CI, 1.02 to 2.18).

Conclusion: The presence of mental health comorbidity in breast cancer survivors significantly increases the risk of opioid use and mortality, which highlights the need for better management of comorbid mental health conditions.
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http://dx.doi.org/10.1200/JOP.18.00781DOI Listing
September 2019

Examining the relationship between changes in personality and depression in older adult cancer survivors.

Aging Ment Health 2020 08 3;24(8):1237-1245. Epub 2019 Apr 3.

Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, School of Medicine, Charlottesville, VA, USA.

Despite widespread agreement that personality traits change across the lifespan into older adulthood, the association between changes in personality and depression among older adult cancer survivors is unknown. It was hypothesized that older adults with (vs. without) a past cancer diagnosis would experience an increase in neuroticism, and decreases in conscientiousness, agreeableness, openness, and extraversion, and that changes in these traits would mediate the relationship between receiving a cancer diagnosis and change in depression. Two hypotheses were tested in a cancer survivor sample. First, that increased chronic stressors and decreased physical health would mediate the link between personality change and increased depression. Second, that personality change would mediate the link between changes in chronic stressors/health and increased depression. Secondary data analysis utilizing three waves of data from the Health and Retirement Study. Data was compiled from 5,217 participants, among whom 707 received a cancer diagnosis. Older adults with (vs. without) a cancer diagnosis decreased in conscientiousness, which was associated with increased depression. Among cancer survivors, worsening chronic stressors/health mediated many pathways between personality change and an increased depression. Increased neuroticism mediated the link between worsening health/chronic stressors and increased depression. With the exception of conscientiousness, changes in personality did not mediate the link between cancer survivor status and depression. Among older adult cancer survivors, changes in personality traits may increase depression through worsening physical health and chronic stressors, potentially informing targeted interventions. Interventions that target increased neuroticism may be particularly useful in older adult cancer survivors.
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http://dx.doi.org/10.1080/13607863.2019.1594158DOI Listing
August 2020

Parental Perspectives on Roles in End-of-Life Decision Making in the Pediatric Intensive Care Unit: An Integrative Review.

J Pediatr Nurs 2019 May - Jun;46:18-25. Epub 2019 Mar 1.

School of Nursing, University of Virginia, Charlottesville, VA, United States. Electronic address:

Problem: Little is known about how parents perceive their role or the role of health care providers (HCPs) during end-of-life decision making (EOL DM) in the context of the pediatric intensive care unit (PICU).

Eligibility Criteria: The authors searched CINAHL, PubMed, Ovid Medline, Web of Science, Social Science Database, PsycINFO, and Google scholar for English language studies performed in the United States related to parental perception of parental or HCP roles in EOL DM in the PICU since 2008.

Sample: Eleven studies of parents and health care providers (HCPs) of critically ill children in the PICU and/or receiving inpatient pediatric palliative care, and bereaved parents of PICU patients.

Results: Most parents reported belief that EOL DM is within the domain of parental role, a minority felt it was a physician's responsibility. Parental EOL DM is rooted more firmly in emotion and perception and a desire to be a 'good parent' to a child at EOL in the way they see fit than HCP recommendations or 'medical facts'. Parents need HCPs to treat them as allies, communicate well, and be trustworthy.

Conclusions: Role conflict may exist between parents and HCPs who are prioritizing different attributes of the parental role. The role of the nurse in support of parental role in the PICU is not well-elucidated in the extant literature.

Implications: Future research should focus on what parents need from HCPs, especially nurses, to support their parental role, and factors that facilitate the development of trust and good communication.
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http://dx.doi.org/10.1016/j.pedn.2019.02.029DOI Listing
December 2019

What Is the Rural Cultural Perspective?

Oncol Nurs Forum 2018 11;45(6):683-685

University of Virginia.

An article by Lally et al. (2018) in the current issue describes the process of collecting end-user feedback from a sample of rural Nebraskan women with breast cancer regarding a web-based, psychosocial distress management program, CaringGuidance™. The current article uses that study to inform discussion on future work in the realm of interventions for rural cancer survivors.
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http://dx.doi.org/10.1188/18.ONF.683-685DOI Listing
November 2018

The use of cannabis in response to the opioid crisis: A review of the literature.

Nurs Outlook 2018 Jan - Feb;66(1):56-65. Epub 2017 Sep 21.

