decision making. We hope you find this information helpful to your practice!

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1 Alberta Health Services - Cancer Care Community Oncology Community Cancer Support Network Newsletter For Health Care Professionals Volume 5, Issue 1 January 2012 ISSN: In this issue of the Community Cancer Support Network Newsletter we are pleased to introduce Tricia Hutchison, the new interim Provincial Coordinator for the network. In addition, please see the From Evidence to Action section to learn about current research on cultural safety. We also are pleased to spotlight palliative care in the North Zone of Alberta Health Services. We invite you to read the Education Corner with information on the oral effects of chemotherapy. Finally, we encourage you to read the article from the Alberta Cancer Foundation on ethical Introducing Tricia Hutchison decision making. We hope you find this information helpful to your practice! If you would like to be added to the network distribution list or have any questions or comments regarding this newsletter please contact the Community Cancer Support Network Team; Vivian Collacutt, Manager, Tricia Hutchison, Provincial Coordinator, and Glenda Armstrong, Program Assistant. vivian.collacutt@albertahealthservices.ca; tricia.hutchison@albertahealthservices.ca glenda.armstrong@albertahealthservices.ca Inside this issue: From Evidence to Action: Cultural Safety in Relation to Nursing Practice Spotlight: Palliative Care in the North Zone Education Corner: Oral Effects of Chemotherapy No Easy Answers 4 Upcoming Events 5 Articles of Interest 5 Resources for You My name is Tricia Hutchison and I am very excited to be a part of the Community Cancer Support Network as the interim Provincial Coordinator. Some of you may remember me from my field experience in Drumheller and Red Deer while others may remember me from my Graduate experience with the Network in I am looking forward to joining the team and bring with me over 15 years of rural and urban healthcare experience where I have worked as a Social Worker in Community Care as a Continuing Care Counselor. In this role I was able to follow people wherever their healthcare experience would take them in all areas of healthcare provision such as community, acute care, hospice palliative care, cancer care and long term care. As a member of several communities of practice and many valued interdisciplinary teams I have gained a great deal of knowledge from my fellow colleagues and look forward to this new role expanding my experience in Cancer Care. I will be located in the Red Deer Hospital, South Tower however I hope to get the chance to meet many of you in the months to come!

2 From Evidence to Action Page 2 Cultural Safety in Relation to Nursing Practice Submitted by: Lisa Bourque-Bearskin, PhD Candidate, Sessional Instructor/Aboriginal Nursing Coordinator Global Nursing Office Faculty of Nursing, University of Alberta Leadership Director Aboriginal Nurses Association of Canada The notion of culture in nursing is grounded in the essentialist perspective, which defines different features of different groups of people against race, identity, and social class 1. The danger with this philosophy is that it pigeonholes people into distinct groups and does not promote a nurses self-reflection of how their culture is impacted when coming into contact with people from other cultures. From a critical constructivist perspective, culture is socially constructed from within a historical and social context that reflects the values and assumptions of society 2. Within this framework, concepts and their meanings serve a variety of overt and covert political, political, sociological, and economic purposes. Client-centered care requires nurses to expand their understanding of culture and cultural competence to ensure culturally safe nursing practice enhances relationships of our diverse society. To achieve effective relationships between healthcare providers and clients, nurses must move towards the enactment of cultural safe principles to promote ethically sound care. Ramsden, a Maori nurse, developed the theory of cultural safety. It was born from the New Zealand experience of poor health and access to healthcare 3. The Treaty of Waitangi provides the framework for its progression, which emphasizes shifting power in the health care arena from nurses to those receiving care. Once this transfer of power has occurred, the recipients of care are empowered to define what culturally safe practice is how health and nursing services should be delivered. The strength of this concept lies in the fact that cultural safety is not about cultural practices; rather, it involves the recognition of the social, economic, and political position of certain populations within society, such as the Aboriginal people in Canada, and the consequent impact on their health. Nurses responsibilities for cultural safety must include paying attention to the disparities in health care; more specifically, to improving health care access for all nations; acknowledging that we are all bearers of culture; exposing the social, political, and historical context of health care; and interrupting unequal power relations. It fosters the self-discovery of attitudes and biases by tracing them to their origins in nursing practice. Cultural safety can be used as lens for reflexive thinking to highlighted the current limitations of Canada s illness service model in addressing the health needs of Aboriginal