Oncological Care at the Charité

The oncological nursing concept of Charité was developed with the aim of providing comprehensive, needs-oriented care to patients in all organ centers. Based on the current state of scientific knowledge, nursing specialists ensure patient-oriented care. The abilities and resources of patients and their relatives are systematically recorded, supported and encouraged. Nursing specialists accompany patients in various life and crisis situations, while fully respecting the patient's dignity and right to self-determination.
In their everyday nursing work, nurses are guided by the mission statement of Charité -Universitätsmedizin Berlin- Vision, Mission, Values.
For Charité, as a signatory of the Charter for the Care of the Seriously Ill and Dying, the recommendations for action for the expansion of palliative care are a voluntary commitment.

2.1 Nursing Process

Nursing professionals manage the nursing process in collaboration with the professional groups involved and are involved in complex interdisciplinary/professional decision-making.
By systematically determining individual care needs and carefully planning activating care, in collaboration with patients as well as their relatives, nurses maintain and promote the greatest possible autonomy and quality of life. The nurses ensure the uniform implementation of nursing measures, their documentation and evaluation, taking into account the nursing standards and procedural instructions of the Charité.

The documentation of nursing care and medical treatment forms the basis for quality-assured patient care. Digital documentation at Charité makes it possible to make relevant information available to all those involved in treatment, regardless of location. On this basis, decisions on the implementation of diagnostic, therapeutic and nursing measures can be made at any time.

On the day of admission, all patients with oncological diseases undergo a standardized assessment to determine their needs and, if necessary, to initiate supportive services from other professional groups, e.g. social services, psychooncology, physiotherapy, pastoral care. To promote and improve the quality of care and patient satisfaction, nurses regularly conduct nursing rounds for inpatients with oncological diseases. With the involvement and participation of the patients, the current situation as well as problems and needs with regard to the disease are discussed in this meeting. This allows necessary measures to be initiated and existing interventions to be adapted. The aim of the nursing rounds is to improve the care of the patients concerned.

Close cooperation between the social services and all the professional groups involved ensures that nursing-related care is provided during discharge or transfer planning to the home environment and/or inpatient care facilities, taking specific oncological aspects into account. Discharge management at Charité is based on the framework agreement on discharge management and is interprofessionally oriented. Nursing additionally takes into account the expert standard Discharge Management in Nursing of the DNQP *1).

2.2 Procedural Instructions

Procedural instructions are stored in the document management system of the Charité and can be viewed and accessed by all employees. In order to ensure professional care of oncological patients across all disciplines, procedural instructions on important oncological topics have been drawn up and coordinated and implemented throughout the Charité.

• Skin care in the radiation field
• Administration of i.v. cytostatic drugs
• Administration of oral cytostatics
• Prevention and treatment of cytostatic extravasation
• Tracheostoma care
• Mucositis, gingivitis and periodontitis in patients with chemotherapy and radiotherapy
• Reverse isolation
• Handling of port catheter systems

The procedural instructions are binding for the interprofessional treatment team; any deviating action must be justified. They are prepared on an interdisciplinary and interprofessional basis. Approval is given by the Director of Nursing and the Charité's Executive Board for Patient Care. The nursing staff of the various organ centers with advanced training in oncology, a Bachelor of Nursing (BoN) degree, and nursing staff studying for advanced clinical nursing in oncology are actively involved in this process, and a regular review and continuous supplementation or further development of the procedural instructions takes place. 

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*1) German network for quality development in nursing care.

All outpatients and inpatients are surveyed using a standardized questionnaire. The board of directors, the hospital management, the center management as well as all ward and function managers are informed about the feedback of the inpatients on a quarterly basis. The evaluation of the survey of outpatients takes place every six months within the centers. In this process, attention is always paid to ensuring data protection and the prompt processing of change notices.

4.1 Prevention and Risk Management

Especially for vulnerable patients with oncological diseases, risk-reducing nursing activities and long-term monitoring of risks are necessary. Nurses initiate these in close collaboration with the medical service. Various recording instruments and prevention recommendations are available for risk management, which are based on the procedural instructions of the Charité - Universitätsmedizin Berlin and the following national expert standards of the DNQP:

• national expert standard for fall prophylaxis in nursing care
• National expert standard for pressure ulcer prophylaxis in nursing care
• National expert standard for discharge management in nursing care
• National expert standard on pain management in nursing care
• National expert standard for the care of people with chronic wounds 
• national expert standard nutrition management in nursing care

4.1.1 Fall Prevention

Patients with tumor diseases often suffer from weakness and even fatigue syndrome. Those affected therefore have an increased risk of injury due to a fall. Based on a standardized risk assessment, an initial fall risk assessment is performed on the day of admission. The nurse implements the indicated general and individual precautionary measures. The assessment is repeated at regular intervals. Fall events are recorded uniformly and the results are made available semi-annually by Clinical Quality and Risk Management in order to reliably keep an eye on and increase patient safety and quality of care.
Risk assessment, implementation of precautionary measures, and quality assurance of the pressure ulcer prevention, nutrition monitoring, delirium prevention, pain management, and wound management listed below follow the structures of fall prevention in an analogous manner.
Quality assurance is currently carried out via audits of clinical quality and risk management.