Pain & Policy Studies Group/WHO Collaborating Center, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI.

Background: A staggering number of Americans are dying from overdoses attributed to prescription opioid medications (POMs). In response, states are creating policies related to POM harm reduction strategies, overdose prevention, and alternative therapies for pain management, such as cannabis (medical marijuana). However, little is known about how the use of cannabis for pain management may be associated with POM use.

Purpose: The purpose of this article is to examine state medical cannabis (MC) use laws and policies and their potential association with POM use and related harms.

Methods: A systematic literature review was conducted to explore United States policies related to MC use and the association with POM use and related harms. Medline, PubMed, CINAHL, and Cochrane databases were searched to identify peer-reviewed articles published between 2010 and 2017. Using the search criteria, 11,513 records were identified, with 789 abstracts reviewed, and then 134 full-text articles screened for eligibility.

Findings: Of 134 articles, 10 articles met inclusion criteria. Four articles were cross-sectional online survey studies of MC substitution for POM, six were secondary data analyses exploring state-level POM overdose fatalities, hospitalizations related to MC or POM harms, opioid use disorder admissions, motor vehicle fatalities, and Medicare and Medicaid prescription cost analyses. The literature suggests MC laws could be associated with decreased POM use, fewer POM-related hospitalizations, lower rates of opioid overdose, and reduced national health care expenditures related to POM overdose and misuse. However, available literature on the topic is sparse and has notable limitations.

Conclusions: Review of the current literature suggests states that implement MC policies could reduce POM-associated mortality, improve pain management, and significantly reduce health care costs. However, MC research is constrained by federal policy restrictions, and more research related to MC as a potential alternative to POM for pain management, MC harms, and its impact on POM-related harms and health care costs should be a priority of public health, medical, and nursing research.
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http://dx.doi.org/10.1016/j.outlook.2017.08.012DOI Listing
February 2019

Global Oncology Volunteering: Making an Effective Contribution.

Oncol Nurs Forum 2017 09;44(5):530-533

University of Virginia.

Elements of a good health system are lacking in most low- and middle-income countries (LMICs) and in many high-income countries, including the United States. 
A major problem is financing health care. On average, about 50% of healthcare financing in low-income countries comes from out-of-pocket payments, compared to 30% in middle-income countries and 14% in high-income countries.
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http://dx.doi.org/10.1188/17.ONF.530-533DOI Listing
September 2017

Burden of palliative care issues encountered by radiation oncologists caring for patients with advanced cancer.

Pract Radiat Oncol 2017 Nov - Dec;7(6):e517-e524. Epub 2017 May 25.

Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts. Electronic address:

Purpose: Radiation oncologists frequently provide care for patients with advanced cancer who are in their last months or weeks of life. This study examined the previously not well-characterized types and frequencies of palliative care issues encountered in consultations for palliative radiation therapy (PRT).

Methods And Materials: This prospective, survey-based study assessed consecutive consults for PRT from May 19, 2014, to September 26, 2014 at 3 Boston-area community and academic, hospital-based centers. Participating physicians and nurse practitioners completed a survey to identify and rank the relevance (5-point Likert scale, not at all to extremely) of palliative care issues. Eight domains adapted from national palliative care guidelines (physical symptoms, psychosocial issues, cultural considerations, spiritual needs, care coordination, advance care planning, goals of care, and ethical and legal issues) were evaluated. A total of 162 consecutive consultations were surveyed with 140 responses received (86% response rate).

Results: Most (82%) consults had 2 or more palliative care domains ranked as highly (very or extremely) relevant to care. The domains of physical symptoms (91%), care coordination (70%), goals of care (59%), and psychosocial issues (52%) were the most commonly reported domains as highly relevant to care. Forty-six percent of consults involved a high palliative care burden (4 or more palliative care domains identified as highly relevant to care). Predictors of high palliative care burden in multivariable analysis were Eastern Cooperative Oncology Group performance status >2 (odds ratio, 3.57; P = .047), a plan for no further anticancer therapy after PRT (odds ratio, 3.46; P = .03), and a recommendation against PRT (odds ratio, 4.80; P = .01).

Conclusions: Radiation oncology clinicians encounter multiple palliative care issues when consulting on patients for PRT. Clinicians identified physical symptoms, care coordination, and goals of care as the most relevant palliative care domains. These findings can help guide palliative care development within radiation oncology, including education and structures of care delivery.
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http://dx.doi.org/10.1016/j.prro.2017.05.005DOI Listing
July 2018

Opioid use among female breast cancer patients using different adjuvant endocrine therapy regimens.