people 4. Cultural Safety can help nurses to address the root causes of health problems, which stem from the residential schooling, colonization, and assimilation policies of the Canadian government. By drawing attention to the structural, historical, and political dimensions and viewing health and health care through a cultural safety lens, a nurse can become informed by asking a series of moral questions to unmask current disparities. The goal is to push health care providers to think beyond the cultural characteristics of others to allow them to critique the issues of institutional racism and discrimination in the health care system. Inherent to cultural safety is the philosophical underpinning of relational ethics, which considers relational space the point at which self-awareness and self-consciousness of power in the health care systems begins 5. Cultural safety is a component of client safety, which is enhanced or diminished by specific factors (e.g. attitudes, processes, practices, policies and competencies, etc.), including the culture of health care. Cultural safety is concerned with fostering an understanding of the relationship between social status and health status as a way of changing nurses attitudes from those, which continue to support current dominant practices and systems of health care to those, which are more supportive of the health of vulnerable populations. 1 Gregory, D., Harrowing, J., Lee, B., Doolittle, L., & O Sullivan, P. (2010). Pedagogy as influencing nursing students essentialized understanding of culture. International Journal of Nursing Education Scholarship, 7(1), Aboriginal Nurses Association of Canada, Canadian Association of Schools of Nursing, & Canadian Nurses Association. (2009a). Cultural competence and cultural safety in First Nations, Inuit and Métis nursing education: An integrated review of the literature. Ottawa, ON: Author. 3 Ramsden, I. M. (2002).Cultural safety and nursing education in Aotearoa and TeWaipounamu. (Unpublished doctoral dissertation). Retrieved from culturalsafety.massey.ac.nz/.htm 4 Smye, V., & Browne, A. (2002).Cultural safety and the analysis of health policy affecting aboriginal people. Nurse Researcher 9(3), BourqueBearskin, R.L. (2011). A Critical lens on culture in nursing practice. Nursing Ethics, 18 (4),

3 Spotlight Page 3 Palliative Care in the North Zone Submitted By: Terri Woytkiw, Lead, Clinical Support, North Zone Seniors Health Alberta Health Services North Zone is working hard to support patients, families who require palliative services and staff providing that care. Work is underway, in a number of areas and gaining momentum. Palliative Care Resource Nurses: Two full time Palliative Care Resource Nurses are settled into their new roles and a third part time position will commence in the near future. They provide consultation, work with local physicians, provide education, link staff and patients to resources and help communities build their capacity around palliative care. Education: North Zone offered 5 LEAP sessions in the past year. Zone staff have also developed and delivered 6 sessions on Communication at the End of Life (sponsored by an Interface grant). The Canadian Hospice Palliative Care Association Health Care Aide Education program was offered by Telehealth to several sites. Palliative education has reached well over 200 staff in North Zone in Hospice Bed opening: North zone is looking forward to the opening of a 10 bed hospice unit in partnership with Points West Living in Grande Prairie in Drawing on the experience of other zones, planning is well underway to make this a successful project by providing education and support to staff on site and in the community as a whole. Changes Tool Pilot: Several home care offices in the zone are piloting the Changes Tool, a resource developed by Dr. Wendy Duggleby and associates to provide information to patient and family as they move through the many transitions that accompany the end of life. Primary Care Demonstration Project: The Wood Buffalo Primary Care Network is participating in a demonstration project funded by the Provincial End of Life Strategy. The demonstration project will support staff education, equipment purchases and community organizations involved in end of life care Planning for the future: In the New Year, the North Zone will move forward with a focused plan to develop palliative care services. This will include ongoing education, development of consultation services including working with the Cross Cancer Institute Virtual Pain and Symptom Clinic, liaison with community groups and strengthening local capacity to provide excellent end of life care. Education Corner Oral Effects of Chemotherapy Extracted from Paladino, A., (2010) Patient Information Sheet: Chemotherapy: Oral Effects. Foothills Medical Centre Dental Clinic Patients receiving chemotherapy can develop several side effects as described below. Oral Mucositis Mouth Sores (similar to canker sores) may develop inside the mouth. This can increase risk for pain, infection, and nutritional compromise. This is temporary mouth tissues will heal over days/weeks following the cessation of chemotherapy treatment. If patients develop oral mucositis they can help lessen the effects by avoiding hot or spicy foods, and rinsing their mouth with club soda throughout the day. Painkillers can be prescribed if necessary. Taste Alterations A taste alteration or even complete loss of taste can occur during chemotherapy. The loss of taste may affect only certain foods, may alter taste of all foods or may cause food to have no taste at all. This is usually temporary, however can be permanent. Dry Mouth This effect can be permanent or temporary. A dry mouth increases the risk of dental caries and mouth infections. Dryness of the mouth occurs because of thickened or reduced saliva. A dry mouth can also compromise

