It’s all about the team. That sums up my memory of Dr. Arti Hurria. She was always including other team members, and most importantly, other team members that were non-physicians. She understood the value that the interdisciplinary team brought to the care of older adults with cancer. Older adults have unique concerns and potential vulnerabilities and it takes a team with diverse expertise to manage their care. No one understood that more than Dr. Hurria.
She also fostered the development of the team. As a mentor and a role model, she would meet with staff and ask what is important to them, what do they want to accomplish. She and I had many of those conversations. She understood the value that the role of oncology nurses had in the care of the older adult with cancer. My role at City of Hope as a Clinical Nurse Specialist was to train oncology nurses in the special needs of older adults. What did I want? I wanted all oncology nurses to understand the special needs of the older adult and their potential vulnerabilities too. Dr. Hurria suggested the idea that we expand beyond City of Hope, what if we could train nurses across the country in a similar manner to what we started at City of Hope? She always had confidence in others to achieve more. I did not think that I could possibly do that. At the time she was contemplating an R25 to educate oncology fellows in geriatrics. But she said to me one day “What if we did an R25 for nurses?” And so the process began. Many, many, many hours of writing and re-writing a grant proposal to the NIH for an R25 educational grant focused on oncology nurses nationwide in the care of older adults. Dr. Hurria was committed to making the proposal the best it could be; so we worked this submission, over and over, correcting and re-wording, including one night when we were finishing up in her office with other colleagues until midnight. She reinforced our late night camaraderie with pizza, salads, and doses of humor to keep us going.
Developing a Proposal
To initiate the project we performed a pilot study and queried oncology nurses and oncology nurse executives to determine if there was a need for a program of this type. Overwhelmingly, the response was positive that this education was needed. We then assembled a team of experts in the field that could address each content area that was identified as key to an education in geriatric oncology. Due to Dr. Hurria’s vast network of diverse professional contacts these experts were eager to sign on to be a part of this effort. Our proposal was submitted in 2013 and was not funded. However, we were determined to re-submit, and in 2014 our re-submission was filed. However, our rank was on the border for funding and in December of 2014 we were told we should await further word and that it is possible we could get funded later in the year, but there is no guarantee. The next communication said our score was beyond their payline. It didn’t seem likely; in fact I planned my retirement thinking this was not going to happen. Dr. Hurria continued to stay in touch with the program manager to inquire if any opportunity for funding was available. Then late in the cycle, in fact on August 31, 2015, we received a positive email saying we were funded starting September 1, 2015. So the journey began.
Specific Aims
We based our proposal on several key points: 1) Cancer is a disease associated with aging;1 2) The number of older adults in the US is growing;2 3) There is a growing population of patients with cancer;3 4) Older adults have different needs and potentially increased vulnerabilities versus younger adults;4 5) Nurses are the key healthcare professionals who interface with older patients;2 6) A low proportion of nurses are trained in geriatrics;2 and 7) Very little geriatric specific education is available for oncology nurses.
Despite the rapid increase in the U.S. aging population, there remains a shortage of healthcare specialists with geriatric training.2 This includes a current and projected future shortage of nurses with experience in geriatrics who will be needed to care for this growing population of older adults with cancer.2,5 Because geriatric oncology training is not part of a standard nursing curriculum, most nurses require supplemental knowledge specific to the healthcare needs of older patients with cancer. Furthermore, the education of oncology nurses focuses primarily on oncology itself rather than on geriatric information and training. A survey of our comprehensive cancer center found that oncology nurses actually scored lower on geriatric knowledge than scores reported from a nationwide sampling of nurses.6
The mission of this R25 proposal was to teach the essential principles of geriatrics and geriatric oncology to oncology nurses by working with a multidisciplinary team of educators in geriatrics and oncology. The overall goal of our program was to develop and implement a national education curriculum in geriatric oncology to be given for oncology nurses. This proposal united the fields of nursing, geriatrics, and oncology through the creation of a curriculum including geriatric principles geared to oncology nursing professionals who are already caring for an aging oncology population. Experts in key areas, representing a multidisciplinary team, served as faculty for the curriculum consisting of four annual conferences. A total of 400 nurse participants were planned. Continuing follow-up with participants after the conferences allowed us to focused on continuing the impact of this geriatric oncology curriculum through the development of geriatric oncology nursing initiatives by participants in their home institutions. The specific aims of this innovative educational initiative are listed in Table 1.