Breast Cancer Res Treat 2017 Sep 21;165(2):455-465. Epub 2017 Jun 21.

Department of Public Health Sciences, School of Medicine, University of Virginia, 560 Ray C. Hunt Drive, Charlottesville, VA, 22903, USA.

Purpose: To explore differences in opioid use across different adjuvant endocrine therapy (AET) regimens, factors associated with opioid use, and the impact of opioid use on overall survival in female breast cancer patients treated with AET.

Methods: This retrospective study analyzed 2006-2012 SEER-Medicare datasets, following patients for at least two years from the index date, defined as the first date they filled an AET prescription. The study included adult women with incident, primary, hormone-receptor-positive, stage I-III breast cancer. They were also first-time AET users, and fee-for-service Medicare enrollees continuously enrolled in Medicare Parts A, B, and D. The main independent variable was the AET regimen. We measured whether patients used opioids after the initiation of AET.

Results: After the adjustment of inverse probability treatment weights and unbalanced covariates, the average treatment effect probabilities of opioid use were similar between those who used aromatase inhibitors (AI) only and those used tamoxifen (TAM) only (56.2 vs. 55.3%, respectively). Opioid use probabilities for those who switched from AI to TAM were higher than those for the TAM-only and AI-only groups. Opioid use was also significantly associated with AET non-adherence. Opioid users had a significantly higher risk of death (adjusted hazard ratio [HR] = 1.59, p < 0.001).

Conclusions: Switching from AI to TAM was associated with a high likelihood of opioid use. Opioid use was significantly associated with AET non-adherence and higher risk of mortality in female Medicare beneficiaries with breast cancer even after adjusting for adherence.
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http://dx.doi.org/10.1007/s10549-017-4348-8DOI Listing
September 2017

Recommendations to Support Nurses and Improve the Delivery of Oncology and Palliative Care in India.

Indian J Palliat Care 2017 Apr-Jun;23(2):188-198

Division of Acute and Chronic Care, University of Utah College of Nursing, Salt Lake City, Utah, USA.

Context: Nurses in India often practice in resource-constrained settings and care for cancer patients with high symptom burden yet receive little oncology or palliative care training.

Aim: The aim of this study is to explore challenges encountered by nurses in India and offer recommendations to improve the delivery of oncology and palliative care.

Methods: Qualitative ethnography.

Setting: The study was conducted at a government cancer hospital in urban South India.

Sample: Thirty-seven oncology/palliative care nurses and 22 others (physicians, social workers, pharmacists, patients/family members) who interact closely with nurses were included in the study.

Data Collection: Data were collected over 9 months (September 2011- June 2012). Key data sources included over 400 hours of participant observation and 54 audio-recorded semi-structured interviews.

Analysis: Systematic qualitative analysis of field notes and interview transcripts identified key themes and patterns.

Results: Key concerns of nurses included safety related to chemotherapy administration, workload and clerical responsibilities, patients who died on the wards, monitoring family attendants, and lack of supplies. Many participants verbalized distress that they received no formal oncology training.

Conclusions: Recommendations to support nurses in India include: prioritize safety, optimize role of the nurse and explore innovative models of care delivery, empower staff nurses, strengthen nurse leadership, offer relevant educational programs, enhance teamwork, improve cancer pain management, and engage in research and quality improvement projects. Strong institutional commitment and leadership are required to implement interventions to support nurses. Successful interventions must account for existing cultural and professional norms and first address safety needs of nurses. Positive aspects from existing models of care delivery can be adapted and integrated into general nursing practice.
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http://dx.doi.org/10.4103/IJPC.IJPC_153_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412128PMC
May 2017

Challenges Encountered by Vietnamese Nurses When Caring for Patients With Cancer.

Oncol Nurs Forum 2017 03;44(2):147-151

University of Virginia.