4 speaking, chewing, and swallowing. For a persistent dry mouth (greater than 6 weeks), applying fluoride to the remaining teeth can help reduce the risk of teeth cavities. Dry mouth products such as Biotene (lubricant, toothpaste, mouthrinse) may help. Page 4 If wearing dentures consider having a reline patients with no sources of irritation in their mouth have fewer complications. If you smoke tobacco, then please try not to smoke during your chemotherapy. Phantom Tooth Pain When taking some chemotherapeutic agents patients can often get the sensation of a toothache (constant, deep, usually bilateral pain). The pain is there but there is no tooth or oral tissue abnormality causing the pain. Increased Risk of Bleeding From Mouth Reduction of platelets and other clotting factors during periods of bone marrow suppression are the major causes of bleeding from the mouth. This is usually the case when platelets are low in counts. Susceptibility to Infection Many chemotherapeutic drugs can cause periods of significant immunosuppression which leaves patients at an increased risk of infections. Oral infections may lead to systemic infection or sepsis and can be life threatening. What should patients be made aware of? These things will make your mouth worse and should be avoided: Smoking Alcoholic beverages Commercial mouthwashes (due to high alcohol content) Concentrated sugars such as candy or gum (unless on special instruction by a Dietician or Doctor) Lemon and glycerine swabs or petroleum-based lip moisturizing products (eg. Vaseline, Chapstik, Lypsol) Pre-Chemotherapy Consider seeing a dentist for an oral/dental exam prior to the start of Chemotherapy Consider getting a teeth cleaning patients who maintain good oral hygiene throughout chemotherapy have fewer complications. Consider extracting all hopeless and abscessed teeth or roots. They may be a source of infection. Dental treatment should be scheduled to allow for days of healing prior to the anticipated bone marrow suppression. Patients receiving chemotherapy will usually reach their lowest blood counts days after start of chemotherapy. All treatment should be scheduled in consultation with the oncologist. Treatment should be scheduled before the start of chemotherapy or just before the next scheduled round of chemotherapy (after the blood counts have recovered from the previous round of chemotherapy). The dentist will need to review blood tests: Dental treatment can be safely performed if the neutrophil count is 1,000 mm 3 or higher If dental treatment is necessary and the neutrophil count is less than 1,000mm 3 then pre-procedural antibiotics are recommended. During and Immediately Post-Chemotherapy Do not have unnecessary dental treatment during this period because there is a higher risk of developing an infection. Keep excellent oral hygiene (gentle but effective tooth brushing). Avoid mouth rinses containing alcohol. If you wear dentures leave them out of your mouth while you sleep or when the dentures irritate/rub on ulcerated tissues. Clean your dentures well with a soft toothbrush before replacing in your mouth. After Chemotherapy Preventive dentistry continues to be important. Return to family dentist for preventive dentistry when the acute oral side effects of chemotherapy have resolved and blood counts are back to normal. This is not intended as an exhaustive review of all the possible dental/oral complications that may develop in the treatment of cancer using chemotherapy. Further information may be obtained by reviewing related literature.

5 No Easy Answers Submitted By: Cailynn Klingbeil for the Alberta Cancer Foundation s Magazine, Leap. Page 5 In the radiation oncology division at Calgary s Tom Baker Cancer Centre, Dr. Jackson Wu sees many different patients. Some cases are straight forward and some less so. For example, how aggressively should doctors treat an elderly and frail patient who has lung cancer? Situations like that come with many more questions that Dr. Wu and other health-care providers, as well as patients and their families, must grapple with - questions that do not come with easy answers. These days, our culture is full of fast food, of getting movies on demand, and Googling for everything. We pick and choose and right away the answer is delivered, in an instant, Dr. Wu says. But when it comes to more difficult treatments or situations, you can t just instantaneously get the menu, pick and choose and get it delivered. Sometimes, the decision-making takes more time and thought. Complexities in decision-making in cancer care and treatment are varied and, Wu says, may be driven by ethical principles. This is particularly so among the elderly and those who are in a weakened state because of cancer and its treatments. Determining the level of physical condition or deficit and verbalizing realistic and achievable goals for therapy isn t always straightforward. It s conversation that requires the involvement of the patient s family, to help assess the patient s overall health. How aggressive cancer treatment should be is a very difficult question for the patient, the family, and the oncologist, especially in the elderly and