4.1.2 Pressure Ulcer Prevention

Patients with oncological diseases are restricted in their ability to move their bodies in many ways. Fatigue, tumor- or therapy-related restrictions, malnutrition, etc. thus considerably increase the risk of pressure sores developing. This is exacerbated by therapy-related, restricted cell renewal and the resulting slowed and/or disturbed wound healing.
As far as possible, the patient's mobility is promoted and strengthened by interventions to support physical activities.
In immobile phases of illness, patients are supported by conscious positioning of the body or a part of the body in order to avoid support pressure, shear forces and deficient blood circulation, but also to promote physical and psychological well-being. Experts in mobilization support, positioning and transfer are regularly involved in the needs-based care of high-risk patients.
The nursing experts advise on special nursing interventions and special beds and mattresses.

4.1.3 Nutritional Monitoring

Patients with tumor diseases often develop nutritional problems due to disease and therapy. In particular, the threat of malnutrition must be detected at an early stage so that interventions can be initiated to change or maintain the patient's nutritional status. This includes weight management - to maintain a balanced body weight with a favorable body fat percentage - and support for weight gain.
In addition to drug treatment, individual nutrition therapy is an important component in the overall structure of tumor therapy. An individual and balanced diet can have a positive effect on the further course of therapy and contributes significantly to the quality of life of oncological patients. Outpatient and inpatient oncological patients and their relatives are advised by the nutrition team according to their needs.
Depending on the therapy, the nursing activities described in the nursing interventions for nausea and vomiting management are individually tailored to the patient.

4.1.4 Delirium Prevention

Patients with oncological diseases are particularly at risk of developing delirium. The provision of a safe and therapeutic environment, as well as the physical and cognitive activation of patients with delirium, serves to prevent significant health consequences (cognitive and functional limitations, increased need for care, etc.). 

Reliable detection of delirium in inpatient settings is currently performed using the Delirium Observation Screening Scale (DOS). A revised procedural instruction for delirium prevention with the identification of high-risk patients and the application of mainly non-pharmacological preventive measures will be implemented in 2020.

4.1.5 Skin and Mucous Membrane Prevention

The skin and mucous membranes of tumor patients are temporarily damaged by antitumor therapies and cell renewal is delayed. Painful inflammations considerably impair the patient's quality of life, and it is not uncommon for the curative goal of treatment to be jeopardized by interruptions, dose limitation or discontinuation of therapy. For patients at risk, the maintenance and promotion of an intact skin and oral mucosa through the implementation of skin care standards of the Charité as well as the promotion of oral hygiene and dental health is particularly important. 

For early detection of skin lesions and oral mucositis, inspection, assessment and documentation of the skin, mucous membranes and condition of the lips of patients at risk is performed daily.

4.2 Promotion of Symptom and Self-management

Patients with tumor diseases often experience very stressful symptoms due to their malignant disease or the side effects of antitumor therapies. Nurses provide support through combinations of different interventions designed to help patients cope with symptoms or make them more bearable.
Self-management support and education of patients and their relatives are considered as a task of the nurses. This includes micro-education that fits into inpatient care situations, as well as instruction and counseling in separate care situations. For safe home care, instruction in adverse event management and the adoption of (self-)care skills are of particular importance. These also take place concurrently in the affiliated university outpatient clinics of the Charité - Universitätsmedizin Berlin.
Nurses with advanced training in oncology and nurses studying for advanced clinical nursing in oncology provide advice within the oncology nursing network on the individual nursing care of patients and, if necessary, provide guidance on special nursing techniques and methods.

4.2.1 Pain Management

Pain management requires a high degree of interprofessional cooperation. The common goal is to alleviate or reduce acute or chronic pain to an acceptable level for the patient. 
Nurses ensure regular standardized pain assessment (localization, quality, pain intensity) by patients. They ensure that patients* receive individualized analgesic care. They carefully monitor and evaluate drug and non-drug interventions. Nurses actively participate in therapy- and disease-related symptom and side effect management. Information and counseling of patients with oncological diseases and their relatives are essential elements. 
The advanced training to become an algesiological specialist assistant qualifies nurses to assume the function of pain representative in the inpatient areas. In addition, the nursing staff can consult an interprofessional pain service.

4.2.2 Wound Management

Nursing care after tumor resection and the treatment of chronic wounds require expertise in order to maintain or restore tissue integrity. Patients with tumor disease suffer from wound healing disorders and associated pain due to disease and therapy. The basis for the prevention of wound complications is laid by a standardized wound description with photo documentation and wound care with the careful selection of wound dressings. Malignant (exulcerating tumor wounds) or other wounds for which no healing is expected require a special procedure taking palliative care approaches into account.