Providing holistic care is acknowledged as central to providing quality care for patients with cancer, but providing competent nursing care consistent with these approaches remains a challenge for nurses in Vietnam. Obstacles for Vietnamese oncology nurses include their low status, the limited scope of nursing practice, work overload in a hierarchical system, and cultural beliefs that view death and dying as taboo. Additional research to support oncology nurses in Vietnam must acknowledge the merits of improving nursing education as an important strategy for enhancing nursing autonomy, quality of care, and outcomes for the increasing number of patients with cancer in low- and middle-income countries.
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http://dx.doi.org/10.1188/17.ONF.147-151DOI Listing
March 2017

Increasing Role of Nurse Practitioners in House Call Programs.

J Am Geriatr Soc 2017 Apr 28;65(4):847-852. Epub 2016 Dec 28.

Division of Geriatric Medicine, Virginia Commonwealth University, Richmond, Virginia.

Objectives: Residence-based primary care provides homebound frail patients with a care plan that is individually tailored to manage multiple chronic conditions and functional limitations using a variety of resources. We (1) examine the visit volume and Medicare payments for residence-based health care provided by nurse practitioners (NPs) in the Medicare fee-for-service environment; (2) compare NP's residential visits to those of internists and family physicians; and (3) compare the geographical service area of full-time house call NPs versus NPs who make nursing facility visits a major portion of their work.

Design: An observational study using secondary data.

Setting: Medicare Provider Utilization and Payment Data.

Participants: Medicare beneficiaries.

Measurements: Medicare payments for home and domiciliary care visits, the number of residence-based medical visits, provider volume, geographical distribution of full-time house call providers.

Results: About 3,300 NPs performed over 1.1 million home and domiciliary care visits in 2013, accounting for 22% of all residential visits to Medicare fee-for-service beneficiaries. A total of 310 NPs individually made more than 1,000 residential visits (defined as a full-time house call provider); among full-time house call providers, including physicians, NPs are now the most common provider type. There are substantial variations in the geographic distribution of full-time house call NPs, internists, and family physicians. Full time NP's service area is about 30% larger than family physicians and internists. Nursing home residents are far more likely to receive NP visits than are homebound persons receiving home visits.

Conclusion: NPs are now the largest type of provider delivering residence-based care and NPs provide care over the largest geographical service area. However, the vast majority of frail Americans are more likely to receive NP's care in a nursing facility versus at home.
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http://dx.doi.org/10.1111/jgs.14698DOI Listing
April 2017

How Community Clergy Provide Spiritual Care: Toward a Conceptual Framework for Clergy End-of-Life Education.

J Pain Symptom Manage 2016 Apr 17;51(4):673-681. Epub 2015 Dec 17.

Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality, Harvard University, Cambridge, Massachusetts, USA.

Context: Community-based clergy are highly engaged in helping terminally ill patients address spiritual concerns at the end of life (EOL). Despite playing a central role in EOL care, clergy report feeling ill-equipped to spiritually support patients in this context. Significant gaps exist in understanding how clergy beliefs and practices influence EOL care.

Objectives: The objective of this study was to propose a conceptual framework to guide EOL educational programming for community-based clergy.

Methods: This was a qualitative, descriptive study. Clergy from varying spiritual backgrounds, geographical locations in the U.S., and race/ethnicities were recruited and asked about optimal spiritual care provided to patients at the EOL. Interviews were audio taped, transcribed, and analyzed following principles of grounded theory. A final set of themes and subthemes were identified through an iterative process of constant comparison. Participants also completed a survey regarding experiences ministering to the terminally ill.

Results: A total of 35 clergy participated in 14 individual interviews and two focus groups. Primary themes included Patient Struggles at EOL and Clergy Professional Identity in Ministering to the Terminally Ill. Patient Struggles at EOL focused on existential questions, practical concerns, and difficult emotions. Clergy Professional Identity in Ministering to the Terminally Ill was characterized by descriptions of Who Clergy Are ("Being"), What Clergy Do ("Doing"), and What Clergy Believe ("Believing"). "Being" was reflected primarily by manifestations of presence; "Doing" by subthemes of religious activities, spiritual support, meeting practical needs, and mistakes to avoid; "Believing" by subthemes of having a relationship with God, nurturing virtues, and eternal life. Survey results were congruent with interview and focus group findings.

Conclusion: A conceptual framework informed by clergy perspectives of optimal spiritual care can guide EOL educational programming for clergy.
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http://dx.doi.org/10.1016/j.jpainsymman.2015.11.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987222PMC
April 2016

Global Cancer Disparities and the Need for New Initiatives.

Oncol Nurs Forum 2016 Jan;43(1):118-20

University of Virginia.