in people who are physically and mentally drained after cancer treatment, Wu says. You get a lot of debate among clinicians across different disciplines and we don t have one right answer for it. Oncologists such as Dr. Wu, as well as patients and their families, can seek guidance from ethics committees at both the Tom Baker Cancer Centre and Edmonton s Cross Cancer Institute, which comprise the resources offered by Alberta Health Services clinical ethics services. Other organizations also exist to provide resources and support, such as the non-profit Provincial Health Ethics Network. Our role is not to find an answer for the people involved, but to provide a process to reflect on the ethical issues, and to provide a number of options for potential decisions that could be made, Dr Shane Sinclair, PhD says. Sinclair is the spiritual care coordinator at the Tom Baker Cancer Centre and a postdoctoral fellow. He also chairs the Tom Baker s Clinical Ethics Committee, which consists or 13 people, including health care professionals from a variety of disciplines and members of the public. While Sinclair emphasizes that ethical issues are few and far between in the majority of cases at the Tom Baker Cancer Centre, they do exist. That s where the committee can help, by making people aware of ethical issues and allowing individuals to make their own decisions in an informed manner. Oftentimes, there is more than one potentially correct answer, Sinclair says. Recognizing that, and allowing people to share their opinions on what they believe to be the right answer facilitates a process and brings people together. It s nice and affirming to know that this is a tough decision, but we ve gone through the best processes that we know to ensure that we are making the right decision. The more common issues that come to the ethics committee at the Tom Baker include end-of-life decisionmaking, such as when to withdraw treatment. Another scenario encountered involves patient competencies; how does the family and health-care team respond in the best interests of a patient who do not have the capacity to make his or her own medical decisions? To read more of this article please visit myleapmagazine.ca/2011/12/no-easy-answers/

6 Upcoming Events Page 6 January 25, :00-1:00 pm CCSN Research in Practice Series: Influence of Hope on the Quality of Life of Women with Breast Cancer and Their Spouses Presented by: Wendy Duggleby, PhD, RN, AOCN, Professor and Endowed Nursing Research Chair in Aging and Quality of Life in the Faculty of Nursing at the University of Alberta; Adjunct Professor, Division of Palliative Care, Department of Oncology, Faculty of Medicine and Dentistry University of Alberta. February 22, :00-3:30 pm Innovations in Supportive Cancer Care in Western Canada Telehealth Forum 12:00 12:10 Introductions 12:10 12:55 Difficult Conversations When Cancer Advances Presented by: Dr. Joel Gingerich, Medical Oncologist, CancerCare Manitoba 1:00 1:30 Self Directed Empower A New Program for Caregivers of Cancer Survivors Presented by: Douglas Ozier, PhD in Counseling Psychology, Research / Clinical, Provincial Psychosocial Oncology Division at the BC Cancer Agency, Affiliated with BrainCare BC, a specialized program that meets the needs of people with brain tumours and their loved ones in BC 1:30 1:40 Break 1:45 2:15 First Nations Cancer Course - Web-based Professional Development Presented by: Tracy Scott, Knowledge Liaison, Saint Elizabeth Health, Manitoba, and Janetta Soup, Knowledge Liaison, Saint Elizabeth Health, Alberta 2:20 2:50 YWCA Encore After Breast Cancer Exercise Program - Presented by: Barb Yanciw BSc. (Hons) Kin, Manager, Fitness on 25th, YWCA Saskatoon 2:55 3:25 We Are So Smart, We Are Dumb: Ethnic Populations and Health Literacy - Presented by: Bejoy Thomas, MPhil, PhD, Coordinator, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Health Services, Cancer Care; Adjunct Assistant Professor, Department of Psychosocial Oncology, Faculty of Medicine, University of Calgary; & Research Scientist, Community Oncology, Alberta Health Services - Cancer Care To register for either of the above telehealth sessions please visit Articles of Interest Widera, E., Rosenfeld, K., Fromme, E., Sulmasy, D., Arnold, R., (2011) Approaching Patients and Family Members Who Hope for a Miracle. Journal of Pain and Symptom Management 42(1): The CON-CPG Initiative has some exciting news. The article Prophylactic feeding tubes for patients with locally advanced Head and Neck cancer undergoing combined chemotherapy and radiotherapy Systematic Review and Recommendations for Clinical Practice, has been published in Current Oncology Volume 18, Number 4 page A guest editorial by E. Isenring is also provided. The Nutrition Screening in Adult Oncology Patients Guideline is also completed. Both of these can be found on the website that the CON-CPG Initiative has developed and launched. The link is Available Resources The following presentation is available on disc for your use. To receive a copy glenda.armstrong@albertahealthservices.ca Research That Never Runs Dry - Outcomes from a RCT on the prevention of xerostomia presented by Dr. Jana Rieger, PhD, CCC-SLP, S-LP(C, Professor, Department of Speech Pathology and Audiology, University of Alberta, Population Health Investigator, Alberta Innovates Health Solutions We encourage your feedback, questions and suggestions for future newsletters! Please contact Glenda Armstrong concerning this newsletter at glenda.armstrong@albertahealthservices.ca or