Oddie, Kay RN, AND, OCN; Pinto, Margaret MA, BSN, RN; Jollie, Shelley BSN, RN, CORLN; Blasiak, Elizabeth MSN, RN, OCN; Ercolano, Elizabeth DNSc, OCN; McCorkle, Ruth PhD, FAAN
Radiation therapy is used globally as a standard treatment for many forms of cancer; approximately 75% of cancer patients receive radiation therapy alone or in combination with another cancer treatment such as surgery or chemotherapy.1 The purpose of radiation therapy is to damage cancer cells by altering their genetic material and ability to replicate, thereby eradicating the cancer. Radiation doses are now delivered with greater precision to spare destruction of normal tissues, but it is impossible to eliminate all of its harmful effects. In some countries, radiation therapy may be the only modality available for treatment and is delivered by dated machines that do not minimize harmful effects.
Skin damage or radiation dermatitis is the most common toxic effect of radiation therapy. It is estimated that 95% of radiation oncology patients will experience radiodermatitis, and 87% will experience moderate to severe radiation dermatitis during or after their therapy.2,3 Radiation-induced skin toxicity includes redness, swelling, loss of skin (desquamation), infection and ulceration, hair loss, skin thickening, and skin death. Cancer-related factors and patient-related factors influence the severity of radiation dermatitis. The areas of the body with skin folds may increase radiation-induced skin reactions. Other skin conditions, medical conditions, medications, (particularly chemotherapy), obesity, smoking, poor nutrition, and concurrent UV exposure are known to increase the risk of radiation dermatitis.4,5
The range and intensity of radiation-induced skin changes and the patient-related demands associated with management of radiation dermatitis impact the role of the oncology radiation nurse. It is essential that oncology nurses be familiar with the clinical presentation of radiation dermatitis and use valid assessment techniques to monitor skin changes and the effectiveness of interventions to control skin reactions. If not managed properly and proactively, radiation dermatitis may result in delays that potentially compromise treatment completion, its effectiveness, and ultimately survival.6
Smilow Cancer Hospital (SCH) at Yale–New Haven is part of a National Cancer Institute (NCI)–designated comprehensive cancer center in the northeastern United States. In fall of 2009, we opened a new cancer state-of-the-art, 15-story clinical facility with the latest advances in diagnostic, therapeutic, and surveillance procedures. This facility includes all services (inpatient and outpatient) and specialties (surgery, radiation, medical oncology, and support services) all centered in 1 healthcare facility.
As of March 2011, our hospital achieved national recognition as an American Nurses Credentialing Center Magnet Hospital. A Magnet hospital is one that delivers excellent care where nurses are involved in data collection and decision making in patient care delivery to improve patient outcomes.7 Nurses shape research-based practice and are encouraged and rewarded in advancement of their practice. There is open communication between nurses and other members of the healthcare team to attain the best patient outcomes and staff work environment. Within Magnet-recognized hospitals, 3 centers must exist for nursing professional improvement: nursing research, clinical practice, and education.
Smilow Cancer Hospital is part of a larger network in the State of Connecticut. Our Radiation Oncology network consists of 4 hospitals and 4 satellites. In compliance with Magnet recognition, collaboration among professions and standardization of nursing practice are goals to unite the radiation oncology network across the entire healthcare system. To that end, the project was guided by the model for evidence-based practice described by Rosswurm and Larrabee.8 They developed a 6-step model based on scientific literature related to evidence-based practice, research utilization, and change theory. The model is comprehensive and helps to guide the nurses through the complete process of changing practice with documentation of the need to change the problem and ending with the integration of a final protocol.
The overall purpose of this ongoing project is to standardize oncology nurses’ assessment and management of radiation dermatitis in patients who receive radiation therapy at SCH at Yale–New Haven (and throughout all the facilities within the network system) in concordance with evidence-based guidelines. This article represents the initial phase of the ongoing project, which was to survey radiation nurses to describe their current practice around assessment and management of radiation dermatitis. The specific aims of the survey were to (1) identify whether nurses routinely screen, manage, and monitor acute skin reactions within the radiation departments of SCH and the network facilities; (2) identify a patient population to begin routine screening across settings; and (3) identify strategies to establish a mechanism for ongoing communication among the nurses to implement and evaluate a standardized skin care protocol in our healthcare network.