The field of oncology is evolving at breakneck speed. Keeping up with the latest research findings, clinical best practices, and new chemotherapy agents is challenging, even with the help of the Internet. These oncologic advances, however, are far from uniformly available, and disturbing global disparities persist. In much of the world, a diagnosis of cancer remains a death sentence, and too many patients struggle to obtain access to screening, treatment, and basic symptom management. The harsh reality is that patients' chances of dying from cancer depends largely on where they live.  
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http://dx.doi.org/10.1188/16.ONF.118-120DOI Listing
January 2016

Clergy Views on a Good Versus a Poor Death: Ministry to the Terminally Ill.

J Palliat Med 2015 Dec 28;18(12):1000-7. Epub 2015 Aug 28.

2 Dana-Farber Cancer Institute, Harvard Cancer Center , Boston, Massachusetts.

Background: Clergy are often important sources of guidance for patients and family members making medical decisions at the end-of-life (EOL). Previous research revealed spiritual support by religious communities led to more aggressive care at the EOL, particularly among minority patients. Understanding this phenomenon is important to help address disparities in EOL care.

Objective: The study objective was to explore and describe clergy perspectives regarding "good" versus "poor" death within the participant's spiritual tradition.

Methods: This was a qualitative, descriptive study. Community clergy from various spiritual backgrounds, geographical locations within the United States, and races/ethnicities were recruited. Participants included 35 clergy who participated in one-on-one interviews (N = 14) and two focus groups (N = 21). Semistructured interviews explored clergy viewpoints on factors related to a "good death." Principles of grounded theory were used to identify a final set of themes and subthemes.

Results: A good death was characterized by wholeness and certainty and emphasized being in relationship with God. Conversely, a "poor death" was characterized by separation, doubt, and isolation. Clergy identified four primary determinants of good versus poor death: dignity, preparedness, physical suffering, and community. Participants expressed appreciation for contextual factors that affect the death experience; some described a "middle death," or one that integrates both positive and negative elements. Location of death was not viewed as a significant contributing factor.

Conclusions: Understanding clergy perspectives regarding quality of death can provide important insights to help improve EOL care, particularly for patients highly engaged with faith communities. These findings can inform initiatives to foster productive relationships between clergy, clinicians, and congregants and reduce health disparities.
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http://dx.doi.org/10.1089/jpm.2015.0176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842946PMC
December 2015

Screening for Pain in the Ambulatory Cancer Setting: Is 0-10 Enough?

J Oncol Pract 2015 Nov 25;11(6):435-41. Epub 2015 Aug 25.

University of Virginia School of Nursing, Charlottesville, VA; Dana-Farber Cancer Institute; Phyllis F. Cantor Center for Research in Nursing and Patient Care Services; and Harvard Medical School, Boston, MA.

Purpose: The purpose of this study was to explore concordance between patient self-reports of pain on validated questionnaires and discussions of pain in the ambulatory oncology setting.

Methods: Adult, ambulatory patients (N = 452) with all stages of cancer were included. Three pain measures were evaluated: two items from the Symptom Distress Scale (frequency [SDSF] and intensity [SDSI]) and the Pain Intensity Numeric Scale (PINS). Relevant pain was defined as: (1) scores 3 of 5 on SDSF or SDSI or 5 of 10 on the (PINS); or (2) discussion of existing pain in an audio-recorded clinic visit. For each scale, McNemar's test assessed concordance of patient self-reports of relevant pain with discussions of relevant pain in the audio-recorded clinic visit. Sensitivity, specificity, and accuracy were calculated and a receiver operating characteristic analysis evaluated thresholds on self-report pain questionnaires to best identify relevant pain discussed in clinic.

Results: Identification of relevant pain by self-report was discordant (P < .001) with discussed pain coded in audio-recorded visits for all three measures. Specificity was higher for intensity (SDSI, 0.94; PINS, 0.97) than frequency (SDSF, 0.87); sensitivity was higher for frequency (SDSF, 0.35) than intensity (SDSI, 0.24; PINS, 0.12). Accuracy was higher for the SDS pain items (SDSF, 0.57; SDSI, 0.54) than for PINS (0.48). Receiver operating characteristic analysis curves suggest that lower threshold scores may improve the identification of relevant pain.

