The Panoramic View

Nurses work within complex organizations and systems that require us to conform to the expectations and limitations they place upon us. We need to be honest and acknowledge that the structures in which we work can and often do compromise our ability to do our jobs the way we want to.

Consequently, as nurses in healthcare systems, we find ourselves focusing through the small lens of the organization, instead of through the panoramic view of the cancer patient who receives the end service.

These days, many healthcare employers are part of big organizations, and there may be only one healthcare system with a cancer center available in some places.

When a patient needs a second opinion, they want to know that the second opinion will be given independently of the first. They need someone to trust, who they can discuss options with and ask questions. In the age of healthcare monopolies, trusting that the second opinion will be independent is becoming more difficult for patients. They fear that two different oncologists within the same organization might be trying to keep the business "in the family."

When patients ask nurses for our opinions, which they often do, it's because they trust us, and they see how busy their oncologists are. Unless we're careful, we can be compromised by the systems we work in, such as when a nurse can't speak out because of real or perceived restrictions that the employer imposes.

Cancer survivors have enough to worry about. They need to trust their doctors, but there are times when a second opinion is something they need for peace of mind. If the patient doesn't trust that the system they rely on due to insurance coverage or proximity to home is acting in their best interest, it's not good for patients.

When a patient asks you, the nurse, if a second opinion is warranted, ask the patient: "What do YOU want from a second opinion? What is your expectation from it?" Sometimes, no one has asked them this before.

Be prepared for anything: the patient might reveal things you didn't know, they might confide their trust, or lack thereof, in a certain physician, or another staff member. Sometimes you find things out that you wish you hadn't heard, and sometimes it can place you in a position of making an uncomfortable decision to report something, even placing your job security on the line.

It is our job to advocate for patients, and one way we can to do this is to teach and encourage patients to advocate for themselves. When our job as advocate is compromised by the organizations we work for, either by limiting the information we're allowed to give, by a lack of options available to the patient geographically, or by not having enough time and staff to do the work of advocacy, it is morally distressing to nurses.

Systems do not have empathy. Organizations are not people, they do not touch, see, or have feelings. They don't see, feel, or experience that the business practice of limiting options by reducing competition, or cutting costs through understaffing at any level of the organization, with the business's interests in mind, doesn't help the patient trying to navigate life with a life-threatening disease.

How can oncology nurses do better within these systems?

Remember that the framework from which the system operates (whether it's policy, evidence, or mission statements) may be valid, but patient needs go far beyond what's in the checkboxes. The patient needs care and information tailored to their reality, so they can use it.

An expected result from a routine lab value might sound like impending death to a cancer patient. Rushing to the next patient, the oncologist might not realize that their mediocre communication skills left the patient terrified, without a nurse to intervene with an explanation. Patients lose sleep over unanswered questions and can't make informed choices when they don't have the information, options, medical perspective, or resources -- like unhurried healthcare providers.

Oncologists have plenty of drugs and treatments, but have few resources devoted to healing and health. Most of what they do is treatment and often that's where contact with the patient ends. Survivorship care plans don't fit patients' individual realities. Patients need help mitigating the everyday side effects and undesirable consequences of treatment, so they can get back to having quality of life. Systems don't know that nurses can do just that. We need to teach patients to let us do that.

Within the constraints of systems, nurses need to remember:

• The patient's goals are different than what our goals are. We have to give information and instructions; the patient needs support and encouragement.
• We have to listen for what the patient is communicating to us and not just say what we are required to communicate to them.
• Patients have fear underlying their needs for someone to listen and care for them, and in an attentive and validating way.

We need people, not plans; actual discussion, not algorithms; collaboration, not competition.

Organizational dynamics and power structures hinder open discussion and collaboration, and limit patient options. If we don't communicate, we're not serving anyone. We as nurses have to be able to verbalize what's missing. We need to claim and use our power. We need to see the panoramic view, not just through the comfort of our own narrow lens.