This descriptive, cross-sectional computerized survey targeted radiation nurses employed at an urban, northeastern teaching hospital. The study population included all 22 nurses currently in practice. To develop the survey, we began by conducting an extensive review of the literature to identify scholarly journal articles that discussed or evaluated existing tools to assess radiation dermatitis and studies evaluating interventions to prevent or lessen radiation skin reactions. We searched the MEDLINE, PsychINFO, HealthSTAR, CINAHL, PubMed, and Cochrane Library databases in addition to conducting manual reference searches using the Google search engine. Synthesis of these articles allowed us to identify categories of needs among nurses who provide skin care to patients receiving radiation therapy. Members of the research team reviewed the items and refined successive drafts of the survey to ensure that each needs domain was represented by an appropriate number of items. Next, a 3-member expert panel reviewed the items for clarity, redundancy, and gaps in conceptual areas. The final survey consisted of 34 items organized into 6 sections.
The first section (8 items) comprised questions about demographic and practice characteristics of participants. Demographic items asked about gender, age, and education, including licensure and certification. The second section, practice items (6 items) asked about participants’ work history, number of years practicing in radiation, number of years in current position, areas of expertise, and what populations they cared for. The third section (14 items) addressed participants’ patterns of skin assessment and tools used for assessment. The fourth section (2 items) included items on participants’ current use of interventions and specific products used for prevention and management of skin problems. The fifth section, networking (3 items), asked questions about their access to experts and needs associated with ongoing communication for implementing a protocol. The last section asked participants to describe a patient situation that was particularly challenging and successful. (Full survey is available online.) The respondents were informed that their response to the survey signified their consent to participate. The institutional review board exempted the study.
We distributed the online survey via e-mail to all 22 radiation nurses using the cancer hospital’s e-mail list. The survey remained available online for approximately 4 weeks in October 2011. Participants were sent weekly reminders to complete the survey. We had a 100% response rate, indicating high interest in participating. Survey data were summed as frequencies and percentages. There were no statistical differences between respondents in the hospital settings compared with respondents in the satellites, including education and years of experience (data not shown).
All 22 radiation nurses (100%) representing all 8 facilities within the network responded to the survey and were included in the quantitative analyses; however, not all nurses answered every question. The majority of the nurses have bachelor degrees in nursing (n = 12), hold certifications (n = 15), and care for patients with breast, lung, and head and neck cancers (Table 1). Twelve nurses reported they used some type of skin assessment tool routinely. The nurses reported that they assessed patients for additional factors that may negatively affect the area of skin to be radiated, including nutritional status, presence of other diseases, and medications. Frequency of skin assessments conducted by nurses varied, with 12 doing it at each visit and 8 at the last visit. Five nurses reported that they did not perform a pretreatment skin assessment. Nurses reported that they refer patients for services from other disciplines within their facilities to help with management of skin problems, including nutritionists, dermatologists, physical therapists, and mental health providers. Three nurses identified that they had never made a referral (Table 2).
The respondents reported that they currently used 2 standardized instruments to evaluate the severity of radiation dermatitis, the Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group scale9 and the NCI scale.3 These scales are short and focus on physical skin changes. Other scales reported included clinician observation of skin changes and patient-reported symptoms, for example, the Skin Toxicity Assessment Tool10 and the Radiation-Induced Skin Reaction Assessment Scale.11 These scales have not been widely tested.12 Two respondents reported they followed the Oncology Nursing Society’s guidelines for radiodermatitis, which recommends the routine use of the NCI toxicity scale.13 Seventeen respondents (77%) replied that they are open to using a standardized assessment tool as a part of their practice and thought there was value in standardizing assessment and management across settings. .