Table 1.
Multidisciplinary Faculty
| Geriatricians and Medical Oncology Physicians |
| Advanced Practice Nurses (Nurse Practitioners, Clinical Nurse Specialists, Nursing Administrators) |
| Pharmacist |
| Dietician/Nutritionist |
| Exercise Physiologist |
| Attorneys |
| Licensed Clinical Social Worker |
Our conceptual model included the application of adult learning principles7 and use of geriatric oncology content material (Figure 1). The conference included didactic presentations, as well as hands on practice session, and goal setting exercises. Participants came to the conference as a part of a team from their institution (a nurse manager, a nurse educator, and a direct care nurse) and together they developed goals that would impact the care of older adults at their home organizations. These goals were to be implemented once they returned home from the conference. Our team followed up with these participants on monthly conference calls, as well as for status check-ins at 6, 12, and 18 months to evaluate progress on reaching their individual goals.
Figure 1.
Conceptual Model
The R25 team has now held all four planned annual conferences, the last occurred February 2019 and the data are currently being analyzed and will be reported in subsequent publications. Dr. Hurria was present and oversaw the first 3 conferences. We held the last conference in her honor after her death.
This conference is significant because the U.S. population is aging and cancer is a disease associated with aging. It is significant because the number of oncology nurses with a background in geriatric education to care for the older oncology patient, is far too low to adequately treat this growing population. It was also innovative in the way it filled the gap in knowledge through a multidisciplinary, interactive, targeted curriculum which culminated in nurse teams developing their own plans to integrate geriatric oncology principles and practices into their home organizations. The majority of teams met their goals and these results are pending publication.
It is also noteworthy in the fact that it was initiated and conceived by a physician who felt that nurses were key in providing quality care to older adults with cancer. Initially we got push back from the reviewers of the grant asking how we will really know if we “improved quality of care”. That is a fair question. Maybe we won’t know, but we have to try. And one physician cared enough to help us try.
We anticipate that these participants will further disseminate what they learn about caring for older adults with cancer, thus creating a ripple effect of individuals with geriatric oncology knowledge throughout the healthcare system. We hope our data will demonstrate that quality of care is improved, but either way, 400 oncology nurses learned Dr. Hurria’s vision for a more perfect geriatric oncology world.
This work is supported by National Institutes of Health (NIH) Grant # R25CA183723–01A1. The project did not require Institutional Review consistent with the published NIH guidelines, it was considered exempt per exemption 1 of the U.S. Health and Human Services Code of Regulations.
Table 2.
Specific Aims of R25 Educational Grant
| Specific Aim #1 | To develop a comprehensive geriatric oncology curriculum for nurses, with input from top level multidisciplinary faculty from around the country, which will advance nurses’ knowledge, attitudes, and skills related to caring for older adults with cancer. |
| Specific Aim #2 | To implement this geriatric oncology curriculum with national workshops for competitively selected nurses from National Cancer Institute-designated comprehensive cancer centers, and other academic and community cancer center programs nationwide. |
| Specific Aim #3 | To evaluate the effectiveness of a comprehensive, interactive geriatric oncology curriculum for nurses based on knowledge acquired from pre- to post-conference. |
| Specific Aim #4 | To evaluate the impact of a comprehensive geriatric oncology curriculum on the development of geriatric oncology nursing initiatives nationwide by measuring the progress and outcomes of workshop activities and changes initiated by the participants in their home settings. |
| Specific Aim #5 | To disseminate the findings through: (a) peer-reviewed publications and communications with various oncology organizations and professional networks both regionally, nationally, and internationally; (b) a network built from course participants who will be expected to share their learning experiences within their home settings and with one another postconference. |
Footnotes
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Conflicts of Interest: None
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