In line with the requirements of modern wound care, the wound experts in the departments are further qualified to become ICW-certified wound experts. Events for the continuous re-certification required by the ICW are guaranteed. The goal is that an ICW-trained wound specialist can be consulted in every inpatient area for advice and guidance. 

4.2.3 Nausea and Vomiting Management

Patients on antitumor therapies often suffer from nausea and vomiting, which can only be controlled to a limited extent with medication. Nurses provide preventive and palliative interventions. They identify and control environmental factors that may trigger or contribute to vomiting. They also demonstrate acceptance of vomiting and assist patients in selecting and testing control strategies. Nurses monitor the effect of emesis management, drawing conclusions about nutritional status and possible changes in the treatment plan. In this way, they contribute to patient safety and promote the preservation of quality of life.

4.2.4 Interventions to Promote Psychological Well-being

The vulnerability and stress of patients with oncological diseases are well known and described. Affected patients and their relatives receive support at the Charité through the early involvement of psychooncologists.
The standardized Distress Assessment is used for individual assessment. The results are made available to all professional groups involved in the care process.
Nurses help patients and their families to develop their own strengths, to adapt to functional changes and to cope with life challenges despite the disease-related crisis. They support cognitive and behavioral efforts to cope with perceived stressors, changes, and threats.
In the last phase of life, they promote physical and emotional well-being to the extent possible.
Palliative services are involved at an early stage to provide comprehensive palliative care that meets the needs and requirements of those affected.
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*2) The chapter is based on the nursing intervention classification (NIC) by Bulecheck GM, Butcher HK, Dochtermann JM, Wagner CM (2016). Hogrefe Verlag, Bern

A large proportion of patients with tumor diseases receive antitumor therapies in the form of chemotherapy / antibody therapy and / or radiation.
Nurses with extended competencies take over the preparation, administration and follow-up of drug treatment according to the physician's orders, while carefully maintaining patient and occupational safety.
Close monitoring, counseling and guidance on symptom management help patients and their families to understand and minimize side effects of antineoplastic agents.

The Charité's inpatient nursing service offers patients the organizational concept of reference nursing, in which a registered nurse cares for a group of patients. The nurse takes responsibility for all nursing activities per shift. The reference nurse coordinates the work processes in close cooperation with all the professional groups involved.
Patient managers plan and coordinate the admission of patients in consultation with the medical service, taking into account diagnostic scheduling and bed occupancy. They monitor the expected length of stay, the discharge date and the assessment of individual post-discharge care needs. In coordination with all professional groups involved, patient managers organize further outpatient or inpatient care.

In addition, the palliative care service or the oncological care network of the Charité can be consulted for the care of oncological patients.
The staff of the social services provide advice on issues such as outpatient care. In principle, a connection to a specialized oncological (also palliative) nursing service is recommended and organized if necessary.

8.1 Strategy of Professional Development

The Oncology Training Program at all three sites and the educational offerings of the Charité Training Academy are available to maintain and expand professional qualifications.
The employee-oriented management culture within the oncology centers enables targeted personnel development, among other things through prospective qualification planning and systematic induction of new employees, taking into account specific oncological aspects.
Ward and functional managers promote nursing staff individually and in a results-oriented manner and hold annual target agreement and milestone discussions for this purpose.

8.2 Career Stages in the Specialist Career Path

The development opportunities for employees in the specialist career path of the nursing and functional service are based on experience in the specialist area, the qualifications acquired and the assumption of functions with a special area of responsibility. Both the centralized and decentralized organizational structures are designed for vertical and horizontal permeability.
Vulnerable patients with serious illnesses depend on excellent nursing care that is tailored to their needs and requirements. Good interaction between nursing assistants, nursing specialists and nursing experts is a prerequisite for this.

8.3 Study and Specialization

Comprehensive expertise is indispensable, which is why Charité supports and promotes the academization of nursing and enables clinically oriented studies in cooperation with the akkon university, with the study program Advanced Clinical Nursing B.sc.-Oncological Nursing. Each year, 10 scholarships are awarded for this course of study at the Charité. The course always starts in the winter semester of the current year. Professional, methodical, social and personal competencies are strengthened and further developed in order to meet the special needs of oncologically ill and dying patients as well as their relatives and caregivers. 

Medical assistants can complete the special qualification in oncology according to the curriculum of the Medical Association.

A fixed interprofessional communication structure has been implemented in all areas of the Charité for patient-oriented coordination of the course of treatment and mutual supplementation.
This includes, for example, joint ward rounds and multiprofessional team meetings.
Regular morbidity and mortality conferences are quality assurance measures and are part of the open and sanction-free error culture at Charité.
Ethical case consultation is an additional service offered by specially trained staff and provides structured support, e.g. in difficult decision-making or treatment situations.