Conclusion: Self-report pain screening measures favored specificity over sensitivity. Asking about pain frequency (in addition to intensity) and reconsidering threshold scores on pain intensity scales may be practical strategies to more accurately identify patients with cancer who have relevant pain.
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http://dx.doi.org/10.1200/JOP.2015.004077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4647066PMC
November 2015

A practical field guide to conducting nursing research in low- and middle-income countries.

Nurs Outlook 2015 Jul-Aug;63(4):462-73. Epub 2015 Feb 14.

University of Utah, College of Nursing, Salt Lake City, UT.

Objectives: The purpose of this report is to offer practical guidance to nurse investigators interested in international research in low- and middle-income countries (LMICs). Lessons learned and strategies for planning and implementing an international research project are addressed.

Methods: Four nurse researchers who conducted studies in diverse international settings (Argentina, India, South Africa, and Tanzania) describe their collective experiences regarding study planning and implementation; data collection using a variety of methods; and cultural, contextual and ethical considerations.

Results: Nurses who undertake international health research projects, particularly in LMICs, can face unique challenges and opportunities. Recommendations for success include advance planning, remaining flexible, having a backup plan, cultivating an attitude of curiosity and cultural humility, establishing collaborative and respectful partnerships, and budgeting adequate time.

Conclusions: Nurse scientists often receive little training and support to conduct international research. Guidance to undertake research projects in LMICs can build capacity for nurses to make significant contributions to global health.
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http://dx.doi.org/10.1016/j.outlook.2015.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4507437PMC
April 2016

Nurse moral distress and cancer pain management: an ethnography of oncology nurses in India.

Cancer Nurs 2014 Sep-Oct;37(5):331-44

Author Affiliations: Dana-Farber Cancer Institute, University of Massachusetts, Boston (Dr LeBaron); College of Nursing, University of Utah, Salt Lake City (Dr Beck); Victoria Hospice, British Columbia, Canada (Dr Black); and the International Network for Cancer Treatment and Research, India (Dr Palat).

Background: The majority of cancer patients in low- and middle-income countries (LMICs) present with late-stage, incurable disease, and basic tools to alleviate patient suffering-such as morphine-are often absent. Oncology nurses must cope with many challenges and may experience moral distress (MD), yet little research has examined this experience in LMICs.

Objective: This ethnographic study explored the experience of MD with oncology nurses (n = 37) and other providers (n = 22) in India and its potential relationship to opioid availability.

Methods: Data (semistructured interviews and field observations) were collected at a 300-bed government cancer hospital in urban South India over 9 months. Dedoose v.4.5.91 supported analysis of transcripts using a coding schema that mapped to an Integrated Model of Nurse Moral Distress and concepts that emerged from field notes.

Results: Primary themes included "We feel bad," "We are alone and afraid," "We are helpless," and "We leave it." A weak link between MD and opioid availability was found.

Conclusions: Participants described significant work-related distress, but the moral dimension to this distress was less clear as some key aspects of the Integrated Model of Nurse Moral Distress were not supported. The concept of MD may have limited applicability in settings where alternative courses of action are unknown, or not feasible, and where differing social and cultural norms influence moral sensitivity.

Implications For Practice: Improving job-related conditions is prerequisite to creating an environment where MD can manifest. Educational initiatives in LMICs must account for the role of the oncology nurse and their contextual moral and professional obligations.
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http://dx.doi.org/10.1097/NCC.0000000000000136DOI Listing
July 2016

An ethnographic study of barriers to cancer pain management and opioid availability in India.

Oncologist 2014 May 22;19(5):515-22. Epub 2014 Apr 22.

Dana-Farber Cancer Institute/Harvard Global Equity Initiative/University of Massachusetts, Boston, Massachusetts, USA; University of Utah College of Nursing, Salt Lake City, Utah, USA; Pain and Policy Studies Group, University of Wisconsin Carbone Cancer Center, Madison, Wisconsin, USA; Victoria Hospice, Victoria, British Columbia, Canada; Two Worlds Cancer Collaboration Foundation, Canada, International Network for Cancer Treatment and Research, India.