In response to the 9 types of skin problems frequently encountered over the course of radiation therapy, the nurses reported they were experienced in assessing skin problems and managed a range of these problems (Table 3). They also reported they used a number of products that they applied to the skin; however, there was great variation when they used them and under what conditions (Table 4). They also added they primarily used products based solely on the manufacturer’s recommendations. The respondents reported there were limited educational opportunities for them to increase their knowledge and skills related to skin care. Overall, the majority of the respondents reported that they welcomed the opportunity to work together to improve their practice. They also reported they would be receptive to a variety of strategies to increase communication among the nurses throughout the network, including e-mails, conference calls, video conferencing, newsletter, in-services, and monthly seminars.
The purpose of the first phase of this project was to survey radiation nurses’ current practice around assessment and management of radiation dermatitis. We received 100% response rate from the radiation nurses working in the network. This response rate represents the entire population of nurses who work in radiation oncology in these facilities. Most radiation therapy departments employ only a small number of nurses, so 22 respondents represent wide interest and signify its importance.
As part of our quality initiatives at SCH, we recognized a need to establish a standard for assessment and management of skin reactions associated with radiation therapy throughout the network facilities. Our results demonstrated that within 1 healthcare system nursing care lacks standardization to assess and manage patient’s skin placing patients at increased risk for radiation dermatitis and associated complications. These results provide strong justification that a skin care protocol is needed that defines the type and frequency of skin assessments and recommended treatments for prevention and management of common skin problems associated with radiation dermatitis. This survey, easily replicated, can be used in other healthcare systems to assess current practice. The first priority is to reach consensus on the identification of a tool to assess patient’s skin.
Because of the wide range of the geographic locations of the hospitals and satellites of the Yale Radiation Oncology network, communication and monitoring of consistency and compliance to a proposed protocol may be a potential barrier. We plan to use multiple strategies to increase communication among the nurses including telephone, e-mail, and teleconferencing where available and also site visits for in-services and one-on-one contact where individual assistance is needed.
The protocol development and its adoption involve all 6 steps developed by Rosswurm and Larrabee.8 We have completed the first 2 steps in which we assessed the need for change and linked the problem to interventions and outcomes. The key stakeholders within the network are supportive of the change, including hospital administration, medical and nursing management, and radiation staff. The team is currently addressing the third step: synthesizing the best evidence. The fourth step is to design the practice change. As a working group, we will report the survey results to participants and develop the protocol over a series of meetings for implementation and evaluation. The entire group of 22 nurses will be asked to select the final assessment tool and the frequency of administration and the selection of products and to identify intervention strategies to manage patient skin reactions. Initially, an invitation to participate in a scheduled teleconference inviting all 22 radiation oncology nurses will be distributed. Prior to meetings, all materials to be discussed will be distributed at least a week before calls. Active participation by all nurses will be encouraged, and individual follow-up will be made if additional time is needed. A second teleconference will be held to review skin assessment tools, discussing the pros and cons of each, before reaching consensus on the final skin toxicity assessment tool. Nurses will have an opportunity to review the tools prior to the meetings. Once a tool has been selected, a draft protocol will be established. The nurses will be asked to test the assessment tool with 4 or 5 patients and report their experiences before the final assessment protocol is established. Additional teleconferences will be scheduled to discuss the list of products and interventions used within the network facilities as displayed in Table 4. Based on evidence-based practice, products for specific problems will be recommended for use throughout the network. There will also be guidelines developed for standardizing procedures for securing consults with experts from other disciplines when indicated.
Step 5 will begin once the final protocol is approved by the nurses and submitted for review by the approving bodies within the network. The final standardized skin care protocol will operationalize how and when to assess the patients’ skin and document skin reactions, when and what product will be used for the different stages of reaction, what patient education materials to use, and consultations services available. With our main goal being prevention and minimizing any potential skin reactions, we will come to consensus on a standardized nursing skin care protocol to focus on the care of patients with 1 of 2 types of cancer: breast and head/neck. Large numbers of patients with these 2 types of cancers are seen throughout the network, and their treatment includes multiple radiation treatments. Early recognition of skin problems can limit infections, enhance the patient’s quality of life, and increase patient compliance to their treatment plan and their overall satisfaction with care (see the Figure for the steps that have been completed that are ongoing and our future directions).
In order to implement the protocol, in-services will be given throughout the network, distributing the written protocol and guidelines as well as ensuring the selected products are available for use in all facilities and expert services are accessible to all patients. We will also inform experts within the consultation services of our protocol and elicit their participation in documenting outcomes. An evaluation plan will be created to monitor consistency and continuity of the nursing interventions, patient responses, patient education materials used, and outcomes of referrals to consultation services, including nutrition, physical therapy, social work, wound care, and dermatology. In addition, the in-service training of staff throughout the network will be documented. Step 6, integration and maintenance, will be monitored by the working group through a medical record audit after the protocol has been in practice for at least 6 months. The reviews will be staggered over the network facilities and completed within the next year.
The results of our survey validated the need for a system-wide standardized approach to the management of patients undergoing radiation therapy, specifically a skin care protocol that defines type and frequency of skin assessments as well as recommends treatments for prevention and management of common skin conditions related to radiation dermatitis.
The protocol implementation phase will begin with breast and head/neck patients, but our intent is to extend the standard of care to the entire radiation oncology population. Quality-of-life concerns for patients undergoing radiation therapy include a range of problems including nutrition, function, pain, itching, burning, tenderness, and disfigurement. In order to lessen the burden of radiation dermatitis, between treatments, patients or their caregivers should check the integrity of the skin; manage their pain, itching, and burning; and prevent exposure to any additional toxic chemicals or UV radiation to the skin.4 The establishment of a standard method of assessing the skin will improve the quality of care provided in the radiation department and potentially limit patient complications and costs. A standardized skin care protocol will also increase nurses’ confidence and skills in their ability to recognize acute skin reactions and provide safe and effective quality care.
2. McQuestion M . Evidenced-based skin care management in radiation therapy. Semin Oncol Nurs. 2006; 22:(3): 163–173.
3. Fisher J, Scott C, Stevens R, et al. Randomized phase III study comparing best supportive care to Biafine as a prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: Radiation Therapy Oncology Group (RTOG) 97–13. Int J Radiat Oncol Biol Phys. 2000; 48: 1307–1310.
4. Hymes SR, Strom EA, Fife C . Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J Am Acad Dermatol. 2006; 54:(1): 28–46.
5. Yarbro CH, Frogge MH, Goodman M. , ed. Cancer Nursing: Principles and Practice. Sudbury, MA: Jones and Bartlett Publishers; 2005; .
6. D’haese S, Bate T, Claes S, Boone A, Vanvoorden V, Efficace F . Effective management of skin reactions during radiotherapy: a study of nursing practice. Eur J Cancer Care. 2005; 14: 28–42.
7. Kelly L, McHugh MD, Aiken LH . Nurses outcomes in Magnet and non-Magnet hospitals. J Nurs Adm. 2011; 42:(1): 428–433.
8. Rosswurm MA, Larrabee JH . A model for change to evidence-based practice. Image J Nurs Scholarsh. 1999; 31:(4): 317–322.
9. Watson LC, Gies D, Thompson E, Thomas B . Randomized control trial: evaluating aluminum-based antiperspirant use, axilla skin toxicity, and reported quality of life in women receiving external beam radiotherapy for treatment of stage O, I, and II breast cancer. Int J Radiat Oncol Biol Phys. 2012; 83:(1): 29–34.
10. Berthelet E, Truong PT, Musso K, et al. Preliminary reliability and validity testing of a new Skin Toxicity Assessment Tool (STAT) in breast cancer patients undergoing radiotherapy. Am J Clin Oncol. 2004; 27:(6): 626–631.
11. Noble-Adams R . Radiation-Induced Skin Reaction (RISRAS). 3: Evaluating the RISRAS. Br J Nurs. 1999; 8:(19): 1305–1312.
12. Kumar S, Juresic E, Barton M, Shafiq J . Management of skin toxicity during radiation therapy: a review of the evidence. J Med Imaging Radiat Oncol. 2010; 54: 264–279.
13. 13. Eaton LH, Tipton M, Irwin M. Putting Evidence Into Practice: Improving Oncology Patient Outcomes. Pittsburgh, PA: Oncology Nursing Society Publishers; 2011.