The world's global cancer burden disproportionally affects lower income countries, where 80% of patients present with late-stage disease and have limited access to palliative care and effective pain-relieving medications, such as morphine. Consequently, millions die each year with unrelieved pain. Objective. The objective of this study was to examine barriers to opioid availability and cancer pain management in India, with an emphasis on the experiences of nurses, who are often the front-line providers of palliative care. Methods. Fifty-nine participants were recruited using a purposive, snowball sampling strategy. Ethnographic data collection included in-depth, semistructured interviews (n = 54), 400+ hours of participant observation, and review of documents over 9 months at a government cancer hospital in South India. Systematic qualitative analysis led to identification of key barriers that are exemplified by representative quotes. Results. Morphine is more available at this study site than in most of India, but access is limited to patients seen by the palliative care service, and significant gaps in supply still occur. Systems to measure and improve pain outcomes are largely absent. Key barriers related to pain management include the role of nursing, opioid misperceptions, bureaucratic hurdles, and sociocultural/infrastructure challenges. Implications. Interventions must streamline process details of morphine procurement, work within the existing sociocultural infrastructure to ensure opioids reach patients most in need, target unexpected audiences for symptom management education, and account for role expectations of health care providers. Conclusion. Macro- and micro-level policy and practice changes are needed to improve opioid availability and cancer pain management in India.
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http://dx.doi.org/10.1634/theoncologist.2013-0435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012971PMC
May 2014

Multivariate analysis of countries' government and health-care system influences on opioid availability for cancer pain relief and palliative care: more than a function of human development.

Palliat Med 2013 Feb 26;27(2):105-14. Epub 2012 Oct 26.

Pain & Policy Studies Group, University of Wisconsin Carbone Cancer Center, University of Wisconsin, Madison, WI, USA.

Background: Many international governmental and nongovernmental organizations regard unrelieved cancer pain as a significant global public health problem. Although opioids such as morphine are considered essential medicines in the provision of palliative care and for treating cancer pain, especially when the pain is severe, low- and middle-income countries often lack such medications.

Aim: The primary aim of this study was to examine countries' government and health-care system influences on opioid availability for cancer pain and palliative care, as a means to identify implications for improving appropriate access to prescription opioids.

Design: A multivariate regression of 177 countries' consumption of opioids (in milligrams/death from cancer and AIDS) contained country-level predictor variables related to public health, including Human Development Index, palliative care infrastructure, and health system resources and expenditures.

Results: Results were highly explanatory (adjusted R(2) = 82%) and Human Development Index was the most predictive variable when controlling for all other factors in the statistical model (B = 11.875, confidence interval = 10.216, 13.534, p < 0.0001).

Conclusions: Study findings demonstrate that a limited number of predictor variables characterizing a country's government and health-care system infrastructure can explain its opioid consumption level, with the greatest influence being very high Human Development Index. However, Human Development Index is not the most policy-relevant factor, and this finding should be reconciled against the reality that many countries with low or medium Human Development Index have succeeded in creating and sustaining a health-care system to strengthen cancer pain care and palliative care, including through the appropriate use of essential prescription opioids.
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http://dx.doi.org/10.1177/0269216312461973DOI Listing
February 2013

Transitioning a cancer patient from high-dose intravenous hydromorphone therapy to intravenous methadone.

J Pain Palliat Care Pharmacother 2011 ;25(4):356-61

University of Arizona College of Nursing and University Medical Center, Tucson, Arizona, USA.

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http://dx.doi.org/10.3109/15360288.2011.620688DOI Listing
May 2012

The medical-surgical nurse's guide to ovarian cancer: Part II.

Medsurg Nurs 2007 Oct;16(5):323-31; quiz 332

University Medical Center, Tucson, AZ, USA.

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October 2007

The medical-surgical nurse's guide to ovarian cancer: part I.

Medsurg Nurs 2007 Aug;16(4):259-66; quiz 267

University Medical Center, Tucson, AZ, USA.

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August 2007

Palliative care development: the Nepal model.

J Pain Symptom Manage 2007 May;33(5):573-7

Palliative Care Program, International Network for Cancer Treatment and Research, Institut Pasteur, Brussels, Belgium.

Over the last few years, Nepali and international colleagues have been collaborating in the development of palliative care services in Nepal. The program continues to move forward amid the considerable social and political difficulties facing Nepal. Although a number of individuals and organizations have been involved, the partnership between the International Network for Cancer Treatment and Research and the Nepal Palliative Care Group is described in this paper. This joint effort has been broadly based on the World Health Organization foundation measures for palliative care: governmental policy, opioid availability, and education.
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http://dx.doi.org/10.1016/j.jpainsymman.2007.02.009DOI Listing
May 2007